UFE Travels for the First Time to Haiti, Bringing Relief to Women with Fibroids
Alicia Armeli

Madeline, 38 and a mother of four, lives in the town of Léogâne, Haiti. Every month, she endures severe pelvic pain. Her periods are so heavy she has become anemic, and medication isn’t giving her any relief. When she visits the local clinic, they tell her there’s nothing more they can do to help except refer her to a medical facility two hours south in the city of Jacmel. Hoping for answers, Madeline boards a lavishly painted bus called a tap-tap, a modern-day staple in Haitian public transportation. And it’s not until she reaches the Jim Wilmot Surgery Center that she is diagnosed with a uterine fibroid the size of a grapefruit.

This is a common scenario in Haiti. With nearly 11 million people living on the island, over half live below the poverty line, leaving the majority without access to medical care.1,2 This means women like Madeline will rely on non-profit medical organizations to help diagnose and treat conditions like fibroids. This year, Community Coalition for Haiti (CCH), a 501(c)3 non-profit, teamed up with Ask4UFE to bring Haitian women uterine fibroid embolization (UFE), a minimally invasive treatment for fibroids that would otherwise be unavailable.

“Haiti is the poorest country in the Western Hemisphere. On average, a family makes around $750 per year. Many can’t afford medical care,” says Dr. Wayne Reichman, medical director and medical co-chair of CCH. “Even if Madeline sought out care in a public hospital, the waiting period for an open hysterectomy to treat her fibroids would be a one to two year waiting list.”

Uterine fibroids are noncancerous growths that develop in the wall of the uterus and are a common tumor of the female reproductive system. They become more frequent as women age and are especially found among women in their 30s and 40s through menopause.3 Although women of any race can develop fibroids, black women are at a higher risk for multiple fibroids as well as larger fibroids and tend to develop this condition at a younger age with more severe symptoms.3,4 Although noncancerous, fibroids become even more serious in countries like Haiti.

According to Dr. Reichman, the majority of women seen through CCH at the Jim Wilmot Surgery Center have fibroids that grow to resemble the size of a 20-week pregnancy. “For the most part, the majority of the fibroids we see in Haiti are not the size of the fibroids seen in the United States. Women in the U.S. have access to medical care. They’ll be followed by a gynecologist and treated, whereas in Haiti women don’t have access to medical care and fibroids just continue to grow.”

In cases where fibroids grow to be this large, hysterectomy is likely to be the only treatment available in least developed countries like Haiti—but comes with serious risks. Even in developed countries, complications associated with hysterectomy include infection, bleeding, and injury to surrounding tissue.5 These risks are heightened even more so in impoverished areas. Damage to Haiti’s infrastructure from the 2010 earthquake left half of the rural population without clean water and 90% without access to improved sanitation.6

“Because the uterus grows so large in these situations, hysterectomy puts surrounding organs like the bladder and ureters at risk of injury. But the biggest complication is blood loss during surgery and in Haiti there’s limited access to blood to transfuse patients,” Dr. Reichman tells Ask4UFE. “Post-operative care is also a challenge. Because of the environment, there’s a higher risk of infection compared to the U.S. Patients are discharged the day after surgery because there’s limited room at our facility to keep patients long-term. Even in public hospitals there’s only 24 hours of observation and then women are discharged with Tylenol or Advil.”

Recovery after a hysterectomy requires at least two to three weeks rest, but for many women in Haiti, taking time to recover is an unattainable luxury. Most people residing in rural areas are small-scale farmers called “planteurs” who live off their land and sell any crops they can at markets.7 Dr. Reichman explains that along with tending to crops and traveling to make sales via dirt roads that are difficult to traverse, women in Haiti have family responsibilities that make recovery after hysterectomy difficult.

Given the complications related to surgery and the many obstacles Haitian women face, minimally invasive UFE is a practical option. Unlike hysterectomy, UFE is an outpatient procedure that generally requires only a matter of days to recover. A small pinhole is made in the wrist or groin area and then a thin tube called a catheter is inserted and threaded through the arteries that lead to the uterine arteries. Once these vessels are reached, tiny particles called embolic are injected, blocking blood flow to the fibroids. This process called embolization causes fibroids to shrink and die and symptoms to improve. UFE has been shown to significantly alleviate fibroid-related symptoms in 85-90% of patients and has proven effective in women with large fibroids.8

To make UFE available to women in Haiti, Ask4UFE donated Embosphere® Microspheres to CCH. An established embolic of over twenty years, Embosphere is used around the globe for embolization procedures and made it possible for six Haitian women to be treated with UFE this year—the first UFE procedures performed on the island. “We’ve been using Embosphere for about a year now,” Dr. Reichman continues. “One of the most important benefits Embosphere offers, especially treating patients in this type of environment, is its ease of use. Embosphere provides predictable and reliable results as opposed to some of the other embolics on the market.”

After women undergo UFE, they’re sent back to their referring clinics to ensure fibroids are shrinking and that they’re no longer experiencing fibroid-related symptoms. What’s more, post-procedure quality of life patient questionnaires provide Dr. Reichman and his team with valuable follow-up information. “In 2017, five out of the six patients reported being completely satisfied with UFE,” Dr. Reichman notes. “The other patient was lost to follow-up.”

Thanks to the generosity of many hands and hearts collectively working together, the lives of Haitian women are changing for the better because of UFE. “I appreciate the support of Ask4UFE in helping us deliver health care to the poor in Haiti,” Dr. Reichman says. “In the next two years, we’re hoping to enroll more patients and follow their progress after UFE with the goal of showing that fibroid embolization is an effective alternative to hysterectomy in under-developed countries.”

ABOUT THE AUTHOR   Alicia Armeli is a freelance writer and editor, registered dietitian nutritionist, and certified holistic life coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad, and volunteering in her community. She is a paid consultant of Merit Medical.

ABOUT THE DOCTOR  Wayne Reichman, MD, is medical director and medical co-chair of Community Coalition for Haiti. A board certified vascular surgeon from Baltimore, Dr. Reichman joined CCH in 2012 to expand medical care to the people of Haiti. The Jim Wilmot Surgery Center provides free medical care to a region of 250,000 people and is a surgical training site for Haitian health-care providers. In addition to gynecologic procedures, care includes vascular surgery, plastic surgery, orthopedics, general surgery, urology, ophthalmology, and dentistry. For volunteer opportunities, Dr. Reichman can be reached at [email protected].

REFERENCES

  1. Central Intelligence Agency. (n.d.). The World Fact Book. Central America and Caribbean: Haiti. Retrieved https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html
  2. Central Intelligence Agency. (n.d.). The World Fact Book: Population Below Poverty Line. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/fields/2046.html
  3. Office on Women’s Health, U.S. Department of Health and Human Services. (2017). Uterine Fibroids. Retrieved from https://www.womenshealth.gov/a-z-topics/uterine-fibroids
  4. Eunice Kennedy Shriver National Institute of Child Health and Human Development. (n.d.). How many people are affected by or at risk of uterine fibroids? Retrieved from https://www.nichd.nih.gov/health/topics/uterine/conditioninfo/Pages/people-affected.aspx#f5
  5. Clarke-Pearson, D. L., & Geller, E. J. (2013). Complications of hysterectomy. Obstet Gynecol, Mar;121(3):654-673.
  6. Gelting, R., Bliss, K., Patrick, M., et al. (2013). Water, sanitation and hygiene in Haiti: past, present, and future. Am J Trop Med Hyg, Oct 9; 89(4):665-670.
  7. Oxfam International. (2017). An economic lifeline for women in rural Haiti. Retrieved from https://www.oxfam.org/en/countries/haiti-haiti-earthquake-4-years-later/economic-lifeline-women-rural-haiti
  8. Silberzweig, J. E., Powell, D. K., Matsumoto, A. H., et al. (2016). Management of uterine fibroids: a focus on uterine-sparing interventional techniques. Radiology, Sep;280(3):675-692.

The content on the ask4UFE.com website is not intended nor recommended as a substitute for medical advice, diagnosis or treatment. Always seek the advice of a qualified physician regarding any medical questions or conditions.

Could UFE Be a Fertility-Restoring Treatment Option? This Study Says Yes.
Alicia Armeli

Uterine fibroids are the most frequently seen noncancerous tumors of the female reproductive system, affecting nearly 70% of white women and over 80% of black women by age 50.1 Given their frequency, how these uterine growths impact fertility is an important topic—but one that isn’t entirely understood.

Just as important as understanding how this condition may affect your ability to conceive is choosing a fibroid treatment that protects it. Currently, surgically removing fibroids—a procedure called myomectomy—is considered the only treatment recommended to women thought to suffer from fibroid-related infertility. But according to a study published in the journal Radiology, minimally invasive uterine fibroid embolization (UFE) may help restore fertility in women with uterine fibroids who were previously unable to conceive.2

“Exploring UFE as a treatment option for women who desire pregnancy is of major importance,” explains João Martins Pisco, MD, PhD, from the Department of Interventional Radiology at Saint Louis Hospital in Lisbon, Portugal, and study co-author. “It’s a minimally invasive technique performed under local anesthesia with shorter hospital stay.”

Unlike surgery, UFE only requires a small puncture in the wrist or groin area. A doctor called an interventional radiologist then inserts a small tube called a catheter. With the use of real-time imaging, the catheter is guided through the arteries that lead to the uterine arteries. Tiny particles called embolic are injected into the uterine arteries, blocking blood flow to the fibroids. This process, called embolization, leaves fibroids without a blood supply, causing them to gradually shrink over time.

Even though UFE is less invasive than surgery, it still isn’t fully supported by the medical community as a fibroid treatment option for women wanting to become pregnant. Concerns the procedure may impede circulation to the uterine lining and the ovaries has categorized UFE as a treatment option only for women who don’t desire future pregnancy.

To gain more knowledge on this issue, Dr. Pisco and his colleagues examined pregnancy rates following UFE among 359 women with fibroids and/or adenomyosis who were previously unable to conceive.2 Adenomyosis causes the inner uterine lining to abnormally grow into the wall of the uterus, which can also negatively impact fertility.

Of the women participating in the study, 160 underwent partial embolization—a technique where only the small vessels are embolized, leaving the large vessels intact—instead of conventional UFE to potentially better preserve fertility.2 Conventional UFE embolizes all uterine artery branches.

All women were followed up for an average of almost 6 years.2 During this time, 149 women became pregnant (41.5%) at least once, and 131 women gave birth to 150 babies. For over 85% of these women, it was their first pregnancy. Since the time of writing the study, more pregnancies and newborns have been recorded. Obstetric complication rates were low at 23.1% for conventional UFE and 14.6% for partial UFE; however, it was noted that these rates are comparable with rates of the general population.

Neither conventional nor partial UFE seemed to negatively affect fertility but instead may have restored it. “Several of these women weren’t able to conceive despite having been submitted to IVF and many to myomectomy,” Dr. Pisco says. “They were only able to conceive after a UFE procedure.”

What’s more, UFE had a clinical success rate of almost 79% in treating fibroid-related symptoms, such as heavy menstrual bleeding and pelvic pain and pressure.2 Even though partial UFE only embolizes small artery branches, it still cut off blood supply to the dominant fibroid by more than 90% and wasn’t linked with higher rates of repeat intervention. Throughout the study, UFE was repeated in 28 women whose MRI scans showed incomplete treatment, with 11 of these patients going on to get pregnant for the first time.

This is good news especially as research in this area continues. Partial embolization might be able to reduce blood supply to the fibroids without limiting circulation to the uterus and ovarian arteries, potentially allowing for a better pregnancy rate and lower complication rate.2 A study comparing partial and conventional UFE is the next step.

Giving women who want to protect their fertility or restore it, as Dr. Pisco mentions, is important particularly for those who aren’t the best candidates for myomectomy or who have had no prior success with the surgery. “UFE is the only effective option when a woman has multiple fibroids or fibroids that are very large,” Dr. Pisco notes. Myomectomy may also be difficult if large fibroids are located within the uterine wall—a type called intramural—or just under the inner uterine lining—a type called submucosal.2 For these patients, having UFE as an option is essential.

In this study, an increased likelihood of pregnancy following UFE was linked to having a dominant submucosal fibroid as well as when UFE restricted fibroid blood supply by 90% or more, which both conventional and partial approaches are capable of doing.2 Treating fibroids to this degree, the study explains, stops them from growing and allows them to continue to shrink during pregnancy.

Whether UFE holds a place as a viable treatment for women desiring pregnancy is still being investigated. But with UFE research constantly unfolding, the number of options we have is increasing, as is our hope for something better.

ABOUT THE AUTHOR   Alicia Armeli is a Freelance Writer and Editor, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad, and volunteering in her community. She is a paid consultant of Merit Medical.

ABOUT THE DOCTOR   João Martins Pisco, MD, PhD, is director of interventional radiology at St. Louis Hospital, chief radiologist at Hospital Pulido Valente, and professor of radiology at New University of Lisbon in Lisbon, Portugal. He is a world-renowned expert in embolization procedures and treats patients all over the globe. In addition to his practice, Dr. Pisco lectures regularly at international medical conferences and has written thousands of published book chapters and papers.

REFERENCES

  1. Baird, D. D., Dunson, D. B., Hill, M. C., et al. (2003). High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence.Am J Obstet Gynecol, Jan; 188(1), 100–107.
  2. Pisco, J. M., Duarte, M., Bilhim, T., et al. (2017). Spontaneous pregnancy with a live birth after conventional and partial uterine fibroid embolization. Radiology, Oct; 285(1):302-310.