Outcome of unintended pregnancy after ultrasound-guided high-intensity focused ultrasound ablation of uterine fibroids

Achieving NPVR ≥ 80% as technical success of high-intensity focused ultrasound ablation for uterine fibroids: a cohort study

OBJECTIVE

To report the long-term re-intervention of patients with uterine fibroids after ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation and to analyse the influencing factors of re-intervention in patients in the NPVR ≥ 80% group.

MATERIALS AND METHODS

Patients with a single uterine fibroid who underwent USgHIFU at our hospital from January 2012 to December 2019 were enrolled. The patients were divided into four groups according to different nonperfusion volume ratio (NPVR). Kaplan-Meier survival curve was used to analyse long-term re-intervention in different NPVR groups, and Cox regression was used to analyse the influencing factors of re-intervention in the NPVR ≥ 80% group.

MAIN RESULTS

A total of 1,257 patients were enrolled, of whom 920 were successfully followed up. The median follow-up time was 88 months, and the median NPVR was 85.0%. The cumulative re-intervention rates at 1, 3, 5, 8 and 10 years after USgHIFU were 3.4%, 11.8%, 16.8%, 22.6% and 24.1%, respectively. The 10-year cumulative re-intervention rate was 37.3% in the NPVR < 70% group, 31.0% in the NPVR 70-79% group, 18.2% in the NPVR 80-89% group and 17.8% in the NPVR ≥ 90% group (P < 0.05). However, no difference was found between the group of NPVR 80-89% and the group of NPVR ≥ 90% (P = 0.499). Age of patients and signal intensity on T2-weighted imaging (T2WI) of tumours were found to be independent risk factors for long-term re-intervention in the NPVR ≥ 80% group. A younger age and greater signal intensity on T2W images corresponded to a greater risk of re-intervention.

CONCLUSION

USgHIFU, an alternative treatment for uterine fibroids, has reliable long-term efficacy. NPVR ≥ 80% can be used as a sign of technical success, which can reduce re-intervention rates. However, an important step is to communicate with patients in combination with the age of patients and the signal intensity on T2WI of fibroids.

TRIAL REGISTRATION

This retrospective study was approved by the ethics committee at our institution (Registration No. HF2023001; Date: 06/04/2023). The Chinese Clinical Trial Registry provided full approval for the study protocol (Registration No. CHiCTR2300074797; Date: 16/08/2023).

Reproductive and Obstetric Outcomes after UAE, HIFU, and TFA of Uterine Fibroids: Systematic Review and Meta-Analysis

Novel treatment options for uterine fibroids, such as uterine artery embolization (UAE), ultrasound-guided and magnetic resonance-guided high-intensity focused ultrasound (USgHIFU and MRgHIFU), and transcervical radiofrequency ablation (TFA) methods, are widely used in clinical practice. This systematic review and meta-analysis (CRD42022297312) aims to assess and compare reproductive and obstetric outcomes in women who underwent these minimally invasive approaches for uterine fibroids. The search was performed in PubMed, Google Scholar, ScienceDirect, Cochrane Library, Scopus, Web of Science and Embase. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and Cochrane guidelines. The articles were selected to meet the following eligibility criteria: (1) research article, (2) human subject research, and (3) the study of pregnancy outcomes after the treatment of uterine fibroids by either one of three methods-UAE, HIFU, and TFA. The analysis of 25 eligible original articles shows a similar rate of live births for UAE, USgHIFU, MRgHIFU, and TFA (70.8%, 73.5%, 70%, and 75%, respectively). The number of pregnancies varied considerably among these studies, as well as the mean age of pregnant women. However, the results of pregnancy outcomes for TFA are insufficient to draw firm conclusions, since only 24 women became pregnant in these studies, resulting in three live births. The miscarriage rate was highest in the UAE group (19.2%). USgHIFU was associated with a higher rate of placental abnormalities compared to UAE (2.8% vs. 1.6%). The pooled estimate of pregnancies was 17.31% to 44.52% after UAE, 18.69% to 78.53% after HIFU, and 2.09% to 7.63% after TFA. The available evidence confirmed that these minimally invasive uterine-sparing treatment options for uterine fibroids are a good approach for patients wishing to preserve their fertility, with comparable reproductive and obstetric outcomes among the different techniques.

HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment

OBJECTIVES

To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU.

MATERIALS AND METHODS

A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU.

RESULTS

In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039).

CONCLUSIONS

HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.

Comparison of pregnancy outcomes in infertile patients with different types of adenomyosis treated with high-intensity focused ultrasound

OBJECTIVE

This study assessed the improvement of symptoms and pregnancy outcomes in infertile patients with various types of adenomyosis who were treated with high-intensity focused ultrasound (HIFU).

MATERIALS AND METHODS

Between October 2017 and January 2022, 129 infertile patients with adenomyosis who wished to conceive were treated with HIFU. Based on the relationship between the adenomyotic lesion, the endometrium, and the subserosa of the uterus on magnetic resonance imaging, the adenomyotic lesions were divided into internal, external, intramural, and full-thickness types. Menstruation pain score, menstruation blood volume score, anti-Müllerian hormone (AMH) levels, reproductive results, pregnancy and delivery complications, and other clinical variables were compared among these four groups.

RESULTS

Patients with external adenomyosis had the greatest menstrual distress, whereas patients with internal adenomyosis had the greatest menstrual blood volume. Dysmenorrhea and heavy menstruation were significantly improved after HIFU treatment in all groups. AMH levels were not significantly different before and six months after HIFU. Of the 129 patients, 50 (38.7%) became pregnant after HIFU, and patients with internal adenomyosis had the highest pregnancy rate. Patients with adenomyotic lesions located in the posterior wall of the uterus had a higher pregnancy rate than those with lesions located in the fundus of the uterus.

CONCLUSIONS

The classification of adenomyosis is closely related to distinctions in clinical symptoms and pregnancy outcomes. Infertile patients with different types of adenomyosis could be effectively treated with HIFU. HIFU can be considered as an option for infertile patients with adenomyosis who want to maintain their fertility.

Tolerance and efficacy of HIFU ablation for uterine fibroids NPVR ≥ 90%: a nested case-control study

OBJECTIVE

To investigate the tolerance and efficacy of HIFU ablation for uterine fibroids with a non-perfused volume ratio (NPVR) ≥ 90%.

METHODS

A prospective cohort study of 2411 patients from 20 clinical centers was available. Contrast-enhanced MRI was used to assess the non-perfused volume ratio (NPVR). The International Society of Interventional Radiotherapy (SIR) complication grading system was used as the tolerance index. Uterine Fibroids-related Symptoms-Quality of Life (UFS-QoL) was used to evaluate the efficacy.

RESULTS

A total of 1352 patients underwent USgHIFU ablation treatment enrolled, NPVR was median 91.9% (IQR, 81.4%,100.0%). There was 761 case (56.3%) in the NPVR ≥ 90% group in which 17.5% case experienced SIR-B abdominal pain, 591 cases (43.7%) in NPVR < 90% group in which 9.3% case had SIR-B abdominal pain. There were statistically differences in the improvement degree of UFS at 12 months among the four subgroups (NPVR < 70%, 70%-80%, 80%-90%, 90%-100%) (all p < 0.05).

CONCLUSIONS

Patients with NPVR ≥ 90% had a higher incidence of SIR-B lower abdominal pain. NPVR was positively correlated with the degree of symptom relief at 12 months, and NPVR ≥ 90% was more likely to obtain better clinical symptom relief.

How to boost an obstetrician's confidence in vaginal delivery after high-intensity focused ultrasound: a comparison study on delivery outcomes

OBJECTIVE

To assess the feasibility of vaginal delivery after HIFU.

METHODS

A total of 37 women who met the trial of labor after HIFU (TOLAH) inclusion criteria and 368 women who met the trial of labor after cesarean delivery (TOLAC) inclusion criteria gave birth at Shanghai First Maternity and Infant Hospital between 14^th June 2018 and 24^th September 2021. The delivery outcomes of the two groups were compared. Multivariable logistic regression analysis was used to estimate the adjusted risk of postpartum hemorrhage (PPH).

RESULTS

In the Qualified Candidates for TOLAH group, vaginal delivery is substantially less common (p = 0.000). The prevalence of PPH in the Qualified Candidates for TOLAH group is lower than in the Candidates for TOLAC group (8.82% vs 10.51%, p = 0.534; 0% vs 2.51%, p = 0.418). Hemoglobin drop in the Qualified Candidates for TOLAH group is also lower (7.03 ± 7.39vs 12.11 ± 12.62, p = 0.001). The rate of using more than two types of uterotonic medications to promote contraction is significantly lower in the Qualified Candidates for TOLAH group (54.05% vs 69.84%, p = 0.04), and the percentage of abnormal uterine contraction is lower in the Qualified Candidates for TOLAH group (35.14% vs 49.18%, p = 0.072). PPH is strongly predicted by abnormal uterine contraction (aOR: 17.177, 95% CI:5.046 ∼ 58.472, p = 0.000), but not by HIFU (aOR:1.105; 95% CI:0.240 ∼ 5.087, p = 0.898). No uterine rupture occurred in the cases after HIFU.

CONCLUSIONS

No uterine rupture occurred in our study group after HIFU. HIFU is not a risk for PPH. It is promising for those after HIFU to choose vaginal delivery.

Physician Experience in Technical Success of Achieving NPVR ≥ 80% of High-Intensity Focused Ultrasound Ablation for Uterine Fibroids: A Multicenter Study

Objective

To evaluate the experience of the physician of the technical success in high-intensity focused ultrasound (HIFU) ablation of uterine fibroids with a nonperfused volume ratio (NPVR) of at least 80%.

Methods

Patients from a 20-center prospective study were enrolled in this study. In this study, among the 20 clinical centers, five centers had physician with >3 years of HIFU experience, and the other 15 centers initiated HIFU therapy <3 years, were defined as the experienced group and the inexperienced group, respectively. Technical success was defined as achieving NPVR ≥ 80% of uterine fibroids with no major complications and it was defined as the successful group; otherwise, it was defined as the unsuccessful group.

Results

A total of 1,352 patients were included at the age of 41.32 ± 5.08 years. The mean NPVR (87.48 ± 14.91%) was obtained in the inexperienced group (86.50 ± 15.76%) and in the experienced group (89.21 ± 13.12%), respectively. The multivariate analysis showed that the volume of uterus, location of fibroids, and physician experience were significantly correlated with technical success (p < 0.05). In the experienced group, 82.20% of uterine fibroids obtained NPVR ≥ 80%, compared with 75.32% in the inexperienced group, and the difference was significant (p = 0.003). The technical success rate of the experienced group was 82.00% which was higher than 75.20% of the inexperienced group (p = 0.004).

Conclusion

In technical success of achieving NPVR ≥ 80%, experience of the physician was positively correlated with technical success; NPVR and major complications for the inexperienced group were comparable to those of the experienced group from a clinical perspective; inexperienced physicians could reach NPVR ≥ 80% of sufficient ablation and were trustworthy in efficacy. Smaller uterus and fibroids of anterior wall were correlated with better technical success; experienced physicians still have better technical success when choosing patients with larger uterus, contributing to clinical decision-making and patient referral.

A comparative analysis of pregnancy outcomes of patients with uterine fibroids after high intensity focused ultrasound ablation and laparoscopic myomectomy: a retrospective study

PURPOSE

The aim of this study was to retrospectively compare and analyze pregnancy outcomes of patients with uterine fibroids after high intensity focused ultrasound (HIFU) ablation and laparoscopic myomectomy (LM).

MATERIALS AND METHODS

The study group consisted of 346 patients with uterine fibroids who wished to conceive, in which 152 patients received HIFU ablation treatment (HIFU group) and 194 patients received LM treatment (LM group). The parents' baseline characters were recorded and the pregnancy outcomes were evaluated in a median follow-up time of 42 months (range: 16 ∼ 81) after the treatment, and the differences of the two groups were compared.

RESULTS

Patients with uterine fibroids in HIFU group had a significant shorter pregnancy interval than that in LM group (10 months VS. 13 months, p < .05). No significant differences were observed in pregnancy rate, miscarriage rate, live birth rate, natural pregnancy rate, cesarean section rate, and perinatal complications rate between the HIFU group and the LM group (p > .05). When stratified by age, infertility history, fibroid types, fibroid numbers, and fibroid sizes, there was no statistically significant difference in pregnancy rate between the HIFU group and the LM group (p > .05).

CONCLUSIONS

Based on the results from this study, both HIFU and LM can be safely used to treat patients who wish to conceive. The pregnancy outcomes of post-HIFU are similar to that of post-LM.

A comparison of the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound ablation and laparoscopic myomectomy for uterine fibroids: a comparative study

Objective: To compare the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation and laparoscopic myomectomy (LM).Materials and methods: This study included 676 women with symptomatic uterine fibroids who wished to become pregnant underwent USgHIFU or LM at three hospitals in China from 1 May 2009 to 31 May 2018. The related information of pregnancy and delivery were followed up and analyzed using the chi-square test and two-sided Student t-test.Results: The median follow-up duration was 5 (1-8) years; 20 patients (2.9%) were lost to follow-up. 320 patients were treated with UsgHIFU, and 336 were treated with LM. Two hundred nineteen (68.4%) women became pregnant after USgHIFU ablation, and 224 (66.7%) became pregnant after LM. Four hundred forty-three patients had 501 pregnancies (natural pregnancies, 405; in vitro fertilisation-embryo transfer pregnancies, 38). Average times to pregnancy were 13.6 ± 9.5 months after USgHIFU and 18.9 ± 7.3 months after LM (p < 0.05). The rate of cesarean delivery was lower in the USgHIFU group (41.6%) than in the LM group (54.9%) (p < 0.05). Incidences of placenta increta, placenta previa, and postpartum hemorrhage were low after USgHIFU compared with after LM. Incidences of preterm birth, fetal distress, fetal growth restriction, and puerperal infection were higher after USgHIFU than after LM. There was a risk of uterine rupture after both procedures.Conclusions: Compared with LM, USgHIFU ablation can significantly shorten the time to pregnancy, although pregnancy rates of the two procedures are similar. Some risks in pregnancy and delivery after HIFU should be evaluated and monitored.

Systematic review of reproductive outcomes after High Intensity Focused Ultrasound treatment of uterine fibroids

PURPOSE

Myomectomy is currently the gold standard for the treatment of uterine fibroids in women who desire pregnancy. However, this surgical fibroid removal has a long convalescence. Promising alternatives may be non-invasive High Intensity Focused Ultrasound (HIFU) under either MRI (MR-HIFU) or ultrasound guidance (USgHIFU). In this systematic review, an overview is provided of reproductive outcomes after these two relatively new ablation techniques.

METHOD

A systematic literature search was performed to identify studies reporting reproductive outcomes after HIFU treatment of fibroids. Only peer reviewed, full papers were included. Outcomes included pregnancy-, live-birth- miscarriage and caesarian section rate, time to conceive, reported complications, and possible prognostic factors.

RESULTS

In total 21 studies were included. Fourteen studies reported 124 pregnancies after MR-HIFU. Two placenta previas and no uterus ruptures were reported. Pregnancy rates were only retrospectively collected and ranged between 7% and 36%. Miscarriage rate in the oldest and largest prospective registry was 39%. After USgHIFU 366 pregnancies were reported with one fetal intrauterine death, six placenta previas and no uterus ruptures. The only prospective study reported a pregnancy rate of 47% and a miscarriage rate of 11%. Possible prognostic factors like age were not available in most studies.

CONCLUSIONS

Based on the heterogeneous data currently available, reproductive outcomes after HIFU appear non-inferior to outcomes after the current standard of care. However, a (randomized) controlled trial comparing reproductive outcomes after HIFU and standard care is necessary to provide sufficient evidence on the preferred fibroid treatment for women with a pregnancy wish.

Outcomes of subsequent pregnancies in patients following treatment of cesarean scar pregnancy with high intensity focused ultrasound followed by ultrasound-guided dilation and curettage

Objective: To evaluate the outcomes of subsequent pregnancies in patients with a history of cesarean scar pregnancy (CSP) treated with high intensity focused ultrasound (HIFU) followed by ultrasound-guided dilation and curettage (USg-D&C). Methods: A retrospective analysis was performed on data collected from 154 patients with CSP who were treated by HIFU followed by USg-D&C in Suining Central Hospital between January 2015 and January 2018. Among them, 28 patients wanted to conceive following treatment. Baseline characteristics, treatment results, intraoperative hemorrhages during USg-D&C, post-curettage serum beta human chorionic gonadotropin (β-hCG) levels and vaginal bleeding were investigated. Subsequent pregnancy outcomes, including intervals between pregnancy and treatment of CSP, complications during pregnancy, and outcomes of newborns were evaluated. Results: All patients with CSP were successfully treated by HIFU combined with USg-D&C. Of the 28 CSP patients who intended to conceive after the treatment, 23 patients (82.14%) successfully conceived. The average interval between conception and HIFU treatment was 18.38 ± 10.04 months. Eighteen patients (78.26%) had an intrauterine pregnancy, in which 12 had delivery by cesarean section, 1 had an ongoing pregnancy, and 5 had an abortion in the first trimester. Among the other 5 women, 3 had tubal ectopic pregnancy and 2 had recurrent CSP. These five patients underwent laparoscopy within the first trimester. Conclusion: HIFU followed by USg-D&C is an effective and safe treatment for patients with CSP who wish to conceive. Prospective multi-center studies with larger sample sizes and longer follow-up periods are needed to compare this treatment with others.

Safety and Efficacy of Ultrasound-Guided High-Intensity Focused Ultrasound Treatment for Uterine Fibroids and Adenomyosis

The objective of this study was to assess the tolerability and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation using a Haifu JC Focused Ultrasound Tumor Therapeutic System (operating transducer frequency: 0.8 MHz, 300-400 W/cm²) under real-time ultrasound guidance (2.5- to 5.0-MHz imaging probe) for uterine fibroids and adenomyosis in 1807 patients (928 with fibroids and 889 with adenomyosis). Volume change and clinical symptom improvement after treatment were evaluated based on symptom severity scores and health-related quality of life scores using the Uterine Fibroid Symptom and Quality of Life questionnaires. At 3, 6 and 12 mo after treatment, symptom severity scores and health-related quality of life scores and reductions in volumes of uterine adenomyosis and fibroids all revealed good effects. The complication rate was 4.6% (84/1807). With supportive care, all complications resolved without any permanent adverse effects. Thus, USgHIFU is an effective, non-invasive modality for treating uterine fibroids and adenomyosis with manageable complications.

Efficacy and safety of ultrasound-guided high-intensity focused ultrasound for uterine fibroids: a preliminary experience

The objective of this prospective cohort study was to evaluate the therapeutic efficacy and safety of ultrasound-guided high-intensity focussed ultrasound (HIFU) in the treatment of uterine fibroids. Twenty premenopausal women with symptomatic fibroids underwent ultrasound-guided HIFU therapy. Twenty-two fibroids with a median baseline volume of 127.0 cm³ (range 18.5-481.2 cm³) were treated. The percentages fibroid volume reduction were 46.9 (range -8.8-73.1) at 1-month, 57.4 (-51.5-95.2) at 3-month, 60.1 (-18.9-97.8) at 6-month and 75.9 (-33.7-99.3) at 12-month, after treatment. The modified Uterine Fibroid Symptom and Quality of Life (UFS-QOL) scores were reduced by 40.7% (0-59.3%) at 3-month, 45.5% (0-70.4%) at 6-month and 44.9% (0-71.4%) at 12-month after treatment. Three patients required subsequent surgical interventions. No significant complications were encountered. Ultrasound-guided HIFU appears to be effective and safe for the treatment of symptomatic uterine fibroids in selected patients. Impact statement What is already known on this subject? Ultrasound-guided high-intensity focussed ultrasound (HIFU) is a relatively new uterine-sparing treatment for fibroids. Most clinical reports are from China, which suggest that this treatment is a safe and effective modality. However, in many other countries, HIFU treatment for fibroids, especially using ultrasound as image guidance, is still considered novel with limited clinical experience. What do the results of this study add? This preliminary report adds to our limited local experience on HIFU and provides reassurance on our continual utilisation of this treatment modality for fibroids. With the increasing demand of uterine-sparing alternatives, experiences shared among different countries are important to make this treatment modality generalisable and universally acceptable. What are the implications of these findings for clinical practice and/or further research?Ultrasound-guided HIFU (USgHIFU) can potential be offered as an alternative treatment modality for women with fibroids.

Normal spontaneous vaginal delivery after transcervical radiofrequency ablation of uterine fibroids: a case report

Transcervical radiofrequency ablation of uterine fibroids was performed on a patient in Germany, who subsequently conceived. This is the first report of a normal spontaneous vaginal delivery after fibroid ablation with the Sonata^® System.

Pilot study: safety and effectiveness of simple ultrasound-guided high-intensity focused ultrasound ablating uterine leiomyoma with a diameter greater than 10 cm

OBJECTIVE

The study aimed to prospectively investigate whether uterine leiomyoma greater than 10 cm in diameter could be treated with simple ultrasound-guided high-intensity focused ultrasound (USgHIFU) in one-time treatment.

METHODS

A total of 36 patients with 36 symptomatic uterine leiomyoma greater than 10 cm in diameter who underwent simple USgHIFU treatment alone were analysed. Enhanced MRI was performed before and after HIFU treatment, and all patients had follow-up for 6 months after treatment. Symptom severity scores, treatment time, treatment speed, ablation rate, energy effect ratio, uterine leiomyoma regression rate, adverse events, liver and kidney functions, coagulation function and routine blood count were included in the study endpoints.

RESULTS

The mean diameter of uterine leiomyoma was 11.2 ± 1.3 cm (10.0-14.3 cm). The median treatment time and treatment speed were 104.0 min (90.0-140.0 min) and 118.8 cm³ h^-1 (86.2-247.1 cm³ h^-1), respectively. The ablation rate of uterine leiomyoma was 71.9 ± 20.4% (32.1-100.0%), and the regression rate of uterine leiomyoma was 40.8 ± 7.5% (25.6-59.9%) at 6 months after treatment. The mean symptom severity scores decreased by an average of approximately 8.6 ± 2.3 (5-14) points. There were no significant changes in haemogram and blood chemical indexes of patients, except for the transient elevation of aspartate aminotransferase, total bilirubin and white blood cells after treatment. No serious adverse reactions occurred.

CONCLUSION

According to our preliminary results, simple USgHIFU is a safe and effective single-treatment method of treating uterine leiomyoma greater than 10 cm in diameter and is an almost innocuous alternative therapeutic strategy. Advances in knowledge: The conclusions indicate simple USgHIFU is safe and effective as one-time treatment of uterine leiomyoma greater than 10 cm in diameter, it could be a promising therapeutic strategy.

Pregnancy outcomes in nulliparous women after ultrasound ablation of uterine fibroids: A single-central retrospective study

To explore the impact of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids in nulliparous women on subsequent pregnancy and delivery. A retrospective analysis was conducted of nulliparous women who received HIFU treatment at Chongqing Medical University, Chongqing,China, from January 1, 2010, to January 1, 2015. A total of 189 cases were enrolled, the median follow-up time was three years. Among them,there were 131 cases pregnancy with a total of 133 times,the pregnancy rate was 69.3% (131/189),and the spontaneous conception rate was 95.4% (125/131). Of 131 pregnant women, 19 were on-going pregnancy, terminated pregnancy 114 times,which include 93 times successfully delivery with a 76.3% (87/114) full-term birth rate,and the cesarean section rate was 72.0% (67/93). Of 94 newborns,the average birth weight was (3.3 ± 0.4)kg (range:1.5–4.8 kg), and a pair of them were identical twins. The incidence of complications during pregnancy and delivery were 10.8% (10/93) and 7.5% (7/93),respectively,except one woman failed on-going pregnancy and one woman suffered hysterectomy due to the complications,others all successful pregnant and delivered. Multiple-factor regression analysis found that age and infertility history were the important factors that may affect pregnancy after HIFU (P < 0.01). Nulliparous women who undergo HIFU treatment for uterine fibroids can subsequently have successful pregnancy and delivery safely.

Preservation of the endometrial enhancement after magnetic resonance imaging-guided high-intensity focused ultrasound ablation of submucosal uterine fibroids

OBJECTIVE

To evaluate the integrity of endometrial enhancement after magnetic resonance imaging-guided high-intensity focused ultrasound (MR-HIFU) ablation of submucosal uterine fibroids based on contrast-enhanced MRI findings, and to identify the risk factors for endometrial impairment.

METHODS

In total, 117 submucosal fibroids (diameter: 5.9 ± 3.0 cm) in 101 women (age: 43.6 ± 4.4 years) treated with MR-HIFU ablation were retrospectively analysed. Endometrial integrity was assessed with contrast-enhanced T1-weighted images at immediate (n = 101), 3-month (n = 62) and 12-month (n = 15) follow-ups. Endometrial impairment was classified into grades 0 (continuous endometrium), 1 (pin-point, full-thickness discontinuity), 2 (between grade 1 and 3), or 3 (full-thickness discontinuity >1 cm). Risk factors were assessed with generalized estimating equation (GEE) analysis.

RESULTS

Among 117 fibroids, grades 0, 1, 2 and 3 endometrial impairments were observed at initial examination in 56.4%, 24.8%, 13.7% and 4.3%, respectively. Among 37 fibroid cases of endometrial impairment for which follow-ups were conducted, 30 showed improvements at 3- and/or 12-month follow-up. GEE analysis revealed the degree of endometrial protrusion was significantly associated with severity of endometrial injury (P < 0.0001).

CONCLUSIONS

After MR-HIFU ablation of submucosal fibroids, endometrial enhancement was preserved intact or minimally impaired in most cases. Impaired endometrium, which is more common after treating endometrially-protruded fibroids, may recover spontaneously.

KEY POINTS

• After MR-HIFU ablation for submucosal fibroid, endometrium is mostly preserved/minimally impaired. • Endometrial-protruded submucosal fibroid is susceptible to more severe endometrial impairment. • The impaired endometrium may recover spontaneously at follow-up MR exams.

A New Paradigm for Uterine Fibroid Treatment: Transcervical, Intrauterine Sonography-Guided Radiofrequency Ablation of Uterine Fibroids with the Sonata System

Purpose of Review

This article provides the current evidence related to transcervical radiofrequency ablation of uterine fibroids under integrated intrauterine sonography guidance (the Sonata System).

Recent Findings

Published data on the treatment of fibroids with the Sonata System has demonstrated significant median reductions in total (73.3%) and perfused (73.3%) uterine fibroid volume, menstrual bleeding (72.3%), symptom severity (62.5%), and improvements in health-related quality of life (127%) at 12 months post-ablation. A clinical trial under an FDA Investigational Device Exemption is in progress.

Summary

The Sonata System is a promising treatment modality for uterine fibroids. As an incisionless, minimally invasive treatment that does not require general anesthesia or hospitalization, it has the potential for redefining the current paradigm for management of symptomatic fibroids.

Review of nonsurgical/minimally invasive treatments and open myomectomy for uterine fibroids

PURPOSE OF REVIEW

The main purpose of this review is to collect the most recent evidence with regards to safety and effectiveness of the nonsurgical and minimally invasive treatment options for uterine fibroids.

RECENT FINDINGS

Among the nonsurgical options, uterine artery embolization (UAE), and in eligible patients, magnetic resonance-guided high-intensity focused ultrasound (MRgFUS) are emerging as effective alternatives to surgical options for treatment of symptomatic fibroids. MRgFUS is comparable to UAE, and appears to be a cost effective treatment option, especially in older women, although long-term data are awaited. The transvaginal route for radiofrequency ablation is a promising new nonsurgical alternative, which needs to be studied in larger trials to establish its safety and efficacy.The laparoscopic myomectomy results in less postoperative pain, reduced febrile morbidity, and shorter hospital stay when compared with open laparotomy. The newer robotic approach is comparable to traditional laparoscopic technique in short surgical outcomes but is associated with higher costs. Hysteroscopic myoma resection is an effective surgical intervention for submucous fibroids and prior misoprostol use can help in reducing cervical lacerations.

SUMMARY

UAE and MRgFUS can be offered as an alternative nonsurgical option for eligible women with symptomatic fibroids. Laparoscopic myomectomy remains a safe and effective surgical option with advantage of less postoperative pain and faster recovery compared with open laparotomy for women who wish to retain their fertility options.

Effects of High-Intensity-Focused Ultrasound Treatment on Benign Uterine Tumor

In this study, the effects of high-intensity-focused ultrasound (HIFU) treatment on benign uterine tumor patients were examined. A total of 333 patients diagnosed with fibroids or adenomyosis using diagnostic sonography, treated with HIFU between February 4, 2010 and December 29, 2014 at a hospital in Korea, and followed up for three or six months were selected for this study. Their benign uterine tumor volume was measured, and the effects of HIFU treatment on the volume were analyzed according to age, disease, fertility, and treatment duration. The volume of benign tumors of the uterus changed by age in all age groups after conducting HIFU treatment for 3 and 6 months, respectively. The rate of decrease in individuals' in their twenties was the largest, at 64.9%. When the decreasing volume of benign tumors of the uterus was analyzed by type of disease, the treatment efficacy for adenomyosis was the best, with a decrease of 164.83 cm(3) after 6 months. Myoma had the fastest decreasing rate, at 68.5%. When evaluated on the basis of fertility, the volume of benign tumors of the uterus continued to decrease until 6 months after completing all procedures. The volume has continued to decrease for 6 months after all procedures. This study showed that HIFU treatments for uterine fibroid and adenomyosis is an effective non-invasive therapy via reducing the benign uterine tumor volume. Therefore, the HIFU method might replace other conventional treatment methods.

Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy

Minimally invasive treatment options are an important part of the uterine fibroid-treatment arsenal, especially among younger patients and in those who plan future pregnancies. This article provides an overview of the currently available minimally invasive therapy options, with a special emphasis on a completely noninvasive option: magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we describe the background of MRgFUS, the patient-selection criteria for MRgFUS, and how the procedure is performed. We summarize the published clinical trial results, and review the literature on pregnancy post-MRgFUS and on the cost-effectiveness of MRgFUS.

Safety of ultrasound-guided ultrasound ablation for uterine fibroids and adenomyosis: A review of 9988 cases

OBJECTIVE

To evaluate the incidence and severity of adverse reactions to ultrasound-guided ultrasound ablation of uterine fibroids through a multicenter, large-scale retrospective study.

METHODS

Between July 2006 and June 2007, 9988 patients with uterine fibroids or adenomyosis were enrolled and received ultrasound ablation treatment under conscious sedation. Forty-two doctors administrated the treatment following a standardized clinical protocol. In-treatment and post-treatment side effects and complications were monitored and each patient was followed up for at least 6 months after the treatment. Complications were classified and graded according to the SIR classification system. The technical success and safety of the treatment were evaluated.

RESULTS

The mean age of the 9988 patients was 40.4±5.8 years (range, 20-56 years). Among them, 7438 had uterine fibroids and 2549 had adenomyosis. Specifically, 6545 patients had solitary uterine fibroid, 818 had multiple uterine fibroids, and 76 had fibroids complicated with adenomyosis. There were mainly three types of fibroids: submucous myoma in 89 patients (12.0%), intramural myoma in 5059 patients (68.0%) and subserosal myoma in 1478 patients (20.0%). In terms of fibroid location, 3496 fibroids were found in the anterior wall (47.0%), 2306 in the posterior wall (31.0%), 447 in the lateral wall (6.0%), and 1190 in fundus (16.0%). The length of treatment for uterine fibroids and adenomyosis averaged 84.2±38.8 min (range, 30.0-240.0 min) and 93.3±55.4 min (range, 15.0-240.0 min), respectively; and the lengths of sonication were 1243.8±725.2 s (range, 506.0-2658.0 s) and 1169.7±707.7 s (range, 185.0-3600.0 s), respectively. Of the uterine fibroids patients, 98.38% (7319/7439) underwent successful ablation with a mean volume ablation rate of 83.1%±15.6% (range, 25-100%). Of the adenomyosis patients, 94.59% (2411/2549) underwent successful ablation with a mean volume ablation rate of 73.2%±23.6% (range, 21-100%). A total of 1062 patients (10.6%) presented with 1305 events of adverse reactions. According to the SIR classification system, 1228 (94.1%) of these reactions fell under Class A; 45 (3.4%) fell under Class B; 24 (1.8%) fell under Class C; and the rest 8 (0.6%) fell under Class D. Adverse reactions included 874 cases (8.67%) of vaginal secretion, 225 cases (2.23%) of lower abdominal pain 24h after the treatment but requiring no painkillers, 76 cases (0.76%) of melosalgia or buttock pain, 52 cases (0.52%) of odynuria, 20 cases (0.20%) of menstruation-like vaginal bleeding, 2 cases (0.2%) of temporary blurred vision, 26 cases (0.26%) of blisters or tangerine pericarp-like burns in the abdominal skin, 16 cases (0.16%) of urinary retention, 4 cases (0.4%) of fever of 38.5°C, 3 cases (0.3%) of acute renal insufficiency, 2 cases (0.2%) of intestinal perforation, and 1 case (0.01%) of long-term lateral ventral syndrome. No permanent injury or fatal complication occurred.

CONCLUSIONS

Based on our observations from 9988 cases, ultrasound ablation treatment for uterine fibroid and adenomyosis is highly effective and safe. Adverse reactions to ultrasound ablation under conscious sedation are slight and temporary for both conditions. Hence, this clinically effective and safe treatment is an alternative treatment for women with uterine fibroids and adenomyosis.

Ultrasound-guided high-intensity focused ultrasound treatment for uterine fibroid & adenomyosis: A single center experience from the Republic of Korea

OBJECTIVES

This study aimed to assess the therapeutic outcomes of patients with uterine fibroid or adenomyosis treated by ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation at Incheon Christian Hospital, Korea.

METHODS

This study included 618 patients, of which 272 suffered from uterine fibroid and 346 suffered from adenomyosis. Treatment was administrated using the Model Haifu JC Focused Ultrasound Tumor Therapeutic System (Chongqing Haifu Technology, Chongqing, China) under real-time ultrasound guidance. A follow-up was conducted on volume change as well as on symptom improvement using the Symptom Severity Score (SSS) and Uterine Fibroid Symptom and Quality of Life (UFS-QOL) after treatment.

RESULT

The uterine fibroid volume reduction rates (%) were 58.08%, 66.18%, and 77.59% at 3, 6, and 12 months after treatment, respectively. The SSS reduction rates (%) were 55.58%, 52.76%, and 50.39% by 3, 6, and 12 months, respectively. The UFS-QOL score increasing rates (%) were 42.66%, 43.50%, and 43.45% by 3, 6, and 12 months, respectively. The uterine volume reduction rates (%) for adenomyosis were 43.99%, 47.01%, and 53.98% by 3, 6, and 12 months, respectively. The SSS reduction rates (%) for adenomyosis were 55.61%, 52.38%, and 57.98% by 3, 6, and 12 months, respectively. The UFS-QOL score increasing rates (%) for adenomyosis UFS-QOL score were 80.06%, 69.39%, and 85.07% by 3, 6, and 12 months, respectively.

CONCLUSION

We conclude that USgHIFU treatment for uterine fibroid and adenomyosis is an effective non-invasive therapy via the assessment of fibroid volume reduction, symptom improvement, UFS-QOL score increase, and acceptable level of side effects. Although preliminary experience of HIFU is encouraging, well-designed prospective trials and more clinical experiences are needed to ascertain the efficacy and safety of this new treatment.

An Ultrasound Image-Based Dynamic Fusion Modeling Method for Predicting the Quantitative Impact of In Vivo Liver Motion on Intraoperative HIFU Therapies: Investigations in a Porcine Model

Organ motion is a key component in the treatment of abdominal tumors by High Intensity Focused Ultrasound (HIFU), since it may influence the safety, efficacy and treatment time. Here we report the development in a porcine model of an Ultrasound (US) image-based dynamic fusion modeling method for predicting the effect of in vivo motion on intraoperative HIFU treatments performed in the liver in conjunction with surgery. A speckle tracking method was used on US images to quantify in vivo liver motions occurring intraoperatively during breathing and apnea. A fusion modeling of HIFU treatments was implemented by merging dynamic in vivo motion data in a numerical modeling of HIFU treatments. Two HIFU strategies were studied: a spherical focusing delivering 49 juxtapositions of 5-second HIFU exposures and a toroidal focusing using 1 single 40-second HIFU exposure. Liver motions during breathing were spatially homogenous and could be approximated to a rigid motion mainly encountered in the cranial-caudal direction (f = 0.20 Hz, magnitude > 13 mm). Elastic liver motions due to cardiovascular activity, although negligible, were detectable near millimeter-wide sus-hepatic veins (f = 0.96 Hz, magnitude < 1 mm). The fusion modeling quantified the deleterious effects of respiratory motions on the size and homogeneity of a standard "cigar-shaped" millimetric lesion usually predicted after a 5-second single spherical HIFU exposure in stationary tissues (Dice Similarity Coefficient: DSC < 45%). This method assessed the ability to enlarge HIFU ablations during respiration, either by juxtaposing "cigar-shaped" lesions with spherical HIFU exposures, or by generating one large single lesion with toroidal HIFU exposures (DSC > 75%). Fusion modeling predictions were preliminarily validated in vivo and showed the potential of using a long-duration toroidal HIFU exposure to accelerate the ablation process during breathing (from 0.5 to 6 cm3 · min(-1)). To improve HIFU treatment control, dynamic fusion modeling may be interesting for assessing numerically focusing strategies and motion compensation techniques in more realistic conditions.

Emerging non-cancer applications of therapeutic ultrasound

Ultrasound therapy has been investigated for over half a century. Ultrasound can act on tissue through a variety of mechanisms, including thermal, shockwave and cavitation mechanisms, and through these can elicit different responses. Ultrasound therapy can provide a non-invasive or minimally invasive treatment option, and ultrasound technology has advanced to the point where devices can be developed to investigate a wide range of applications. This review focuses on non-cancer clinical applications of therapeutic ultrasound, with an emphasis on treatments that have recently reached clinical investigations, and preclinical research programmes that have great potential to impact patient care.

Effect of abdominal liposuction on sonographically guided high-intensity focused ultrasound ablation

OBJECTIVES

The aim of this study was to evaluate the effect of abdominal liposuction on sonographically guided high-intensity focused ultrasound (HIFU) ablation.

METHODS

A total of 10 women with uterine fibroids or adenomyosis who had received abdominal liposuction were analyzed after sonographically guided HIFU ablation. Of the 10 women, 6 had a diagnosis of uterine fibroids, and 4 had a diagnosis of uterine adenomyosis. All of them had a history of a horizontal-margin split-cesarean delivery. In addition, 26 women with a history of a single horizontal-margin split-cesarean delivery who had a diagnosis of uterine fibroids or adenomyosis but had not received liposuction were analyzed together as a control group.

RESULTS

Of the 10 women, 1 woman with uterine fibroids developed local skin erythema after treatment; 1 women with uterine adenomyosis developed a skin burn after treatment; and the remaining women had obvious skin-burning pain during treatment. All women who had not received liposuction finished the treatment with no serious adverse events during or after treatment. The pain scores and incidence of skin-burning pain were significantly higher in the liposuction group than the control group (P= .021 and .038, respectively).

CONCLUSIONS

Abdominal liposuction may increase the risk of skin burns during sonographically guided HIFU ablation.

Reproductive impact of MRI-guided focused ultrasound surgery for fibroids: a systematic review of the evidence

PURPOSE OF REVIEW

Magnetic-resonance-guided focused ultrasound surgery (MRgFUS) is a minimally invasive technique for the treatment of uterine fibroids. The purpose of this review is to highlight the impact of MRgFUS on fertility and reproductive outcomes.

RECENT FINDINGS

The role of MRgFUS in the treatment of fibroids has been evolving since its introduction in 2004. Several new devices and techniques including location-specific treatment, volumetric therapy, and vessel-targeted therapy have been introduced over the last few years. Several case series report uncomplicated pregnancy following MRgFUS; however, results of the ongoing studies will further elucidate the utility of MRgFUS in patients planning future fertility. A systematic review of the literature was completed and studies that reported quality of life at baseline and after 6 months were included in a meta-analysis.

SUMMARY

MRgFUS represents a minimally invasive treatment for uterine fibroids that is able to improve the quality of life and fibroid size with durability. It is possible that MRgFUS could be the treatment of choice for patients desiring future fertility; however, further investigation is needed.

High-Intensity Focused Ultrasound Ablation of Uterine Fibroids - Potential Impact on Fertility and Pregnancy Outcome

Laparoscopic myomectomy is regarded as the gold standard for women with symptomatic fibroids who wish to become pregnant. High-intensity focused ultrasound (HIFU or MRgFUS) ablation of uterine fibroids is also being discussed as a non-surgical, minimally invasive, therapeutic option. This review examines the available data on the impact of HIFU/MRgFUS on fertility and pregnancy, focusing particularly on potential direct side-effects of this type of intervention on ovaries, fallopian tubes and uterus and potential late effects on pregnancy and birth, based on the current literature. All pregnancies after HIFU/MRgFUS published to date (around 100 cases) were evaluated. The published case series suggest that HIFU/MRgFUS ablation has no impact on the rate of miscarriages or other obstetrical outcome parameters. Because no prospective studies exist which permit firm conclusions to be drawn on the impact of HIFU/MRgFUS on fertility and pregnancy outcome in women with symptomatic fibroids, this approach is currently only recommended for women with suspected fertility problems due to uterine fibroids who either decline surgery or who have an unacceptably high surgical risk.

Sonographically guided high-intensity focused ultrasound for the management of uterine fibroids

High-intensity focused ultrasound therapy has received increasing interest in the management of solid malignancies and benign tumors. Magnetic resonance imaging has always been used to define the target for controlling and monitoring the ablation. Recently, sonographically guided high-intensity focused ultrasound has been introduced to monitor the ablation process. This article provides an overview of the background, clinical use, and treatment outcomes of sonographically guided high-intensity focused ultrasound in the treatment of uterine fibroids.