Uterine impact
One study of TC-RFA patients showed a greater than 65% reduction in fibroid volume (with a 90% reduction in fibroid volume for fibroids larger than 6 cm prior to RFA), and 54% of patients reported complete resolution of symptoms, with another 36% reporting decreased symptoms.30 Similar decreases in fibroid volume, ranging from 65% to 84%, have been reported in numerous follow-up studies, with significant decreases in bleeding and pain in 78% to 88% of patients.23,31-33 Additionally, a large secondary analysis of a TC-RFA clinical trial showed that patients did not have any significant decrease in uterine wall thickness or integrity on follow-up with magnetic resonance imaging compared with baseline measurements, and they did not have any new myometrial scars (assessed as nonperfused linear areas).22
As with other ablation techniques, most data on RFA pregnancy outcomes come from case series, and further research and evaluation are needed. Existing studies, however, have demonstrated promising aspects of RFA that argue its usefulness in women with fertility plans.
A prospective trial that evaluated intrauterine adhesion formation with use of a TC-RFA device found no new adhesions on 6-week follow-up hysteroscopy compared with baseline pre-RFA hysteroscopy.34 Because intrauterine adhesion formation and uterine rupture are both significant concerns with other uterine-sparing fibroid treatment approaches such as myomectomy, these findings suggest that RFA may be a better alternative for women who are planning future pregnancies, as they may have increased fertility success and decreased catastrophic complications.
The consensus is growing that RFA is a safe and effective option for women who desire minimally invasive fibroid treatment and want to preserve fertility.
Unique benefits of RFA
In this article, we highlight RFA as an emerging treatment option for fibroid management, particularly for women who desire a uterine-sparing approach to preserve their reproductive options. Although myomectomy has been the standard of care for many years, with UAE as the alternative nonsurgical treatment, neither approach provides the best balance between symptomatic improvement and reproductive outcomes, and neither is without pregnancy risks. In addition, many women with symptomatic fibroids do not desire future conception but decline fibroid removal for religious or personal reasons. RFA offers these women an alternative minimally invasive option for uterine-sparing fibroid treatment.
RFA presents a unique “incision-free” fibroid treatment that is truly minimally invasive. This technique minimizes the risks associated with myomectomy, such as intra-abdominal adhesions, intrauterine adhesions (Asherman syndrome), need for cesarean delivery, and pregnancy complications such as uterine rupture or invasive placentation. Furthermore, the evolution of an RFA transcervical approach has enabled treatment with no abdominal or uterine incisions, thus offering all the above reproductive benefits as well as the operative benefits of a faster recovery, less pain, and less risk of intraperitoneal surgical complications.
While many women desire uterine-sparing fibroid treatment even without future fertility plans, the larger question is whether we should treat fibroids more strategically for women who desire future fertility. Myomectomy and UAE are effective and reliable in terms of fibroid symptomatic improvement, but RFA promises more beneficial reproductive outcomes. The ability to avoid uterine myometrial incisions and still attain significant symptomatic improvement should be prioritized in these patients.
Currently, RFA is not approved by the FDA as a fertility-enabling treatment, and these patients have been largely excluded from RFA studies. However, the reproductive-age patient who desires future conception may benefit most from RFA. Furthermore, RFA technology also could address the gap in uterine-sparing treatment for reproductive-age women with adenomyosis. Although a complete review of adenomyosis treatment is beyond the scope of this article, recent studies show that RFA produces similar improvement in both uterine volume and symptom severity in women with adenomyosis.35-37 ●
WHAT THIS EVIDENCE MEANS FOR PRACTICE
The RFA data suggest that both laparoscopic and transcervical RFA offer a safe and effective alternative treatment option for patients with symptomatic fibroids who seek uterine-sparing treatment, and transcervical RFA offers the least invasive treatment option. Women with fibroids who wish to conceive currently face a challenging treatment gap in clinical medicine, and future research is needed to address this concern in these patients. RFA is promising and appears to be a better fertility-enabling conservative fibroid treatment than the current options of myomectomy or UAE.
The RFA data suggest that both laparoscopic and transcervical RFA offer a safe and effective alternative treatment option for patients with symptomatic fibroids who seek uterine-sparing treatment, and transcervical RFA offers the least invasive treatment option. Women with fibroids who wish to conceive currently face a challenging treatment gap in clinical medicine, and future research is needed to address this concern in these patients. RFA is promising and appears to be a better fertility-enabling conservative fibroid treatment than the current options of myomectomy or UAE.