How does the UFE or UAE procedure work?
UFE (Uterine Fibroid Embolization) and UAE (Uterine Artery Embolization) are different terms for the same procedure. There is no difference between them.
The rock-like fibroids need a blood supply to stay alive and grow. During the UFE procedure, this blood supply is purposely blocked. This causes the fibroids to die off. They will first start to soften and liquefy, and eventually they will shrink. While some fibroids will disappear completely, it is not necessary for them to do so. Often the fibroids will still be present on imaging (for example, MRI or ultrasound), but since they are now soft (like bags of water rather than rocks) they can no longer cause the significant symptoms anymore. For example, a woman had increased urinary frequency with waking up multiple times to urinate because of a fibroid compressing the bladder.
After UFE, even if the fibroid does not shrink very much, it is now a bag of water and the bladder can push it out of the way and fill normally. The patient now sleeps through the night without waking up and she urinates much less often. The average reduction in volume of the fibroid after UFE is 40% by 3 months and 65% by 6 months. Therefore, we usually get both significant symptom improvement (“90%) and significant size improvement, but sometimes we only get significant symptom improvement. That’s what is most important. Remember that women who have no symptoms, do not need any treatment. They might have fibroids, but if they don’t have any symptoms, they don’t need treatment of any kind.
How do you perform a UFE procedure?
The approach for UFE is like a heart catheterization. Patients are asleep during the procedure which takes about an hour to perform. They receive conscious (intravenous) sedation like you would get during a colonoscopy. Local anesthetic is placed in the right groin/top of the thigh area. A catheter is positioned under x-ray guidance into the blood supply of the uterus.
This blood supply can be thought of as a tree with leaves. The trunk is the main uterine artery and the leaves are the branches that supply the fibroids. Tiny particles are injected which are specifically sized for the fibroid vessels. These vessels become blocked, resulting in pruning of the tree. The trunk stays open and supplies the normal uterine tissue, but the fibroids will start to wither away, soften, and eventually shrink in size.
How do I know if I am a candidate for UFE?
To know for sure, you would need a consultation with Dr. Lipman in his office. We would obtain a pelvic MRI prior to your consultation, which our office will arrange for you. The consult takes about 45 minutes and Dr. Lipman will discuss your symptoms, treatment options, and go over your MRI pictures with you. In general, patients that have been told that they are candidates for other fibroid treatments (exs. Hysterectomy, myomectomy, endometrial ablation, etc.) are usually candidates for UFE. Rarely, a fibroid may not be suitable for UFE and it is one of the reasons for obtaining the MRI.
What are the benefits of UFE over other fibroid therapies?
- Minimally invasive: There is no general anesthesia, no inpatient hospitalization, and no surgical incision. A tiny nick in the skin (which is covered by the pad of a bandaid) is the only footprint that any procedure was performed. This is usually completely invisible by the one week follow-up visit.
- Highly successful: In our experience, over 90% of patients have found significant improvements in all of their symptoms, or the symptoms are completely gone. The remaining 10% of patients are usually only slightly better or unchanged (i.e. not worse). These patients typically have adenomyosis which is harder to treat than fibroids (see Adenomyosis) or have ovarian branches that are also feeding the fibroids in addition to the uterine branches. These ovarian branches keep the fibroid alive and therefore the symptoms remain after the initial UFE. If a woman is not interested in fertility and has these ovarian branches feeding the fibroid, she can undergo a 2nd embolization to treat this rather than undergoing hysterectomy.UFE is a global therapy (like hysterectomy) in the fact that it treats all of the fibroids. Myomectomy only treat some of the fibroids, and Endometrial Ablation does not treat any of the fibroids (tries to treat the bleeding symptom but does nothing to the actual fibroid(s) causing this symptom).
- Outpatient procedure: 98% of patients discharged home the day of the procedure, and the rest discharged within 23 hours (ie. overnight stay).
- Shorter recovery time: Average recovery 4 days and one week away from work versus 6 to 8 weeks for hysterectomy or myomectomy.
- Less risk: No general anesthesia or surgical incisions. For the risks of UFE see separate discussion in this section.
I had a pelvic ultrasound in my gynecologist’s office. Is this satisfactory imaging, or do I still need a MRI?
While we will look at the ultrasound reports that you have had, it is still necessary to obtain a pelvic MRI. There are conditions that mimic fibroids and are hard to diagnose just on ultrasound (see Adenomyosis).
Does the size and number of fibroids matter?
No. Patients that are told that they are not candidates for UFE because they have too many fibroids or that they are too big are being given false information.
I have had a myomectomy, can I still be considered for UFE?
Yes. Myomectomy is the removal of the largest fibroid or collection of fibroids and attempts to sew the uterus back together. fibroids are often multiple and reside in multiple areas of the uterus. It is often not possible to remove all of the fibroids and still be able to have a uterus left intact (2-3% of patients that undergo myomectomy wake up with a hysterectomy). Therefore, after myomectomy, there is still a significant fibroid burden which will continue to grow after surgery and the symptoms will recur. It recurs at a rate of 10% per year (i.e. over half of the patients will recur within 5 years, over 1/3 within 3 years). UFE treats all of the fibroids that are in the uterus and therefore the recurrence rate after UFE is much lower than that seen with myomectomy.
I have had an Endometrial Ablation, can I still be considered for UFE?
Yes. Endometrial Ablation burns the lining of the uterus through different forms of heat (exs. Scalding hot water in a balloon, microwave energy, etc.). This can only try to treat the bleeding associated with fibroids, but does nothing to the fibroid itself or the bulk symptoms associated with fibroids (exs. Pelvic pain, increased urinary frequency, constipation, etc.)
Do I need to go to a hospital or plan to stay overnight at the Center?
No, the UFE procedure is performed in an outpatient suite at our facility, and patients are routinely discharged 4-5 hours after the procedure, recuperating comfortably at home the same day. In the very rare event that a patient needs further observation beyond the time spent with us, they will be seen at a nearby hospital.
How long does the procedure take?
Unlike many Hospitals that perform the UFE procedure in 2-3 hours, the procedure at our Center typically takes 30-45 minutes. Because of our experience in providing the UFE procedure, along with our specialized equipment and layout that is optimized for the UFE procedure, we are able to minimize the time you spend in the procedure room. This permits you to begin recuperating sooner in one of our private recovery rooms, and return to the comfort of your home typically in the afternoon after your procedure.
Who will perform the procedure?
Unlike hospital teaching facilities, which can use residents or fellows who are training under the supervision of an attending physician, Dr. Lipman himself performs all of the procedures at the Center. With over 5,500 UFE procedures performed during his career, Dr. Lipman is the world’s most experienced individual provider of UFE procedures. He developed a custom-designed, state-of-the-art outpatient facility to specifically serve UFE patients, keeping their safety and comfort foremost in mind.
Will I need a bladder catheter?
No, unlike most clinics and hospitals performing the UFE procedure and require insertion of a catheter in to your bladder, we feel it is generally unnecessary. Your comfort is very important to us, so we avoid the often-uncomfortable process of inserting a catheter unless there is a compelling need.
How is the Atlanta Interventional Institute different from other facilities that offer UFE?
The Center is outfitted with state-of-the-art equipment, including the GE Innova IGS 540, the centerpiece of our procedure room. This device is specifically designed for interventional procedures such as UFE, and is currently the best instrument available for the UFE procedure. Because of its cost and focused suitability, the IGS 540 is only available in the best hospitals. Other outpatient centers are not equipped with dedicated angio equipment, and use much less expensive and lower grade C-arm technology to perform UFE procedures. These are adequate for dialysis management, for which they were originally designed, but are not the optimal equipment for fibroid embolization.
While the proper technical equipment is critical to performing UFE procedures, we have taken several further steps to ensure patients are safe and comfortable. The recovery area of our procedure suite is designed to provide a comfortable setting for patients to rest and gradually recover from the UFE procedure. Each patient receives her own private recovery room with a wide-screen television, a door to ensure privacy, and a comfortable chair for the person accompanying the patient. Our nursing staff are specifically hired and trained by Dr. Lipman himself to provide a welcoming and quiet environment, while ensuring that each patient receives personalized care and recovers as safely, quickly, and comfortably as possible. Each recovery room is tastefully appointed and decorated with soothing and attractive colors. We strive to make your recovery environment more like your home, and less like a hospital.
What is the recovery period at home and how long will I be out of work?
The typical recovery period is about 4 days after the day of the procedure. Patients are generally away from work for 1 week. Occasionally, patients will need a second week away from work, but this is the exception.
What are the risks of UFE?
From a risk profile, UFE is safer than the surgical options for fibroids treatment. The main risks of the procedure are as follows:
1. Menopause: Roughly 2% of women will go into menopause after UFE. The large majority of these women are over 45 years of age. A much smaller percentage of women enter menopause after UFE that are between 40 and 45 years of age. No one under 40 years of age, in our experience, has experienced menopause after UFE treatment.
2. Fibroid slough: Roughly 5% of women will slough fibroid tissue with menses after UFE. The material is from a fibroid that is near the lining and falls into the cavity and passed in pieces after the UFE. This is not concerning, except that it is important to tell patients about this so that they are not alarmed if they see this after UFE. On very rare occasions (~1 in a 1,000 patients), the material is in the cavity, but a woman cannot pass it. Symptoms of sudden, sharp pain, fever, and a foul malodorous discharge alert the women of this occurrence and the Interventional Radiologist should be immediately notified. The patient is placed on antibiotic therapy and watched closely for ~24 hours. If she passes the material, no further steps are taken. If she cannot pass the material, an elective outpatient D&C with her gynecologist may be necessary.
3. Allergy to the contrast: Rarely, patients will be allergic to the x-ray contrast. In the very rare event that a reaction occurs, patients are given medicine to reverse and stop it.
4. Fertility: Myomectomy adversely affects fertility such that after one myomectomy the fertility rate drops to ~50% and after 2 myomectomies to ~10%. We don’t know yet what the drop is with UFE. That is because while the UFE procedure has been performed since 1995, it is only more recently that patients who desired fertility have been treated. A number of patients have delivered full-term babies after UFE (we have even had a set of twins) without difficulty. Small recent papers show higher fertility rates after UFE compared to myomectomy, but the numbers are still too small. Patients need to weigh all the risks before deciding on UFE if they desire fertility. In general, patients with single fibroids (simple myomectomy) may be better served with myomectomy until the fertility risks are known, whereas patients with multiple fibroids and a complex myomectomy favors UFE.
What is MRI-guided Focused Ultrasound (MRgFUS)?
MRgFUS is a non-surgical treatment for uterine fibroids. It was FDA approved in October 2004.
The MRgFUS procedure uses ultrasound waves (much more powerful than those used for diagnostic imaging) which are focused to a small spot about the size of a jellybean. There is enough energy in that spot to destroy the fibroid while leaving all the healthy tissue outside the fibroid unharmed. Many jellybean sized spots are used to treat the entire fibroid.
Unfortunately, Atlanta Interventional Institute is no longer able to provide this procedure due to the closure of Emory-Adventist Hospital. Further, the MRgFUS procedure is not recognized by most insurance companies for treatment of uterine fibroids.