The combination of UAE and myomectomy for myoma is indicated for women who desire uterine preservation and fertility within a short time window. UAE can aid in treatment of myoma with subsequent myomectomy by ensuring no potential for regrowth given successful embolization. Myomectomy alone may not completely ensure uterine preservation because of the possibility of fibroid recurrence and subsequent myomectomy (Hanafi 2005) or surgical conversion from myomectomy to hysterectomy (Subramanian et al. 2001). UAE alone is not a contraindication for fertility. Pregnancy following UAE is not uncommon (McLucas 2013); however some complications of UAE may affect ability to achieve a viable pregnancy (Mara et al. 2012). Thus myomectomy combined with embolization may increase the likelihood of subsequent pregnancies (Nabeshima et al. 2003).

Our guidelines for UAE as a stand-alone procedure for women desiring fertility are as follows. The uterus should be less than the size of a 10-week gestation. The position of the myomas should be intramural to subserosal. The largest myoma should be less than 8 cm. Our percentage of patients who conceived without combination procedures was 48 % in women under 40 who stated a desire for fertility (McLucas 2013). We, however, are sensitive to the woman in her late 30s desiring fertility. We recommend that patients wait 6 months after UAE before conception (McLucas 2013). If patients feel that such a wait is too long, and with the possibility of additional wait time if the UAE is not successful, we will offer the patient the combination procedure. Patients need to be told that the combination procedure in this circumstance is optional.

UAE prior to myomectomy is an appropriate approach for treatment of fibroids in women who wish to achieve pregnancy shortly following treatment (Nabeshima et al. 2003). Generally women can begin to try to achieve pregnancy after 6 months after having UAE and myomectomy, the same amount of time for UAE alone. Concerning future pregnancies, UAE may be beneficial for women in whom extensive pelvic adhesions following myomectomy may result in a high possibility for hysterectomy. Such patients with extensive adhesions may require in vitro fertilization, and should be told such prior to any other procedure.

Some authors have said that pedunculated submucous or subserous myomas are often considered a contraindication for UAE because of potential risks and complications, including ischaemic necrosis and separation from the uterus due to torsion at the stalk of the myoma (Levy 2008; Al-Fozan and Tulandi 2002). However in these cases, the only option may be a complicated myomectomy or hysterectomy. Women may opt for UAE if they do not want to undergo invasive surgery or wish to preserve their uterus. UAE has been suggested to be a viable and safe form of treatment for pedunculated subserous myomas with a relatively small stalk diameter and these major complications may be rare (Katsumori et al. 2005). UAE may be useful prior to myomectomy for these types of fibroids because it facilitates easier removal of the fibroid. There is no need for gonadotropin-releasing-hormone agonists prior to myomectomy (Paxton et al. 2006). The outcome is better for patients with submucous and subserous myomas when undergoing myomectomy after uterine artery embolization as a pre-treatment (Butori et al. 2011).

First, hysteroscopic resection will have relatively decreased blood loss after embolization (Wamsteker et al. 1993; Walker and Barton-Smith 2006). The surgeon will have less worry about fluid absorption following embolization (Al-Mahrizi and Tulandi 2007). Thus, the hysteroscopic removal of pedunculated submucous myoma will be facilitated by prior embolization as well as allowing the surgeon to attack a larger myoma (Walker and Barton-Smith 2006). Pre-treatment with UAE decreases blood flow to a pedunculated subserous myoma, again allowing the surgeon the opportunity to remove a larger myoma that might be possible without prior embolization (Butori et al. 2011). A combination of UAE and myomectomy may be the optimum choice in these instances because it maximizes the benefits of both procedures for women choosing invasive but conservative treatment options.

Furthermore, a combination of UAE with either hysteroscopic or laparoscopic myomectomy will greatly diminish the incidence of necrosis following embolization (Al-Fozan and Tulandi 2002). The first reported death due to uterine sepsis was reported to have been found with a submucosal myoma (Vashisht et al. 1999) (Fig. 2).

Myomectomy after UAE allows both the surgeon and the patient benefits compared to stand-alone myomectomy. We will address differences in laparotomy, laparoscopy, and hysteroscopy for myomectomy. Abdominal myomectomy is our preferred technique for multiple intramural myomata. We use this as the technique for large uteri as well. If the myomectomy is performed within 2 weeks of the UAE procedure, surgeons will be pleased by the almost bloodless field encountered. We have not had to convert any of our myomectomy patients to hysterectomy because of blood loss after embolization.

After 3 months, the amount of blood loss will increase, but not to the level of patients who have not undergone UAE. Myomectomy performed after 3 months is most commonly performed for a necrotic myoma. This condition is associated with malodorous discharge, and liquifications (Fig. 3). Cultures of the material within the myoma should be obtained, both aerobic and anaerobic. During the myomectomy, margins of the myoma and healthy myometrium may be blurred. Care should be taken to remove as much necrotic material as possible from the margins. We use manual pressure with lap sponges and gauze pads to aid in this process. A point of advise: the surrounding myometrium is invariably healthy, once the necrotic myoma is removed. We have only performed one hysterectomy (McLucas et al. 2001) on a patient post embolization with symptoms of necrosis. This was at the request of the patient.

During the post-operative myomectomy period when the procedure is performed for a necrotic myoma, we routinely continue broad spectrum antibiotic coverage for 7–10 days gram negative and anaerobic bacteria. This generally includes combination of antibiotics such as gentamycin and clindamycin (Spies et al. 2002). For patients with a penicillin allergy, vancomyocin is used (Weed 2003). No study has shown that the use of prophylactic antibiotics prevents infection after UAE, however it is suggested that prophylactic antibiotics reduce the risk of sepsis (Walker et al. 1999). Our patients often experience some febrile morbidity, and leukocytosis from bacteria at the margins of myomata. In spite of this, we have not had to perform a hysterectomy for post-operative infection. We counsel our patients prior to surgery of the likelihood of fever, and perhaps an extra day or two for antibiotic therapy.