Adenomyosis in infertile women: prevalence and the role of 3D ultrasound as a marker of severity of the disease

Abstract

Background: Adenomyosis is linked to infertility, but the mechanisms behind this relationship are not clearly established. Similarly, the impact of adenomyosis on ART outcome is not fully understood. Our main objective was to use ultrasound imaging to investigate adenomyosis prevalence and severity in a population of infertile women, as well as specifically among women experiencing recurrent miscarriages (RM) or repeated implantation failure (RIF) in ART.

Methods: Cross-sectional study conducted in 1015 patients undergoing ART from January 2009 to December 2013 and referred for 3D ultrasound to complete study prior to initiating an ART cycle, or after ≥3 IVF failures or ≥2 miscarriages at diagnostic imaging unit at university-affiliated private IVF unit. Adenomyosis was diagnosed in presence of globular uterine configuration, myometrial anterior-posterior asymmetry, heterogeneous myometrial echotexture, poor definition of the endometrial-myometrial interface (junction zone) or subendometrial cysts. Shape of endometrial cavity was classified in three categories: 1.-normal (triangular morphology); 2.- moderate distortion of the triangular aspect and 3.- "pseudo T-shaped" morphology.

Results: The prevalence of adenomyosis was 24.4 % (n = 248) [29.7 % (94/316) in women aged ≥40 y.o and 22 % (154/699) in women aged <40 y.o., p = 0.003)]. Its prevalence was higher in those cases of recurrent pregnancy loss [38.2 % (26/68) vs 22.3 % (172/769), p < 0.005] and previous ART failure [34.7 % (107/308) vs 24.4 % (248/1015), p < 0.0001]. The presence of adenomyosis has been shown to be associated to endometriosis [35.1 % (34/97)]. Adenomyosis was diagnosed as a primary finding "de novo" in 80.6 % (n = 200) of the infertile patients. The impact on the uterine cavity was mild, moderate and severe in 63.7, 22.6 and 10.1 % of the cases, respectively.

Conclusions: Our results indicate that adenomyosis is a clinical condition with a high prevalence that may affect the reproductive results. The described severity criteria may help future validating studies for better counseling of infertile couples.

Keywords: Adenomyosis; Infertility; Three-dimensional ultrasound; Ultrasound diagnosis.

Fig. 1

Ultrasonographic diagnostic criteria for adnomyosis. a Globulous aspect of the uterus. b Uterine asymmetry. Longitudinal section of a retroverted uterus, where the posterior uterine wall is clearly thicker than the anterior wall. c Heterogeneous myometrial texture. Transversal section of the uterus at the fundus level, where hypoechoic areas with radial pattern can be seen (arrows). d Linear striations. In this sagital section of an anteverted uterus thin hyperecogenic lines cross the myometrial thickness, visible from the endometrial-myometrial interphase. e Intramyometrial cysts. Transversal section of the uterus at the fundus level with sonoluscent images distributed in posterior wall of the myometrium. f and g, h Hyperechogenic nodules. Transversal (f) and coronal (g, h) sections of the uterus at the fundus level where hyperechogenic Intramyometrial areas can be observed (arrows). i Adenomyoma. Longitudinal section of a retroverted uterus with heterogeneous nodular mass lacking well-defined margins in the posterior wall

Fig. 2

Evaluation of the junction zone (JZ). Multiplanar view in volume contrast image (VCI) mode attaining images with 2 mm slice thickness. Sagital, transversal and coronal views of a retroverted uterus a Normal JZ, observed as hypoechogenic area surrounding all endometrial thickness (arrows). b Thickened, irregular JZ

Fig. 3

Evaluation of the JZ using 3D surface reconstruction mode. a Normal JZ. b and c thickenned, irregular JZ, where it is not possible to adequatly differentiate the endometrial-myometrial transition

Fig. 4

Evaluation of the uterine cavity using 3D reconstrution mode in women diagnosed with adenomyosis. a Normal morphology of the uterine cavity, where JZ is thickenned and irregular, but the uterine cavity maintains its triangular shape. b Moderate alteration of the uterine cavity, with a convex shape in the upper cavity, and a narrowing of the lateral walls (arrows); myometrium is hypertrophic and irregular. c Severe modification of the uterine cavity, with funneling of the lateral walls (arrows), adopting a T-shaped morphology (arrows). Multiple hypoechogenic areas can be observed within the endometrium