Case Report

By Dr. Ping Pisal , Prof. Tae-Hee Kim , Prof. Hae-hyeog Lee , Prof. Wooseok Lee , Dr. Soo-ho Chung
Corresponding Author Prof. Tae-Hee Kim
Soonchunhyang University Bucheon, 1174, Jungdong Wonmigu Bucheon Si Gyeonggido - Republic of Korea 420-767
Submitting Author Prof. Tae-Hee Kim
Other Authors Dr. Ping Pisal
Department of Obstetrics and Gynecology, - Cambodia

Prof. Hae-hyeog Lee
Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Soonchunhyang University Bucheon Hospital, n1174 Jung-1-dong, Wonmi-gu, Bucheon-si, Gyunggi-don - Korea, South 424-767

Prof. Wooseok Lee
Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Soonchunhyang University Bucheon Hospital, n1174 Jung-1-dong, Wonmi-gu, Bucheon-si, Gyunggi-don - Korea, South 420-767

Dr. Soo-ho Chung
Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Soonchunhyang University Bucheon Hospital, n1174 Jung-1-dong, Wonmi-gu, Bucheon-si, Gyunggi-don - Korea, South 420-767


Premature ovarian failure, Menopause, Complication, Uterine artery embolization

Pisal P, Kim T, Lee H, Lee W, Chung S. Premature Ovarian Failure After Uterine Artery Embolization. WebmedCentral OBSTETRICS AND GYNAECOLOGY 2013;4(7):WMC004231
doi: 10.9754/journal.wmc.2013.004231

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 10 Jul 2013 07:55:29 AM GMT
Published on: 10 Jul 2013 09:14:50 AM GMT


We report two cases of premature ovarian failure after uterine artery embolization (UAE). Our cases provide guidance for gynecologists who perform UAE. The first patient, aged 42 years, was para 1-0-0-1 and did not have a significant family history. She complained of metromenorrhagia, but she wanted to preserve her uterus for fertility. We performed a bilateral UAE. After 4 months, she complained of amenorrhea. She was diagnosed with early ovarian failure by checking follicle stimulating hormone (FSH). The second patient, aged 40 years, had infertility from uterine myoma, endometriosis, and adenomyosis. She had undergone UAE and in vitro fertilization (IVF) 6 years earlier. After IVF, she became pregnant and was admitted from 26 weeks to 29 weeks for preeclampsia and preterm labor. After delivery, she had postpartum hemorrhage, and repeat UAE was performed. Two years later, she complained of hot flashes and amenorrhea. She was diagnosed with premature ovarian failure.


Uterine artery embolization (UAE) has emerged as a safe, effective, and durable alternative to surgery for treating uterine fibroids (1,2), However, premature ovarian failure has been described as one possible complication, with reported rates ranging from 3% to 5% in patients aged <45 years and from 7% to 14% in older patients (3,4 ).

This complication is thought to occur because of non-target ovarian embolization via the utero-ovarian collaterals, causing hypoxic ovarian damage and loss of ovarian follicles (5–7). It remains unknown, however, whether this is a sporadic event or whether there is a generalized impact of UAE on ovarian function that is more likely to be apparent in perimenopausal women (>45 years old), who have already-diminished ovarian reserve. For younger women, however, ovarian damage might occur that does not result in sudden ovarian failure but that might compromise subsequent ovarian function and even advance the onset of menopause (6,7).

The available data regarding the impact of UAE on the long-term functioning of the ovaries are relatively few and inconsistent (7–8). This is an important issue because earlier menopause is associated with long-term health risks such as cardiovascular disease and osteoporosis (9).

UAE is advantageous for preserving the uterus for fertility; however, premature ovarian failure negates this advantage by causing infertility. The aim of reporting the cases is educational tip about the serious rare complication after UAE. 

Case reports

Case 1

A 42-year-old woman arrived at the emergency room with vaginal bleeding and menorrhagia. The patient was para 1-0-0-1 and did not have a significant family history. The following laboratory results were reported: white blood cell count (WBC) 17.35 × 103/µl; hemoglobin (Hb)/ hematocrit (Hct), 7.4 g/dl/20.8%; platelets (PLT), 191 × 103/µl.

Due to menorrhagia, the patient had undergone insertion of an intrauterine device (IUD) at a local clinic for 3years. Metromenorrhagia occurred, and she complained of dizziness. She was diagnosed with uterine myoma. Her menstrual flow filled as much as one pad per hour, and she came to the emergency room.

Her symptoms were dizziness, with abdominal pain. Pelvic examination revealed a hard palpable mass and tenderness. Computed tomography revealed a 100 × 98-mm uterine myoma (Figure 1). We perform the embolization for preserving fertility. After transfusion, right femoral artery anesthetic puncture, and application of catheter, both a uterine artery angiography micro-guide wire and a catheter were applied, and embilization was carried out. Angiography revealed Hypertrophied and tortuous both uterine arteries. The women were used 355-500 and 500-700 µm polyvinyl alcohol (PVA)particles

After 4 months, the patient complained of amenorrhea. Ultrasonography revealed a 6 × 5-cm decreasing myoma. A pregnancy test was negative; follicle stimulating hormone (FSH) and estradiol were 34.2 mIU/mL and less than 10 pg/mL, respectively. Menopausal hormone therapy (MHT) was started. After MHT, She had no other complication without amenorrhea.

Case 2

A 37-year-old woman (0-0-0-0) was diagnosed with infertility with uterine myoma, adenomyosis, and endometriosis in the right ovary. We perform the embolization for preserving fertility. Both internal iliac arteriographies are done with 5 French catherter via right common femoral atery. After selecting Uterine artery with 3 French microcatheter, selective angiography is done.

Mixed Gel-foam and antibiotics are injected at both uterine arteries ascending branch.

At post-embolization follow-up angiography, the cervical branch was saved, and both uterine arteries were completely occluded. (figure 2) She became pregnant by in vitro fertilization (IVF) 1 year later. She was admitted for preeclampsia, preterm labor, and severe anemia.

A primary cesarean section was performed at 29+6 weeks. She delivered a male 1,080-g newborn. The Apgar was 7, 8 which was 1 minute or 5 minute respectively, hemoglobin was 7.7 g/dL, and proteinuria was detected. Postpartum hemorrhage occurred. She wanted to preserve uterus for fertility. Pelvic aortography is done via right Common femoral artery with 5 French catheter and then internal iliac artery is selected. After then, uterine artery is selected by 3 French micro catheter and angiography is done, at angiography, both uterine body and fundus are stained and via nonuterine arterial collaterals some part of uterine body portions are also stained. With 3 French microcatheter and PVA 700 µm size, both uterine arteries are embolizationed.

She was performed embolization twice because of infertility and postpartum hemorrhage. After two year later, aged 40 year, woman suffered from hot flushes and amenorrhea. Her FSH and β-hCG test results were 95 and negative, respectively. MHT was started. After MHT, hot flushes were subsided.


The patients presented with an increase in FSH values after UAE, suggesting ovarian failure. Changes in hormonal markers after UAE indicated impaired ovarian reserve, as indicated by an increase in FSH levels (7). Complications of UAE include infectious disease, deep vein thrombosis, malignant leiomyosarcoma, ovarian dysfunction, uterine necrosis, urinary tract infection, and hematoma (10). The percentage of patients (>45 years) with premature ovarian failure was higher after UAE because of a higher prevalence of uterine-ovarian anastomosis (10). Premature ovarian failure is thought to reflect the initial ovarian follicles and the rate of follicle depletion with age (11). If this is so, factors that may directly or indirectly damage the follicular pool may affect the timing of menopause by decreasing ovarian perfusion. UAE has been hypothesized to impair ovarian reserve, which could result in earlier menopause, as described in women who undergo hysterectomy with ovarian conservation (12).

Some studies have suggested loss of ovarian reserve in patients of all ages (7, 13), and others have reported no adverse effects, especially in younger patients (14–15).

The polyvinyl alcohol (PVA) particle size is also a risk factor for ovarian failure. The ideal particle size of PVA has not been established, but current opinion is that the particles should not be <350 μm in diameter, as smaller particles have a higher risk of causing endometrial atrophy by penetrating deeply into small-caliber vessels. Conversely, particles should also not be >550 μm, as they can accidentally obliterate non-target vessels (7,12,13). Magnetic resonance angiography has been helpful in predicting early menopause in cases of uterine myoma because the presence of ovarian collateral vessels to the uterine myoma increases the risk of premature ovarian failure or early menopause (10).

We reported only two cases about early menopause and premature ovarian failure, which is limitation of our cases.

However,  Performance of UAE twice in the same woman may be a risk factor for premature ovarian failure, such as in our patient. Early menopause is a rare complication of UAE but should be discussed in advance with patients.


Please accept our sincerest appreciation for a medical crops' director Shin, Won-Han, the chairman of the board of Soonchunhyang University Suh, Kyo-Il,  the director of a hospital Hwang, Kyung-Ho, a pastor Yun, Dae-Young, a librarian Jung, Eun-Ae who lead us with unsparing guidance and encouragement until this paper is completed.


1. Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, Houdart E, Aymard A, et al. Arterial embolisation to treat uterine myomata. Lancet 1995; 346: 671-2.
2. Tropeano G, Amoroso S, Scambia G. Non-surgical management of uterine fibroids. Hum Reprod Update 2008; 14: 259-74.
3. Hovsepian DM, Siskin GP, Bonn J, Cardella JF, Clark TW, Lampmann LE, et al. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol 2009; 20: S193-9.
4. Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up. Br J Obstet Gynaecol 2002; 109:1262–72.
5. Chrisman HB, Saker MB, Ryu RK, Nemcek AA, Jr., Gerbie MV, Milad MP, et al. The impact of uterine fibroid embolization on res6umption of menses and ovarian function. J Vasc Interv Radiol 2000; 11: 699-703.
6. Payne JF, Robboy SJ, Haney AF. Embolic microspheres within ovarian arterial vasculature after uterine artery embolization. Obstet Gynecol 2002; 100: 883-6.
7. Hehenkamp WJ, Volkers NA, Broekmans FJ, de Jong FH, Themmen AP, Birnie E, et al. Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy. Hum Reprod 2007; 22: 1996-2005.
8. Tropeano G, Di Stasi C, Amoroso S, Gualano MR, Bonomo L, Scambia G. Long-term effects of uterine fibroid embolization on ovarian reserve: a prospective cohort study. Fertil Steril 2010; 94: 2296-300.
9. Shuster LT, Rhodes DJ, Gostout BS, Grossardt BR, Rocca WA. Premature menopause or early menopause: long-term health consequences. Maturitas 2010; 65: 161-6.
10. Kitamura Y, Ascher SM, Cooper C, Allison SJ, Jha RC, Flick PA, et al. Imaging manifestations of complications associated with uterine artery embolization. Radiographics 2005; 25 Suppl 1: S119-32.
11. te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod Update 2002; 8: 141-54.
12. Farquhar CM, Sadler L, Harvey SA, Stewart AW. The association of hysterectomy and menopause: a prospective cohort study. BJOG 2005; 112: 956-62.
13. Tulandi T, Sammour A, Valenti D, Child TJ, Seti L, Tan SL. Ovarian reserve after uterine artery embolization for leiomyomata. Fertil Steril 2002; 78: 197-8.
14. Spies JB, Roth AR, Gonsalves SM, Murphy-Skrzyniarz KM. Ovarian function after uterine artery embolization for leiomyomata: assessment with use of serum follicle stimulating hormone assay. J Vasc Interv Radiol 2001; 12: 437-42.
15. Rashid S, Khaund A, Murray LS, Moss JG, Cooper K, Lyons D, et al. The effects of uterine artery embolisation and surgical treatment on ovarian function in women with uterine fibroids. BJOG 2010; 117: 985-9.

Source(s) of Funding

This work was supported in part by the Soonchunhyang University Research Fund.

Competing Interests

There are no conflict of interests


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

2 reviews posted so far

Two Case Presentations
Posted by Dr. Mohammad Othman on 12 Jul 2013 03:14:29 PM GMT

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)