Uncomplicated term vaginal delivery following magnetic resonance-guided focused ultrasound surgery for uterine fibroids
Department of Academic Obstetrics and Gynaecology,
Imperial College, St. Mary�s Hospital, London, United Kingdom
A 35 year-old para 1+0 underwent MRgFUS per study protocol
for multiple uterine fibroids, the largest of which measured 5 cm. She
conceived 10 months following the procedure. The patient was induced at 41+6
weeks and underwent a normal vaginal delivery. � 2010 Biomedical Imaging
and Intervention Journal. All rights reserved.
Keywords: Magnetic resonance guided focused ultrasound
Magnetic Resonance-guided Focused Ultrasound Surgery
(MRgFUS) was developed as a non-invasive alternative to conventional surgical
techniques. It combines the use of high-powered ultrasound energy with Magnetic
Resonance (MR) technology for accurate visualisation, control and feedback,
allowing for safe thermo-ablation of tumours. The U.S. Food and Drug
Administration (FDA) approved the technology in 2004. Data supporting the
safety and efficacy of MRgFUS as an alternative treatment option for
symptomatic uterine fibroids have been published previously [1, 2].
MRgFUS offers several advantages for treating uterine
fibroids, in that it is a completely non-invasive, outpatient procedure that
requires minimal sedation and allows for a speedy recovery. Patients undergoing
MRgFUS typically return to work within 24 hours, compared with ten days after
Uterine Artery Embolisation (UAE) and 6 weeks after myomectomy or hysterectomy.
The initial FDA recommendation was that only women who had completed their
families should be treated with MRgFUS. However, with the advantage of
consistently good safety and efficacy results being reported, multi-centre
fertility studies were commenced and are on-going. These studies are recruiting
women with symptomatic uterine fibroids, who wish to become pregnant. The non-invasive
nature of ExAblate, whereby only the uterine fibroids undergo thermal ablation
with no damage to healthy surrounding tissue, suggests that MRgFUS should be a
safe approach for women who want to preserve their fertility.
A 39 year-old para 1+0 presented to the fibroid clinic at
the authors� hospital with a known diagnosis of fibroids made 3 years ago. The
patient�s first pregnancy resulted in a premature delivery at 28 weeks
(attributed to fibroids) of a 1.17kg female infant. She presented to the unit
with a history of fibroid-related menorraghia and urinary pressure symptoms
including frequency and nocturia. Symptoms were assessed using the Uterine
fibroid-specific quality of life Questionnaire (UFS-QOL) . The patient�s
baseline score was 65. The severity of symptoms is directly related to the
greatness of the score with a maximum score being 100.
In July 2006, a radiological MRI assessment deemed the
patient to be suitable for treatment with MRgFUS. She was enrolled in an
ongoing clinical trial of MRgFUS for treatment of symptomatic fibroids, where
the subjects consisted of women wishing to preserve their fertility. The
patient gave informed consent and fulfilled all eligibility criteria for the
The patient�s screening MRI (see fig.1) revealed an
enlarged fibroid uterus with an inferio-superior diameter of 13.5 cm. Five
fibroids were identified, the largest being a fundal posterior intra-mural
fibroid of 5 cm, as well as three other anterior intramural fibroids, and
a low anterior wall fibroid of 4.5 cm which distorted the endometrial cavity
posteriorly. All fibroids showed a hypo-intense signal as compared to
myometrial tissue on T2-weighted imaging.
The patient had a pre-treatment course of 3 GnRH analogue
s/c injections, of which the first was given on the first day of the cycle and
subsequent injections 28 days after the previous. She then underwent
MRgFUS treatment in October 2006. Immediate post-treatment contrast-enhanced
images revealed excellent results with approximately 90% non-perfusion of total
fibroid volume achieved.
The treatment did not produce any complications and the
patient was discharged on the same day. By 6 months post-procedure, the
patient had experienced almost complete resolution of her pre-treatment
symptoms, with her UFS-QOL score now 24. The patient conceived 4 months later,
with no antenatal problems noted at booking. All booking observations were
normal. An anomaly scan performed at 20 weeks gestation again revealed no
abnormalities. Serial sonography at 28, 32, 36 and 40 weeks demonstrated
appropriate foetal growth with cephalic presentation and an anterior placenta,
which was not low-lying. There were no myomata viable on the 40-week scan.
At 41 +6 weeks the patient was admitted for induction of
labour as she was past her due date. Labour was augmented by artificial rupture
of the membranes and lasted for 5 hours 8 minutes. Foetal monitoring throughout
was reassuring, and an uncomplicated vaginal delivery of a healthy female
infant with a birth weight of 3580gms was achieved. Apgar scores were 8 at 1
minute, 9 at 5 minutes and 9 at 10 minutes. In the institution at which the
patient delivered, cord gases are not routinely done for non-distressed
infants. No paediatrician was required at delivery.
At 6 months post-delivery, the patient continued to
maintain symptomatic improvement, with a QOL of 22. Contrast-enhanced MRI shows
persistent non-perfusion of all fibroids; in addition, there has been a
shrinkage in the overall uterine volume of 2.5 cm.
The relationship between leiomyomas and infertility
remains a subject for debate. The incidence of myomas in infertile women
without any obvious cause of infertility is estimated to be between 1% and 2.4%
. However, there are no studies that compare pregnancy rates in women with
and without fibroids, and the causal relationship seems to have been assumed
from case studies of women who have conceived after their fibroids were removed
A shift in cultural trends of women delaying pregnancy has
resulted in many women presenting with symptomatic fibroids at a stage when
preservation of the uterus is a priority. The National Office of Statistics in
the United Kingdom reports a 74% increase in the number of conceptions in the
40-44 age group in 2004, when compared to that of 1988 [?]. This has resulted
in a dilemma for the gynaecologist who is faced with providing an effective
solution to his patient�s fibroid symptoms, while ensuring no detrimental
effect on her fertility. The current standard of practice remains surgical in
the many forms of myomectomy (laparotomy, laparoscopy, hysteroscopy).
Despite myomectomy being the gold standard, few studies
agree on the actual increase in pregnancy rates following surgery, this being
described as anything from 44%-81%; however, all report a fall in the rate of
pregnancy loss [6-9].
Unfortunately fertility enhancement is not the only factor
to be considered when recommending treatment; complications related to fibroid
removal also have to be taken into account. During myomectomy, part of the
uterine wall is severed in order to enucleate the fibroid. This damage to the
wall is independent of the surgical technique used. Surgical sutures are placed
in order to control bleeding and close the severed uterine wall, which results
in a fibrotic scar. In addition to the resulting relative weakness of the
uterine wall post-surgery � which may result in the low but major risk of
uterine rupture during pregnancy/labour � adhesions can also form within the
abdomen, resulting in mechanical infertility.
A further point to be considered is the risk of
surgery-associated complications. Even if uncommon, intra-operative
complications, such as bladder, bowel, ureteral injury, severe bleeding and
unintended conversion to hysterectomy, have been reported. Moreover,
post-operative complications, such as fistula or thrombosis and embolism, may
also occur . The minimally invasive treatment option of UAE has increased
in popularity and reported pregnancies following treatment are plentiful.
Although most pregnancies following UAE have good outcomes, the risk of
pre-term delivery, spontaneous abortion, abnormal placentation and post-partum
haemorrhage, are increased following uterine artery embolisation compared to
myomectomy. This may be due to the resultant ischaemia, which not only occurs
in the fibroid, but the entire uterus. This ischaemia may result in chronic
weakness of the pregnant uterus. Uterine rupture has been reported with both
myomectomy and UAE.
Although both myomectomy and UAE are seen as effective and
safe treatment options for fibroids, the increase in pregnancy complications
seen with UAE means that patients desiring future fertility should be
recommended myomectomy as the treatment of choice over UAE.
With MRgFUS, heat ablation is limited to the core of the
fibroid and no damage to the surrounding uterine wall occurs. Real-time
monitoring of the volume of ablation enables limitation of the thermal damage
to a distinct targeted region of the fibroid as shown in pathology specimens
 and MR-contrast imaging. Accordingly, there arises the hypothesis that
MRgFUS may enable non-invasive treatment of uterine fibroids in women desiring
pregnancy, without compromise to the integrity of the uterus or increase in
�This out-patient procedure with minimal sedation
requirements and a speedy recovery time, allows patients to return to work
within 24 hours, compared to 10 days after UAE and 6 weeks with myomectomy.
Over 4000 women with symptomatic uterine fibroids have been treated worldwide.
Published studies have shown that up to 84.6% of women treated experienced
significant symptomatic improvement at 24 months post-treatment follow up .
However, initial FDA guidelines still recommend that only women who have
completed their families undergo this treatment, despite there having been
three published studies of achieved pregnancies following MRgFUS treatment
This paper describes the first pregnancy and successful
delivery in a woman who was part of a fertility trial and specifically treated
with MRgFUS for symptomatic fibroids that had caused a previous premature
delivery at 28 weeks.
Fertility data continues to accumulate and the results are
encouraging. MRgFUS appears to be a safe fertility-preserving treatment option
Figure 1 T2 weighted sagittal image prior to treatment. Maximum uterine dimension measuring 13.9cm, uterine volume of 509cc.
Figure 2 Contrast enhanced image showing non-perfusion of all fibroids, and overall shrinkage. Uterine volume now shrinking to 235cc.
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|Received 12 August 2009; received in revised form 21 January 2010, accepted 23 January 2010
Correspondence: Department of Academic Obstetrics and Gynaecology, Imperial College, St. Mary�s Hospital, Praed St., London W2 1NY, United Kingdom. Fax: +44 20788 7607; E-mail: firstname.lastname@example.org (Summia Zaher).
Please cite as: Zaher S, Lyons D, Regan L,
Uncomplicated term vaginal delivery following magnetic resonance-guided focused ultrasound surgery for uterine fibroids, Biomed Imaging Interv J 2010; 6(2):e28