FERTILITY AND STERILITY

VOL. 80, NO. 2, AUGUST 2003

Copyright 2003 American Society for Reproductive Medicine
Published by Elsevier Inc.
Printed on acid-free paper in U.S.A.

Spontaneous expulsion of three large

fibroids after uterine artery embolization
Francoises Laverge, M.D.,a Arianna DAngelo, M.D.,a Nigel J. Davies, M.R.C.O.G.,a
Andrew Wood, M.R.C.P.,b and Nazar N. Amso, Ph.D.a
University Hospital of Wales, College of Medicine, Cardiff, United Kingdom

Objective: To report a case of uneventful expulsion of huge fibroids after uterine artery embolization.
Design: Case report.
Setting: The Department of Obstetrics and Gynaecology of a university hospital.
Patient(s): A 45-year-old woman who underwent uterine artery embolization for fibroids.
Intervention(s): Transfemoral selective bilateral uterine artery catheterization and injection of 500 700 m
polyvinyl alcohol particles.
Main Outcome Measure(s): Recovery of the patient.
Result(s): The spontaneous expulsion of three fibroids on three different occasions over several months
resulted in a significant reduction in menstrual loss and dysmenorrhea.
Conclusion(s): Delivering fibroids or sections of fibroids may be a natural process after uterine artery
embolization, therefore it is essential to warn women about the possible risk. Close follow-up is also essential.
The size of the fibroids discharged did not require hysterectomy. Adequate antibiotic cover may be necessary
to prevent sepsis. (Fertil Steril 2003;80:450 2. 2003 by American Society for Reproductive Medicine.)
Key Words: Uterine artery embolization, fibroid, expulsion of fibroid, menorrhaggia

Uterine artery embolization (UAE) is an mg tds had failed to control the symptoms. A
effective nonsurgical treatment for uterine my- clinical examination revealed a uterus that was
omas (1, 2). The success worldwide has been 20 weeks in size. A pelvic ultrasound scan
reported to be over 80%, with an average re- showed a 200 105 mm central mass with the
Received September 10, duction in dominant fibroid volume of 39% appearance of a fibroid. Because of the large
2002; revised and
accepted December 30, 69% (1). Major complications are uncommon. size of the fibroid it was not possible to identify
2002. Short-term complications include infection, al- the location. The hemoglobin level was 8.6
Reprint requests: Arianna lergic reaction, and trauma at the site of injec- g/dL; a blood transfusion was performed, and
DAngelo, M.D.,
Department of Obstetrics tion. Premature ovarian failure and unchanged oral iron supplements prescribed.
and Gynaecology, fibroid dimensions are possible long-term com-
University Hospital of
Surgical and medical options for the man-
plications. Expulsion of the fibroid is not a
Wales, College of agement of the fibroids were discussed with the
Medicine, Heath Park, complication in itself but an unusual response
patient and UAE was chosen. Transfemoral
Cardiff, CF14 4XN United by the uterus to the degenerated fibroid.
Kingdom (FAX: 44-0-29-
selective bilateral uterine artery catheterization
20743722; E-mail: d- We report an unusual case of a woman who was performed, and 500 700 m polyvinyl
angeloa@cardiff.ac.uk). passed three huge fibroids uneventfully. alcohol particles were injected to vascular
a
Department of Obstetrics standstill. The procedure was performed under
and Gynaecology,
University Hospital of sedation and was technically uncomplicated
Wales, College of CASE REPORT and successful. The patient was allowed to go
Medicine. home the next day on antibiotic therapy, oral
b
Radiology Department, A 45-year-old woman (para 2) with a body
co-amoxiclav (Augmentin, SmithKline Beecham,
University Hospital of mass index of 44 kg/m2 was referred to us for
Wales, College of Oxbridge, UK) for 7 days.
Medicine.
menorrhagia and dysmenorrhea of 6 months
duration. Her medical history was unremark- At 4 weeks of follow-up there were no prob-
0015-0282/03/$30.00 able. Medroxyprogesterone acetate (Provera, lems. Ten weeks after the procedure, she pre-
doi:10.1016/S0015-0282(03)
00606-X Pharmacia & Upjohn, Milton Keynes, UK) 10 sented complaining of crampy pelvic pain and

450
 FIGURE 1
Uterine fibroid expelled after UAE.
Laverge. Fibroids expulsion after uterine embolization. Fertil Steril 2003.
a very offensive vaginal discharge. On clinical examination
a 150 140 30 mm necrotic soft mass was protruding out
of the vagina. This was removed and sent for histology (Fig.
1). The patient was apyrexial, but a neutrophilia (15.49
109/L) was noted and a high vaginal swab revealed heavy
growth of mixed anaerobes. Intravenous antibiotics were
started immediately and continued for 3 days, and after that
they were changed to oral. The following day, a second
mass, 110 100 60 mm in size, was passed vaginally and
also sent for histology. Histopathology examination of the
two specimens revealed a degenerative infarcted benign
leiomyoma.
We performed a magnetic resonance imaging scan to
assess the uterus. The uterine cavity was enlarged to 170
102 120 mm and contained material of mixed signal
intensity and possibly several small pockets of gas. The
surrounding myometrium was 10 mm thick without evidence
of rupture. This was confirmed by hysteroscopy under seda-
tion. The patient was discharged from the hospital on oral
antibiotics 7 days after the first fibroid was passed. Weekly
follow-up visits were arranged. The patient complained of an
offensive vaginal discharge for several weeks and passed a
third fibroid (the size of an orange) 3 weeks after the first
fibroid was passed.
FERTILITY & STERILITY
Transvaginal ultrasound examination 6 months after em-
bolization showed a normal size uterus with a 49.5 57
61 mm fibroid. A significant reduction in menstrual loss and
dysmenorrhea was reported. At 1 year of follow-up a trans-
vaginal ultrasound scan of the pelvis revealed a normal size
uterus with no evidence of fibroids on ultrasound scan and a
complete resolution of her symptoms.
DISCUSSION
Transcervical expulsion of myomas a few months after
UAE has been described in several studies and is not un-
common (3). In most cases, the myomas were expelled
spontaneously within 3 months after the procedure or were
easily removed by ligating the connecting stalk or by hys-
teroscopy.
Pollard and Goldgerg (3) reported a case where the my-
oma was so large and broadbased that it could not be
removed transvaginally, resulting in an abdominal hysterec-
tomy. Felemban et al. (4) reported one case of expulsion of
a 90 50 30 mm fibroid. Symptoms before and during
the expulsion of the myoma were various. To the best of our
knowledge, this is the only case where the expulsion of such
large fibroids (up to 150 140 30 mm) in sequence over
451
a prolonged period of time was associated with mild dis-
comfort only and without the need for significant surgical
intervention.
The fibroids expelled in this case were probably submu-
cous and became pedunculated after the UAE. However, it is
not always possible to differentiate large submucous from
intramural fibroids when the uterus is so large and distorted,
as in this case. It is important to ensure that the uterine wall
is intact after expulsion of fibroids either by hysteroscopy or
by magnetic resonance imaging, especially if the woman
wishes to preserve fertility. Successful unplanned pregnan-
cies have been reported after UAE (5). However, uterine
fistula has also been reported after UAE (6).
In conclusion, it is essential to warn women undergoing
UAE about the possible risk of spontaneous expulsion of
fibroids. In addition, a close follow-up is needed to prevent
short-term complications such as infection after expulsion of
fibroids. Adequate antibiotic prophylaxis is important to
prevent endometritis and sepsis (7). UAE seems to be an
452 Laverge et al. Fibroids expulsion after uterine embolization
effective alternative to surgical treatment for the manage-
ment of symptomatic uterine fibroids and should be consid-
ered for women who are not keen on surgical intervention or
who are at high perioperative risk. The size of the fibroids
does not seem to be a contraindication for UAE.
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Vol. 80, No. 2, August 2003