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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
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Figure 1

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.1 Satisfaction with treatment up to 24 months.
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Figure 3

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.1 Satisfaction with treatment up to 24 months.

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.2 Satisfaction with treatment at 5 years.
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Figure 4

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.2 Satisfaction with treatment at 5 years.

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.3 Live birth.
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Figure 5

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.3 Live birth.

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.10 Further interventions within 2 years.
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Figure 6

Forest plot of comparison: 1 UAE versus surgery, outcome: 1.10 Further interventions within 2 years.

Comparison 1 UAE versus surgery, Outcome 1 Satisfaction with treatment up to 24 months.
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Analysis 1.1

Comparison 1 UAE versus surgery, Outcome 1 Satisfaction with treatment up to 24 months.

Comparison 1 UAE versus surgery, Outcome 2 Satisfaction with treatment at 5 years.
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Analysis 1.2

Comparison 1 UAE versus surgery, Outcome 2 Satisfaction with treatment at 5 years.

Comparison 1 UAE versus surgery, Outcome 3 Live birth.
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Analysis 1.3

Comparison 1 UAE versus surgery, Outcome 3 Live birth.

Comparison 1 UAE versus surgery, Outcome 4 Adverse events: intraprocedural complications.
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Analysis 1.4

Comparison 1 UAE versus surgery, Outcome 4 Adverse events: intraprocedural complications.

Comparison 1 UAE versus surgery, Outcome 5 Adverse events: Need for blood transfusion.
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Analysis 1.5

Comparison 1 UAE versus surgery, Outcome 5 Adverse events: Need for blood transfusion.

Comparison 1 UAE versus surgery, Outcome 6 Adverse events: minor postprocedural complications.
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Analysis 1.6

Comparison 1 UAE versus surgery, Outcome 6 Adverse events: minor postprocedural complications.

Comparison 1 UAE versus surgery, Outcome 7 Adverse events: major postprocedural complications within one year.
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Analysis 1.7

Comparison 1 UAE versus surgery, Outcome 7 Adverse events: major postprocedural complications within one year.

Comparison 1 UAE versus surgery, Outcome 8 Adverse events: later minor postprocedural complications.
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Analysis 1.8

Comparison 1 UAE versus surgery, Outcome 8 Adverse events: later minor postprocedural complications.

Comparison 1 UAE versus surgery, Outcome 9 Adverse events: major postprocedural complications.
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Analysis 1.9

Comparison 1 UAE versus surgery, Outcome 9 Adverse events: major postprocedural complications.

Comparison 1 UAE versus surgery, Outcome 10 Further interventions within 2 years.
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Analysis 1.10

Comparison 1 UAE versus surgery, Outcome 10 Further interventions within 2 years.

Comparison 1 UAE versus surgery, Outcome 11 Further interventions within 5 years.
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Analysis 1.11

Comparison 1 UAE versus surgery, Outcome 11 Further interventions within 5 years.

Comparison 1 UAE versus surgery, Outcome 12 Unscheduled readmission rate within 4‐6 weeks.
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Analysis 1.12

Comparison 1 UAE versus surgery, Outcome 12 Unscheduled readmission rate within 4‐6 weeks.

Comparison 1 UAE versus surgery, Outcome 13 Cost: duration of procedure (minutes).
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Analysis 1.13

Comparison 1 UAE versus surgery, Outcome 13 Cost: duration of procedure (minutes).

Comparison 1 UAE versus surgery, Outcome 14 Cost: length of hospital stay (days).
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Analysis 1.14

Comparison 1 UAE versus surgery, Outcome 14 Cost: length of hospital stay (days).

Comparison 1 UAE versus surgery, Outcome 15 Cost: resumption of normal activities (days).
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Analysis 1.15

Comparison 1 UAE versus surgery, Outcome 15 Cost: resumption of normal activities (days).

Comparison 1 UAE versus surgery, Outcome 16 FSH levels >40 IU/L (within 2 years).
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Analysis 1.16

Comparison 1 UAE versus surgery, Outcome 16 FSH levels >40 IU/L (within 2 years).

Comparison 1 UAE versus surgery, Outcome 17 FSH levels >10 IU/L (within 6 months).
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Analysis 1.17

Comparison 1 UAE versus surgery, Outcome 17 FSH levels >10 IU/L (within 6 months).

Comparison 1 UAE versus surgery, Outcome 18 Fibroid recurrence within 2 years.
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Analysis 1.18

Comparison 1 UAE versus surgery, Outcome 18 Fibroid recurrence within 2 years.

Comparison 1 UAE versus surgery, Outcome 19 Pregnancy.
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Analysis 1.19

Comparison 1 UAE versus surgery, Outcome 19 Pregnancy.

Comparison 1 UAE versus surgery, Outcome 20 UAE versus myomectomy: Health related quality of life at one year.
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Analysis 1.20

Comparison 1 UAE versus surgery, Outcome 20 UAE versus myomectomy: Health related quality of life at one year.

Comparison 1 UAE versus surgery, Outcome 21 UAE versus hysterectomy or myomectomy: SF‐36 within 1 year.
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Analysis 1.21

Comparison 1 UAE versus surgery, Outcome 21 UAE versus hysterectomy or myomectomy: SF‐36 within 1 year.

Summary of findings for the main comparison. Uterine artery embolization (UAE) compared to surgery for symptomatic uterine fibroids

UAE compared to surgery for symptomatic uterine fibroids

Population: women with symptomatic uterine fibroids
Intervention: UAE
Comparison: surgery

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Surgery

UAE

Satisfaction with treatment up to 24 months

861 per 1000

853 per 1000
(785 to 901)

OR 0.94
(0.59 to 1.48)

640
(6 RCTs)

⊕⊕⊕⊝
MODERATE 1,2

Satisfaction with treatment at 5 years

876 per 1000

864 per 1000
(761 to 927)

OR 0.90
(0.45 to 1.80)

295
(2 RCTs)

⊕⊕⊕⊝
MODERATE 1

Live birth ‐ UAE versus myomectomy

475 per 1000

190 per 1000
(67 to 432)

OR 0.26
(0.08 to 0.84)

66
(1 RCT)

⊕⊝⊝⊝
VERY LOW 3,4

Adverse events: intra‐procedural complications

63 per 1000

57 per 1000
(27 to 117)

OR 0.91
(0.42 to 1.97)

452
(4 RCTs)

⊕⊕⊝⊝
LOW5,6,7

Adverse events: minor post‐procedural complications within one year

230 per 1000

373 per 1000
(296 to 456)

OR 1.99
(1.41 to 2.81)

735
(6 RCTs)

⊕⊕⊕⊝
MODERATE 1,2

Adverse events: major post‐procedural complications within one year

69 per 1000

46 per 1000
(24 to 85)

OR 0.65
(0.33 to 1.26)

611
(5 RCTs)

⊕⊕⊕⊝
MODERATE 1,5,7

Further interventions within 2 years

71 per 1000

222 per 1000
(149 to 317)

OR 3.72
(2.28 to 6.04)

732
(6 RCTs)

⊕⊕⊕⊝
MODERATE 1,2,8

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Studies unblinded

2Two studies did not fully explain randomisation and allocation concealment, but quality not downgraded for this as their omission from analysis did not substantially change the findings

3 Wide confidence intervals compatible with substantial harm from UAE or with no effect

4Includes only those trial participants who wished to conceive (66/121)

5One study did not fully explain methods of randomisation and allocation concealment, but omission of this study did not substantially affect the findings

6Low event rate

7Wide confidence intervals compatible with substantial harm or benefit from either intervention, or with no effect

8Some statistical heterogeneity (I2 = 45%); quality not downgraded for this as direction of effect is consistent

Figuras y tablas -
Summary of findings for the main comparison. Uterine artery embolization (UAE) compared to surgery for symptomatic uterine fibroids
Comparison 1. UAE versus surgery

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Satisfaction with treatment up to 24 months Show forest plot

6

640

Odds Ratio (M‐H, Fixed, 95% CI)

0.94 [0.59, 1.48]

1.1 UAE versus hysterectomy

3

266

Odds Ratio (M‐H, Fixed, 95% CI)

0.63 [0.30, 1.32]

1.2 UAE versus hysterectomy or myomectomy

2

264

Odds Ratio (M‐H, Fixed, 95% CI)

1.29 [0.64, 2.58]

1.3 UAE versus myomectomy

1

110

Odds Ratio (M‐H, Fixed, 95% CI)

1.05 [0.33, 3.36]

2 Satisfaction with treatment at 5 years Show forest plot

2

295

Odds Ratio (M‐H, Fixed, 95% CI)

0.90 [0.45, 1.80]

2.1 UAE versus hysterectomy

1

156

Odds Ratio (M‐H, Fixed, 95% CI)

0.71 [0.29, 1.78]

2.2 UAE versus hysterectomy or myomectomy

1

139

Odds Ratio (M‐H, Fixed, 95% CI)

1.25 [0.42, 3.67]

3 Live birth Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 UAE versus myomectomy

1

66

Odds Ratio (M‐H, Fixed, 95% CI)

0.26 [0.08, 0.84]

4 Adverse events: intraprocedural complications Show forest plot

4

452

Odds Ratio (M‐H, Fixed, 95% CI)

0.91 [0.42, 1.97]

4.1 UAE versus hysterectomy

2

209

Odds Ratio (M‐H, Fixed, 95% CI)

1.23 [0.44, 3.44]

4.2 UAE versus myomectomy

2

243

Odds Ratio (M‐H, Fixed, 95% CI)

0.61 [0.18, 2.03]

5 Adverse events: Need for blood transfusion Show forest plot

2

277

Odds Ratio (M‐H, Fixed, 95% CI)

0.07 [0.01, 0.52]

5.1 UAE versus hysterectomy

1

156

Odds Ratio (M‐H, Fixed, 95% CI)

0.04 [0.00, 0.67]

5.2 UAE versus myomectomy

1

121

Odds Ratio (M‐H, Fixed, 95% CI)

0.21 [0.01, 4.47]

6 Adverse events: minor postprocedural complications Show forest plot

6

735

Odds Ratio (M‐H, Fixed, 95% CI)

1.99 [1.41, 2.81]

6.1 UAE versus hysterectomy

2

211

Odds Ratio (M‐H, Fixed, 95% CI)

2.12 [1.13, 3.96]

6.2 UAE versus hysterectomy or myomectomy

2

281

Odds Ratio (M‐H, Fixed, 95% CI)

2.51 [1.49, 4.23]

6.3 UAE versus myomectomy

2

243

Odds Ratio (M‐H, Fixed, 95% CI)

1.23 [0.62, 2.44]

7 Adverse events: major postprocedural complications within one year Show forest plot

5

611

Odds Ratio (M‐H, Fixed, 95% CI)

0.65 [0.33, 1.26]

7.1 UAE versus hysterectomy

2

211

Odds Ratio (M‐H, Fixed, 95% CI)

1.00 [0.22, 4.58]

7.2 UAE versus hysterectomy or myomectomy

1

157

Odds Ratio (M‐H, Fixed, 95% CI)

0.73 [0.30, 1.74]

7.3 UAE versus myomectomy

2

243

Odds Ratio (M‐H, Fixed, 95% CI)

0.29 [0.06, 1.50]

8 Adverse events: later minor postprocedural complications Show forest plot

3

Odds Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1 UAE versus hysterectomy or myomectomy (to 5 years)

2

268

Odds Ratio (M‐H, Fixed, 95% CI)

2.93 [1.73, 4.93]

8.2 UAE versus myomectomy (1 month‐2 years)

1

120

Odds Ratio (M‐H, Fixed, 95% CI)

1.82 [0.56, 5.94]

9 Adverse events: major postprocedural complications Show forest plot

3

388

Odds Ratio (M‐H, Fixed, 95% CI)

0.56 [0.27, 1.18]

9.1 UAE versus hysterectomy or myomectomy (to 5 years)

2

268

Odds Ratio (M‐H, Fixed, 95% CI)

0.56 [0.27, 1.18]

9.2 UAE versus myomectomy (1 month‐2 years)

1

120

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

10 Further interventions within 2 years Show forest plot

6

732

Odds Ratio (M‐H, Fixed, 95% CI)

3.72 [2.28, 6.04]

10.1 UAE versus hysterectomy

2

209

Odds Ratio (M‐H, Fixed, 95% CI)

2.99 [1.31, 6.80]

10.2 UAE versus hysterectomy or myomectomy

2

281

Odds Ratio (M‐H, Fixed, 95% CI)

2.83 [1.29, 6.24]

10.3 UAE versus myomectomy

2

242

Odds Ratio (M‐H, Fixed, 95% CI)

6.89 [2.60, 18.27]

11 Further interventions within 5 years Show forest plot

2

289

Odds Ratio (M‐H, Fixed, 95% CI)

5.79 [2.65, 12.65]

11.1 UAE versus hysterectomy

1

145

Odds Ratio (M‐H, Fixed, 95% CI)

3.43 [1.41, 8.30]

11.2 UAE versus hysterectomy or myomectomy

1

144

Odds Ratio (M‐H, Fixed, 95% CI)

20.34 [2.68, 154.59]

12 Unscheduled readmission rate within 4‐6 weeks Show forest plot

2

278

Risk Difference (M‐H, Fixed, 95% CI)

0.14 [0.05, 0.22]

12.1 UAE versus hysterectomy

1

157

Risk Difference (M‐H, Fixed, 95% CI)

0.23 [0.09, 0.38]

12.2 UAE versus myomectomy

1

121

Risk Difference (M‐H, Fixed, 95% CI)

0.02 [‐0.04, 0.07]

13 Cost: duration of procedure (minutes) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

13.1 UAE versus hysterectomy

1

156

Mean Difference (IV, Fixed, 95% CI)

‐16.40 [‐26.04, ‐6.76]

13.2 UAE versus myomectomy

1

121

Mean Difference (IV, Fixed, 95% CI)

‐49.7 [‐58.76, ‐40.64]

14 Cost: length of hospital stay (days) Show forest plot

7

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

14.1 UAE versus hysterectomy

3

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

14.2 UAE versus hysterectomy or myomectomy

2

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

14.3 UAE versus myomectomy

2

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

15 Cost: resumption of normal activities (days) Show forest plot

5

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

15.1 UAE versus hysterectomy

2

188

Mean Difference (IV, Fixed, 95% CI)

‐22.85 [‐27.30, ‐18.40]

15.2 UAE versus hysterectomy or myomectomy

2

220

Mean Difference (IV, Fixed, 95% CI)

‐13.68 [‐16.05, ‐11.30]

15.3 UAE versus myomectomy

1

121

Mean Difference (IV, Fixed, 95% CI)

‐10.20 [‐13.60, ‐6.80]

16 FSH levels >40 IU/L (within 2 years) Show forest plot

2

297

Odds Ratio (M‐H, Fixed, 95% CI)

1.01 [0.53, 1.94]

16.1 UAE versus hysterectomy

1

153

Odds Ratio (M‐H, Fixed, 95% CI)

0.70 [0.32, 1.54]

16.2 UAE versus hysterectomy or myomectomy

1

144

Odds Ratio (M‐H, Fixed, 95% CI)

2.35 [0.64, 8.68]

17 FSH levels >10 IU/L (within 6 months) Show forest plot

1

120

Odds Ratio (M‐H, Fixed, 95% CI)

4.8 [0.97, 23.64]

17.1 UAE versus myomectomy

1

120

Odds Ratio (M‐H, Fixed, 95% CI)

4.8 [0.97, 23.64]

18 Fibroid recurrence within 2 years Show forest plot

1

120

Odds Ratio (M‐H, Fixed, 95% CI)

1.32 [0.38, 4.57]

18.1 UAE versus myomectomy

1

120

Odds Ratio (M‐H, Fixed, 95% CI)

1.32 [0.38, 4.57]

19 Pregnancy Show forest plot

1

66

Odds Ratio (M‐H, Fixed, 95% CI)

0.29 [0.10, 0.85]

19.1 UAE versus myomectomy

1

66

Odds Ratio (M‐H, Fixed, 95% CI)

0.29 [0.10, 0.85]

20 UAE versus myomectomy: Health related quality of life at one year Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

20.1 USF‐QOL end scores

1

122

Mean Difference (IV, Fixed, 95% CI)

‐13.40 [‐21.41, ‐5.39]

20.2 USF‐QOL change scores

1

122

Mean Difference (IV, Fixed, 95% CI)

‐7.60 [‐17.55, 2.35]

21 UAE versus hysterectomy or myomectomy: SF‐36 within 1 year Show forest plot

2

1405

Mean Difference (IV, Fixed, 95% CI)

9.14 [8.04, 10.23]

21.1 Physical function

2

281

Mean Difference (IV, Fixed, 95% CI)

7.77 [5.83, 9.70]

21.2 Social function

2

281

Mean Difference (IV, Fixed, 95% CI)

6.14 [2.71, 9.58]

21.3 Mental Health

2

281

Mean Difference (IV, Fixed, 95% CI)

12.00 [9.50, 14.50]

21.4 Emotional role

2

281

Mean Difference (IV, Fixed, 95% CI)

10.28 [7.96, 12.60]

21.5 Vitality

2

281

Mean Difference (IV, Fixed, 95% CI)

8.75 [6.09, 11.41]

Figuras y tablas -
Comparison 1. UAE versus surgery