Indications
| Indication | Clinical Context |
|---|---|
| Heavy menstrual bleeding (menorrhagia) | Symptomatic uterine fibroids causing iron-deficiency anemia or quality-of-life impairment; failed or declined medical management |
| Bulk-related symptoms | Pelvic pressure, urinary frequency, bladder compression, bowel compression, or pelvic pain from uterine enlargement |
| Failed or declined alternative treatments | Failed hormonal therapy; patient declines or is not a candidate for hysterectomy or myomectomy |
Contraindications
| Type | Contraindication |
|---|---|
| Absolute | Pregnancy; suspected uterine malignancy (must exclude endometrial or cervical cancer before proceeding); active pelvic infection or endometritis; severely compromised vascular anatomy precluding bilateral uterine artery access |
| Relative | Desire for future fertility (myomectomy preferred — discuss with gynecology); pedunculated subserosal fibroid with narrow stalk (<2 cm) — risk of fibroid detachment and peritoneal complications; submucosal fibroid with large intracavitary component — consider hysteroscopic resection first; GnRH agonist pretreatment (reduces uterine artery blood flow, may increase technical difficulty) |
Gynecology coordination is essential: UFE should be offered only after gynecologic evaluation to confirm fibroid etiology, exclude malignancy, and confirm that the patient's symptom burden and fibroid characteristics are appropriate for embolization. Multidisciplinary discussion is recommended when fertility preservation is a concern.
Relevant Anatomy
Uterine Artery Supply
The uterine arteries originate from the anterior division of the internal iliac artery (hypogastric artery), arising near the origin of the obturator and superior vesical arteries. Each uterine artery travels medially across the pelvic floor to the uterus, giving branches to the cervix and ascending along the lateral uterine wall before branching into the arcuate arteries, which supply the uterine wall and the fibroids.
Fibroids receive their primary blood supply from the uterine arteries through a hypervascular pseudocapsule network. Collateral supply from the ovarian arteries is present in approximately 10–20% of patients — if dominant ovarian artery supply to fibroids is identified on pre-procedure MRI or during angiography, the ovarian arteries may require embolization, raising the risk of ovarian failure (particularly in women over 45).
Critical Structure: Cervicovaginal Branch
The cervicovaginal branch of the uterine artery arises just proximal to the ascending uterine artery. Embolization distal to this branch is the standard technique — preserving the cervicovaginal branch maintains normal cervical and vaginal perfusion. Embolization proximal to this branch risks cervical and vaginal necrosis. Understanding this branching point on pelvic angiography is fundamental to safe UFE technique.
Pre-Procedure Checklist
Imaging Review
- MRI pelvis with contrast (preferred) — characterize fibroid number, size, location (submucosal, intramural, subserosal), enhancement, and proximity to endometrium; confirm absence of adenomyosis as the dominant process; assess for dominant ovarian artery supply
- Confirm fibroid etiology — rule out adenomyosis (responds poorly to UFE), uterine malignancy, and pedunculated subserosal fibroids with narrow stalks
Labs and Patient Assessment
- CBC (assess anemia severity), coagulation panel, serum creatinine, pregnancy test (mandatory before every UFE)
- Consider iron supplementation before procedure in severely anemic patients
- Confirm last menstrual period — schedule procedure in the follicular phase when possible to minimize endometrial shedding and reduce infection risk
Consent Considerations
Discuss: post-embolization syndrome (majority of patients — fever, pain, nausea for 24–72 hours), treatment failure or incomplete response (~10–20% — may require repeat UFE or surgery), premature ovarian failure (low overall risk; higher in women over 45), endometritis/uterine infection (~1–2%), fibroid expulsion (for submucosal fibroids — typically managed with observation), deep vein thrombosis, non-target embolization, and potential impairment of future fertility.
Procedure Overview
The following is a high-level summary. Full step-by-step technique and troubleshooting are available in RadCall Pro.
- Vascular access — radial or femoral access (approach is institutional preference); anticoagulation administered after access
- Pelvic angiography — diagnostic aortogram and selective internal iliac angiography to map uterine artery anatomy and identify collateral supply; identify the cervicovaginal branch before embolization
- Selective uterine artery catheterization — advance catheter to the uterine artery, distal to the origin of the cervicovaginal branch; confirm position with contrast injection showing the ascending uterine artery and fibroid blush
- Embolization — deploy embolic particles through the catheter into the uterine artery; endpoint is near-stasis with cessation of antegrade flow in the ascending uterine artery; avoid reflux of particles into the internal iliac artery
- Contralateral uterine artery — repeat catheterization and embolization on the contralateral side; bilateral embolization in a single session is mandatory for treatment success
- Completion angiography — confirm bilateral uterine artery stasis; assess for any non-target embolization; document final angiographic result
Complications
| Complication | Rate | Recognition & Management |
|---|---|---|
| Post-embolization syndrome | Majority of patients; expected | Fever, pelvic pain, nausea/vomiting within 24–48 hours; normal inflammatory response to fibroid infarction; managed with scheduled NSAIDs, antiemetics, and analgesics; distinguish from endometritis (persistent fever >72h, purulent discharge, worsening pain) |
| Treatment failure / incomplete response | ~10–20% | Persistent or recurrent symptoms; MRI at 3–6 months to assess fibroid volume reduction; repeat UFE, myomectomy, or hysterectomy for failures |
| Endometritis / uterine infection | ~1–2% | Persistent fever >72 hours, uterine tenderness, purulent cervical discharge; IV antibiotics; hysterectomy for septic uterus unresponsive to antibiotics |
| Premature ovarian failure (POF) | <1–3% overall; higher in women >45 | Non-target embolization of ovarian collaterals; amenorrhea post-UFE in a minority; discuss risk explicitly with patients over 40 |
| Fibroid expulsion | ~2–5% (submucosal fibroids) | Passage of infarcted fibroid tissue through the cervix; often self-limiting; gynecology consultation for retained or infected expelled tissue |
| Non-target embolization | Rare | Particles refluxing into internal iliac artery branches; bladder, bowel, or skin ischemia; prevented by distal catheter positioning and careful embolization technique at stasis endpoint |
Post-Procedure Care
Inpatient Management
- Most patients admitted overnight for pain management — post-embolization pelvic pain is significant and requires scheduled analgesics (NSAIDs + opioids as needed)
- Vital signs every 4 hours; antiemetics for nausea
- Low-grade fever within 24–48 hours is expected — temperatures >38.5°C beyond 48–72 hours or clinical deterioration should prompt evaluation for endometritis
- Resume oral intake as tolerated; IV fluids for nausea or inadequate oral intake
Discharge and Follow-up
- Discharge criteria: pain controlled on oral medications, tolerating oral intake, afebrile or low-grade fever expected post-embolization
- MRI pelvis with contrast at 3–6 months to assess fibroid volume reduction and treatment response
- Gynecology follow-up at 6 weeks to assess symptom response and menstrual pattern
- Return for: persistent fever >72h, purulent vaginal discharge, severe worsening pain, signs of systemic infection
When to Escalate
- Persistent fever >72 hours post-UFE — evaluate for endometritis; CT pelvis with contrast; IV antibiotics; gynecology consultation; hysterectomy for septic uterus unresponsive to treatment
- Fibroid expulsion with retained or infected tissue — gynecology consultation for hysteroscopic removal; antibiotics for infected expelled fibroid
- Treatment failure at 3–6 months MRI — multidisciplinary discussion; options include repeat UFE, targeted myomectomy, or hysterectomy based on symptom severity and patient preference
- Suspected non-target embolization (bladder or bowel symptoms immediately post-procedure) — CT angiography; urology or surgical consultation as appropriate
Fertility After UFE — What the Evidence Shows
UFE should be discussed carefully with women who have a strong desire for future pregnancy. The available evidence — while limited by small sample sizes and low quality — consistently suggests myomectomy offers superior reproductive outcomes compared to UFE.
Pregnancy and Live Birth Rates
A 2022 systematic review found higher rates of clinical pregnancy and live birth following myomectomy than UAE. The landmark trial by Mara et al. (n=121) reported fewer pregnancies, fewer deliveries, and more miscarriages in patients attempting to conceive after UAE compared to myomectomy. The FEMME trial (2020 multicenter RCT, n=254) recorded only 15 pregnancies after UAE — the trial was not powered for fertility outcomes. A 2025 Lancet review concluded that randomized evidence on the effect of UAE on fertility remains poor, with both available trials underpowered for this endpoint.
Obstetric Complications
Compared with expectant management, UFE is associated with significantly higher rates of adverse obstetric outcomes (ACOG Practice Bulletin 228, 2021):
| Outcome | UFE | Expectant Management | Odds Ratio |
|---|---|---|---|
| Pregnancy loss | 35.2% | 16.5% | OR 2.8 |
| Cesarean delivery | 66% | 48.5% | OR 2.1 |
| Postpartum hemorrhage | 13.9% | 2.5% | OR 6.4 |
UFE is also associated with higher rates of spontaneous abortion, abnormal placentation, preterm labor, and malpresentation compared to myomectomy.
Clinical bottom line: Myomectomy should be offered to women with symptomatic fibroids who have a strong desire for future pregnancy. UFE can be offered when surgery is not appropriate, but detrimental effects on fertility must be disclosed during consent. The 10-year reintervention rate after UFE is approximately 31%.
References
- Ravina JH, et al. Arterial embolisation to treat uterine myomata. Lancet. 1995;346(8976):671–672.
- Gupta JK, et al. Uterine artery embolization for symptomatic uterine fibroids (Cochrane Review). Cochrane Database Syst Rev. 2014.
- ACR-SIR-SPR Practice Parameter for the Performance of Uterine Fibroid Embolization.
- Zanolli NC, et al. Fibroids and Fertility: A Comparison of Myomectomy and Uterine Artery Embolization on Fertility and Reproductive Outcomes. Obstet Gynecol Surv. 2022;77(8):485–494.
- de Smit NS, et al. Current Treatment for Symptomatic Uterine Fibroids. Lancet. 2025;406(10498):91–102.
- ACOG Practice Bulletin No. 228. Management of Symptomatic Uterine Leiomyomas. Obstet Gynecol. 2021;137(6):e100–e115.