Long-Term Pregnancy Outcomes of Patients with Diffuse Adenomyosis after Double-Flap Adenomyomectomy

Abstract

Although many studies show that patients with diffuse adenomyosis who underwent fertility-sparing surgery can have a successful pregnancy, their pregnancy outcomes are still controversial. The objective of this study was to determine long-term pregnancy outcomes and possible influencing factors after double-flap adenomyomectomy for patients with diffuse adenomyosis. A total of 137 patients with diffuse adenomyosis who underwent double-flap adenomyomectomy between January 2011 and December 2019 were studied, and correlations between pregnancy outcomes and clinical data, including age and junctional zone measured by magnetic resonance imaging (JZmax-A), were analyzed. The results show that 56 patients (40.9%, 56/137) had 62 pregnancies, including 35 natural pregnancies and 27 assisted reproduction pregnancies, after operation. A univariate regression analysis showed that the pregnancy outcomes were related to age at surgery, visual analog scale (VAS) score of preoperative dysmenorrhea, parity experience, length of infertility, and postoperative JZmax-A. A multivariate regression analysis showed that age at surgery, VAS score of preoperative dysmenorrhea, and postoperative JZmax-A were the independent indicators correlated with pregnancy outcomes. A receiver operating characteristic curve analysis showed that postoperative JZmax-A was the most valuable indicator for predicting pregnancy outcomes. Cumulative pregnancy rates during the first 3 years were 70.1% and 20.9% in the postoperative JZmax-A ≤ 8.5 mm and the postoperative JZmax-A > 8.5 mm groups, respectively. In conclusion, double-flap adenomyomectomy could improve fertility for diffuse adenomyosis, and postoperative JZmax-A might be a promising indicator for predicting pregnancy outcomes.

Keywords: cumulative pregnancy rate; diffuse adenomyosis; double-flap adenomyomectomy; fertility-sparing surgery; junctional zone.

Figure 1

In diffuse adenomyosis, the JZ is irregular or only visible in the isthmus of the uterus, and the other parts are replaced by adenomyotic lesions. Therefore, we introduced the term “JZ_max-A” instead of using JZ. All low-intensity signal areas representing diffuse circumscribed adenomyosis attached to the JZ are included in JZ_max-A. (A) Preoperative JZ_max-A, (B) postoperative JZ_max-A, JZ = junctional zone.

Figure 2

Flow diagram of the clinical data of women who underwent double-flap adenomyomectomy.

Figure 3

(A–C) ROC analysis for pregnancy prediction: (A) AUC of age at surgery = 0.791, p = 0.001; (B) AUC of the VAS score of preoperative dysmenorrhea = 0.773, p = 0.015; (C) AUC of postoperative JZ_max-A = 0.836, p = 0.001; (D) Postoperative JZ_max-A estimation of pregnancy. The K–M analysis showed significantly differences between the postoperative JZ_max-A ≤ 8.5 mm group and the postoperative JZ_max-A > 8.5 mm group (Log-rank Mantel–Cox test, χ² = 38.14, 95% CI = 3.27–9.86, p = 0.001).