Fertility preservation, especially in women of reproductive age undergoing gonadotoxic treatment, has become an important part of our practice. This is reflected in the increasing number of publications on the subject. A recent PubMed search yields 518 articles on fertility preservation published in the time period of 1980–2000 and 4,288 others between 2000 and 2017. Today, failure to discuss fertility preservation with young women scheduled to undergo radiotherapy or chemotherapy could be considered as malpractice.

The number of hysterectomies, a frequently practiced major surgical procedure, varies between different regions and cultures of the world. It reflects differences in health care systems, education, and psychosocial attitudes. The highest rates of hysterectomy are found in the United States and Australia (36% and 40%, respectively) and the lowest in Italy (15.5%) and France (8.5%).

INDICATIONS

Most hysterectomies are performed for leiomyomas, uterine prolapse, endometriosis, and gynecologic cancer. The number of hysterectomies for endometriosis doubled between 1965 and 1984, exceeding the increase observed for any other indication and probably reflecting an increased recognition of endometriosis. Other indications are abnormal uterine bleeding, pelvic infection and its sequelae, ovarian tumors, and complications of pregnancy. These indications account for 15% to 21% of all hysterectomies.

About 75% of all hysterectomies are done abdominally and 25% vaginally. The vaginal approach is primarily used for uterine prolapse. Abdominal hysterectomy is usually done for women with significant pelvic disease, such as endometriosis or pelvic adhesions, which can make a vaginal removal more difficult (Table 13.1.1). Compared to those having a vaginal hysterectomy, women having an abdominal operation have more febrile morbidity, receive more blood transfusions, and have a longer postoperative hospitalization and convalescence. If more women had a vaginal rather than an abdominal approach for their hysterectomy, therapeutic, economic, and social benefits would result.

Leiomyoma or fibroid is the most common benign tumor occurring in the uterus and in the female pelvis. Fibroids are the primary indication for hysterectomies and represent over 30% of the total number of hysterectomies. There are other treatments of uterine fibroids including expectant management, medical treatment, conservative surgical treatment, and the novel uterine artery embolization. If hysterectomy is indicated, it can also be done by laparoscopy. The book Uterine Fibroids: Embolization and Other Treatments has been written to address all these modalities with a special emphasis on the newest treatment – the uterine artery embolization.

The contributors are gynecologists and interventional radiologists who are pioneers in their field and who have many years of experience in the areas they describe. The first nine chapters of the book focus on the epidemiology, diagnosis, histopathology, and the conventional treatments of uterine fibroids. The remaining 10 chapters are dedicated to uterine artery embolization. This second part starts with a history of embolization of uterine myoma written by its pioneer Dr. Jacques H. Ravina. He stated “A new therapeutic approach was born; we have entered an unknown field and began our work as pioneers.” Other contributors are those who have popularized this technique worldwide and they discuss the basic, clinical aspects and limitation of uterine artery embolization.

The most common indication for hysterectomy is uterine fibroids. It is estimated that approximately one-third of all hysterectomies are done for problems related to uterine fibroids. The clinical indications vary from merely the presence of fibroid to menorrhagia, pressure symptoms, infertility, or habitual abortion.

In many instances they are asymptomatic, but in some women they may be associated with heavy menstrual bleeding, infertility, pressure symptoms, and miscarriage. Hysterectomy can be performed abdominally, laparoscopically, or vaginally, and could be total or subtotal. The approach of the procedure is determined by the clinical situation, the preference and the expertise of the surgeon, and to a certain extent by the patient's desire. In this review we will discuss the risks and benefits of different types of hysterectomy in the treatment of uterine fibroid.

Abdominal hysterectomy

Total abdominal hysterectomy (TAH) remains the conventional treatment for uterine fibroids in women who have completed their family. In the United States, 75% of all hysterectomies are done by laparotomy, which is threefold higher than that for vaginal hysterectomy (VH). TAH is a major operation with three to five days of hospitalization and a convalescence time of several weeks. It is associated with major morbidity in 3% and minor morbidity in about 14% of cases. However, it is a well-received operation with as many as 85–90% of women being satisfied with the procedure and reporting improved quality of life.

Leiomyoma is the most common benign tumor occurring in the uterus and in the female pelvis. It is estimated that 25% of women over the age of 35 years have leiomyoma. Accordingly, not all women with myoma should be treated. As women continue to delay their childbearing until the third and fourth decades of life, leiomyoma will be encountered more frequently.

One of the newest treatments of uterine leiomyomata is uterine artery embolization (UAE). The main purpose of UAE is to reduce the size of the myomata and to treat excessive uterine bleeding. In a review of 119 cases of UAE, the authors reported that about 70% of the patients had an immediate cessation of menorrhagia and improvement of pain and pressure symptoms after the procedure. At six months follow-up, the total uterine volume decreased by 56% and the average diameter of the largest myoma decreased by 36%.

The purpose of this review is to evaluate the effects of UAE on reproductive function.

Uterine fibroids and fertility

The association between leiomyoma and infertility has been discussed for many years. Current evidence suggests that leiomyoma that deforms the uterine cavity decreases fertility. This could be related to poor implantation site or to impaired gamete transport. The best evidence came from the experience in in vitro fertilization (IVF).