Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes

Abstract

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Keywords: adenomyosis; diagnosis; infertility; reproductive outcome; treatment options.

Figure 1

Sonographic findings in adenomyosis [30]. (a) Spherical, (b) wall difference in favor of the anterior or posterior wall, (c) subendometrial cysts, (d) echogenic islands, (e) fan-shaped shadowing, (f) echogenic subendometrial lines or buds, (g) translesional vascularity, (h) irregular junctional zone, (i) interrupted junctional zone.

Figure 2

MRI characteristics of the uterine junctional zone. T2-weighted MRI in the sagittal plane, showing the widened junctional zone marked with arrows. B: bladder, V: vagina filled with ultrasound gel, R: rectum filled with ultrasound gel. Image acquisition on 3T, Ingenia Philips Healthcare, with a T2 TSE sequence.

Figure 3

Negative impact of adenomyosis on reproductive outcomes. Adenomyosis leads to changes in the junctional zone (JZ), the anatomy of the uterus itself, and at the cellular level. The transport of the sperm, egg, and finally the embryo is complicated by dysfunctional peristalsis.

Figure 4

(a): Clinical pregnancy rates after ART in patients with and without adenomyosis [43]. The clinical pregnancy rate achieved after ART was 123/304 (40.5%) in women with adenomyosis versus 628/1262 (49.8%) in those without adenomyosis. (b): Miscarriage rates after ART in patients with and without adenomyosis [43]. A miscarriage was observed in 77/241 women with adenomyosis (31.9%) and in 97/687 in those without adenomyosis (14.1%).