Interventions in the Treatment of Infertility

Infertility affects about 15 million couples in the U.S. The etiologies of infertility are diverse, with male factors, female factors and combined male and female factors each accounting for about 1/3 of cases. Two causes of infertility that are potentially treatable by interventional radiological techniques are oligospermia due to varicocele, and proximal fallopian tube obstruction. Treatment of these conditions by interventional radiological techniques is highly efficacious, cost effective, and subjects the patient to minimal discomfort and inconvenience.

Varicocele Embolization

Varicocele is an important cause of male infertility accounting for 10 to 60% of cases. The pathophysiology of infertility due to varicocele is at least partially related to congestion of the pampiniform plexus and elevated scrotal temperature. However, it is likely that additional factors, perhaps hormonal, are involved. These factors result in oligospermia, abnormal sperm morphology, and impaired motility. Obliteration of the varicocele has been shown to improve sperm counts and morphology, and restore fertility in about 70% of cases.

Surgical ligation of the spermatic vein is successful in obliterating the varicocele in most patients, with recurrence rates of 3-25% due to opening of collateral venous channels. Embolization of the spermatic vein with balloons, coils, glue, or sclerosants is quite successful in both primary treatment and in recurrence following operative treatment. Embolization produces far more complete obliteration of the spermatic vein than can be achieved surgically, and recurrence is seen in less than 2% of patients. Fertility rates with embolotherapy are comparable to those obtained with surgical ligation.

Fallopian Tube Recannalization

Infertility in women who have normal ovulatory cycles is often due to disease of the fallopian tubes. Mid and distal tubal obstruction is most often due to pelvic inflammatory disease or endometriosis. Proximal tubal obstruction may occur in otherwise normal tubes, and is probably due to inspissated secretions or adhesions. Hysterosalpingography is used early in the infertility work-up of ovulating women in order to assess tubal patency. Interestingly, hysterosalpingography appears beneficial in itself since fertility in women with a normal study is improved following the procedure.

In cases where the hysterosalpingogram shows proximal tubal obstruction, and there is no history of endometriosis or PID, transcervical catheterization of the fallopian tube will often restore tubal patency. The procedure is done using a coaxial system made up of an 8 Fr. catheter placed through the cervix. An angled 5 Fr. catheter is used to localize the cornu, and a soft tip .015" guide wire is advanced into the mid or distal tube. A 3 Fr. catheter is passed over the guide until resistance is felt. The 5 Fr. catheter is then advanced into the proximal tube. The guide wire and 3 Fr. catheter are removed and contrast media is injected directly into the tube to flush out the debris and check for patency. Fallopian tube recannalization is technically successful in 80-90% of cases, and secondary fertility rates range from 60-90% at 1 year.

Embolization for Non-Surgical Treatment of Uterine Fibroids

Uterine fibroids are the most common pelvic tumors in women, occurring in approximately 30% of women over the age of 35. Although fibroids are benign, they may produce a wide variety of symptoms including excessive bleeding leading to iron deficiency anemia, pain and pressure sensations, and even obstruction of the bowel or urinary tract. Women with fibroids often complain of painful intercourse, and the presence of fibroids may result in pregnancy loss. Each year, approximately 200,000 hysterectomies are performed in the United States for uterine fibroids. Despite this large number of operations, the vast majority of women with symptomatic fibroids are "silent sufferers".

Until recently, the only effective treatments for fibroids were hormonal therapy and surgery. Because fibroids grow in response to the female hormone estrogen, anti-estrogen hormones such as progesterone can shrink fibroids and may result in dramatic improvement in symptoms. However, these hormones have many untoward side effects including menopausal symptoms, osteoporosis and hypercoagulability. Consequently, hormonal therapy can only be used for a short time and, unfortunately, once it is discontinued, symptoms usually return. Therefore, hormonal therapy is most useful in shrinking fibroids prior to surgery.

There are two general types of surgery available for fibroids, hysterectomy and myomectomy. Hysterectomy is the complete removal of the uterus with or without removal of the ovaries. In some cases hysterectomy can be performed through the vagina, avoiding an incision through the abdominal wall. However, with large fibroids, an abdominal hysterectomy is often necessary. Abdominal hysterectomy is a major surgical procedure requiring general anesthesia, approximately 6 days of hospitalization, and at least 6 weeks of recuperation. Obviously, pregnancy is no longer possible following a hysterectomy.

Myomectomy is an alternative surgical procedure for the treatment of fibroids. The object of myomectomy is to remove only the fibroid while leaving the uterus intact and preserving reproductive potential. Depending on the location and size of the fibroid, myomectomy may require an abdominal incision or may be done through a laparoscope or a hysteroscope. With larger fibroids, attempted myomectomy frequently results in hysterectomy due to uncontrollable bleeding in these highly vascular tumors. Even when successful, myomectomy offers only temporary improvement in about one-third of patients because smaller untreated fibroids continue to grow.

Embolization (embolotherapy) is a procedure used to block blood vessels from the inside. Embolotherapy is performed by Interventional Radiologists. For nearly thirty years, embolotherapy has been used as a means of stopping uncontrollable bleeding from the uterus due to cancer, vascular malformations, trauma, and complications of pregnancy. In the early 1990's, investigators in France began using embolotherapy of the uterine arteries to prevent excessive bleeding in women about to undergo myomectomy. A surprising and wholly unexpected result of these uterine artery embolization procedures was that many of the patients had such significant improvement in their symptoms that surgery was postponed. Over the course of months it became clear that the improvement noted in these women was not only significant, it was durable. Consequently, a pilot study was begun to evaluate the long-term results of uterine artery embolization for the primary treatment of fibroids.

In the initial pilot study, 85% of women undergoing uterine artery embolization experienced significant improvement or complete resolution of symptoms. In 75% of cases the size of the uterus decreased by 20-80% within 3 months, and these results remained stable with an average follow-up of more than 18 months (11 to 38 months). In a second study from UCLA, 77% of patients reported "significant improvement" or "complete resolution" of their dominant fibroid symptom at 2 to 9 months follow-up. In this group, 2-month follow-up revealed an average 40% (22-61%) reduction in uterine volume with the dominant fibroid decreased by an average of 58% in 55% of the patients studied. In one-third of the patients the fibroids were no longer visible by ultrasound.

On the basis of these studies, uterine artery embolization programs for the non-surgical treatment of fibroids have been established at several academic medical centers in the United States. The experience gained at these centers will optimize treatment protocols and provide in-depth answers to questions regarding the durability of symptomatic relief and preservation of reproductive function.

The uterine artery embolization procedure is performed by an Interventional Radiologist in the angiography suite. Although patients are awake for the procedure, they are sedated and often have no recollection of events during the embolization. The procedure itself consists of introduction of a catheter into an artery in either the left arm or the groin under a local anesthetic. Once in the artery the catheter is manipulated into the uterine arteries and angiography is performed. When the catheter is positioned well within the uterine artery, tiny pellets of PVA (polyvinyl alcohol) are injected under fluoroscopic control. The PVA is carried by blood flow into the uterus and all of the fibroids present. The particles eventually impact in the very small arteries and produce blockage. Deprived of their blood supply, the abnormal cells in the fibroids die and are slowly removed by normal physiologic processes. Meanwhile, the circulation to the normal tissue is restored both by the in-growth of new arteries and the resorption of a portion of the PVA from some of the existing vessels.

Immediately following the embolization procedure the catheter is removed and hemostasis is achieved by manual compression of the arterial entry site. Almost all patients experience crampy abdominal pain beginning within 30 to 60 minutes following the procedure. Consequently, we provide patients with on-demand pain medication via a patient controlled analgesia (PCA) pump. Many studies have demonstrated that patients experience far less pain, yet actually use far less pain medication when this device is used. Patients are admitted to the hospital overnight and can usually be discharged home the morning following the procedure. Most patients can return to work within a few days. At the current time, we ask patients to return for an ultrasound examination two weeks and two to three months after the procedure to assess results. The patient also is asked to complete a short mail-in questionnaire one year after embolization.