Dr. James Spies
Speaker bio
There are few questions about UFE that are more vexing than that of fertility after the procedure. While most of the indications and outcomes of UFE are settled science, the question of future fertility is not. We don’t have clear data to guide us on this question on a population basis and we certainly don’t for individual patients – unfortunately for many women, the answer is “it depends”.
What we can say is the following: women can and regularly do become pregnant after UFE and most will deliver without incident. The more important question is whether UFE is the best choice for women who are seeking to become pregnant. Are women more likely to have positive outcomes with a myomectomy or UFE if they wish to become pregnant? Should women who have fibroids try to get pregnant with no intervention? The answers to these questions are not simple and are complicated by considerations of age, level of interest in future pregnancy, extent of the fibroids, prior surgery, etc.
The best study we have is that by Mara et al [1, 2], which compared the two-year fertility outcomes of women randomly assigned to myomectomy or UFE. The study demonstrated better outcomes for myomectomy, but was confounded in that one third of the women who had UFE subsequently underwent myomectomy before outcomes were measured. Still, the Cochrane Review of UFE [3] concluded that there was weak evidence favouring myomectomy over UFE for women seeking to become pregnant.
Is there evidence that challenges that conclusion? Not from randomized trials. The recent FEMME Trial [4] had originally intended to help settle this question, but did not enrol sufficient patients to reach a conclusion. One of the largest non-randomized studies is a retrospective review of 359 women by Pisco et al [5]. This study showed a spontaneous pregnancy rate of 29.5% at one year and 40.1% at two years. The probability of successful live birth at one and two years was 24.4% and 36.7% respectively.
What is not known is whether these results are better than those that might be expected with no intervention or after myomectomy. In addition, there are clear reasons to avoid myomectomy, including in women who have had prior myomectomy or other pelvic surgery, those with contraindications to surgery and for those women who choose not to have surgery. The extent of the fibroids and their resectability is also an important consideration.
Given that the evidence is not clearly supporting one single approach, it is important to have a detailed discussion with the patient regarding what is known and unknown about pregnancy outcomes after UAE. With appropriate consideration of her specific circumstances and preferences, a decision can be reached that is best for her. The decision should tempered with the knowledge that there is much we do not know about the comparative outcomes and there is no guarantee of reproductive outcomes after UAE, just as there aren’t with myomectomy or conservative management. We can hope, as we gather more data over time, that we will be able to better answer these questions and better inform our patients.
James Spies
Georgetown University, Washington, DC/US
Dr. Spies is Professor and Chair in the Department of Radiology at Georgetown University Hospital in Washington DC. He was born in Danville, California, one of 10 children. He graduated from the University of California at Davis in 1975 with a degree in fermentation science (winemaking). After a year working in the wine industry, he attended Georgetown University School of Medicine, graduating in 1980. Dr. Spies completed his internship at Pacific Medical Center and his radiology residency at the University of California, San Francisco. He did a fellowship at New York University School of Medicine in vascular and interventional radiology. He also has received a Masters of Public Health from Johns Hopkins University.
Dr. Spies served 4 years in the United States Air Force. After military service, he was in private practice for several years before joining the faculty of Georgetown University in 1997. He has served as Chair of the Department of Radiology there since 2005.
Dr. Spies has an active practice in uterine embolization for fibroids and has performed extensive research in the procedure. He is recognized as an international authority on the procedure. He has over 100 published scientific studies, given over 400 invited presentations and has edited a text on uterine embolization. He has focused much of his research on the outcomes from fibroid therapies, leading the group that created the UFS QOL, the most widely used validated fibroid symptom and quality of life questionnaire. He serves on the steering committees of the COMPARE-UF trial, the largest outcome study of fibroid therapies in the US, and the PRESERVE Trial studying the safety and effectiveness of vena cava filters.
Dr. Spies has served on numerous committees for the SIR and the ACR, including as chair of the SIR Foundation from 2006 to 2008 and SIR President from 2014 to 2015. He was a trustee of the American Board of Radiology (ABR) for Interventional Radiology from 2016 -2019. He currently serves as the ABR Associate Executive Director for IR.
He is a Fellow of the Society of Interventional Radiology (SIR) and the American College of Radiology (ACR). He has also been named a Distinguished Fellow of the Cardiovascular and Interventional Radiology Society of Europe (CIRSE) and Honorary Fellow of the British Society of Interventional Radiology (BSIR). He received the Gold Medal from the Society of Interventional Radiology in 2019.
