What is Adenomyosis?

Adenomyosis is a very common benign disorder of the womb. It has to do with the damage of the borders between the lining and the muscle wall of the womb.  It’s not clear why some women have adenomyosis. It doesn’t always cause symptoms. In fact, one third of the adenomyotic patients can be asymptomatic and not be aware that this condition affects their uterus. When it is symptomatic, the most common symptoms are pain and abnormal bleeding. With regards to fertility, adenomyosis can increase the risk for implantation failure, decrease the chances of a clinical pregnancy and more than double the risk for a miscarriage. This is why it is very important to screen for adenomyosis before initiating fertility treatment. 

Adenomyosis can exist along with fibroids, making the symptoms worse. There seems to be a strong association between adenomyosis and endometriosis. In one study, 90% of women under the age of 36 with endometriosis had also adenomyosis. It is strongly suspected that endometriosis and adenomyosis are variants of the same disease process, like two sides of the same coin.  Special care should therefore be taken during the baseline ultrasound scan of endometriotic women to make sure adenomyosis is ruled out. When the baseline ultrasound scan is inconclusive, a 3D scan or an MRI might reveal an adenomyotic womb. Nowadays adenomyosis is diagnosed more often because doctors have more advanced equipment available to use in the assessment of fertility patients. As we study this condition more and more, we gain more information about the effect it has on fertility. Currently, there is some uncertainty because of the way many studies have been designed. Hopefully, newer classification systems will help scientists get good quality evidence that will guide our treatment options.

Adenomyosis can be difficult to diagnose. Your doctor will assess various ultrasound features. According to the Morphological Uterus Sonographic Assessment (MUSA) group consensus opinion, some ultrasound features may carry a greater diagnostic weight than others, and the presence of more than one ultrasound feature might increase the likelihood of the condition being present. At present 2D transvaginal (internal) ultrasound scan is  83% sensitive for the diagnosis of adenomyosis, when performed by an experienced phycisian. Features considered typical of adenomyosis include asymmetrical thickening, cysts, hyperechoic islands, fan-shaped shadowing, echogenic subendometrial lines and buds, translesional vascularity, irregular junctional zone and interrupted junctional zone.

 

Adenomyosis and intrauterine insemination (IUI)

There is some evidence that adenomyosis can lower the chances of success with IUI, especially in its diffuse form. This is because adenomyosis can impede the transport capacity of the tubes. This can cause problems for the sperm on its way to meet the egg and fertilise it, or for the fertilised egg to get into the womb to implant. IVF could bypass any potential tubal transport problems and lead to healthy pregnancies.

 

Adenomyosis and in vitro fertilisation (IVF)

There is some evidence to suggest that the use of preparing the treatment with long-acting goserelin (Zoladex) can be helpful in frozen cycles. Μany clinicians nowadays prescribe GnRH pretreatment to adenomyotic patients who are about to undergo a frozen embryo transfer. Α freeze all approach might be worth considering, particularly in women with a low ovarian reserve, and your doctor will discuss with you the advantages of this approach. That way, you can have Zoladex pretreatment for 3 months before you have an FET, to maximize chances of success. As for the use of Zoladex pretreatment in women with adenomyosis in fresh IVF cycles, the situation is less clear. Giving 3-6 months of Zoladex before IVF treatment has been shown to increase the chances of success in women with endometriosis. However, this doesn’t seem to be the case in women with adenomyosis. The live birth rate in fresh embryo transfer cycles is not increased, even though the drop in estrogen will help alleviate the symptoms and will result in a reduction of adenomyosis. It is very likely that the controlled ovarian stimulation that follows pretreatment with Zoladex results in very high estrogen levels that lead to the re-enlargement of the uterus.

Other treatments such as HIFU or MRI guided high intensity focused ultrasound (MRgHIFU) or uterine artery embolization (UAE) should be avoided by fertility patients, as the evidence that they might increase success rates is not robust at all. As for surgery, a major concern remains the risk of uterine rupture. This can happen due to the muscle wall of the womb becoming defective following the operation.

 

Key points: 

● Between 7% and 34% of women seeking IVF treatment suffer from adenomyosis

● It may be associated with endometriosis, subfertility, implantation failure, miscarriages, and a poor obstetric outcome such as preterm delivery, and preterm premature rupture of membranes.

● Adenomyosis can have a detrimental effect on IVF outcomes, reducing live birth rates.

● An ultrasound scan in the first half of the cycle is recommended to rule out adenomyosis before setting up one’s treatment plan.

● For women with a normal ovarian reserve, the long GnRH agonist protocol is advised for the fresh cycle.

● For frozen embryo transfers, pretreatment with Zoladex for three months can be considered.

● For women with a low ovarian reserve, a freeze-all approach can be considered.

● Surgery in women with diffuse adenomyosis increases risk of uterine rupture during pregnancy and labor.

 

Common questions:

1) Why did I get adenomyosis?

Adenomyosis has to do with the interplay of the lining and the muscle wall of the womb. Its causes are unclear, but we know that incidence increases with age. 

2) Is it better to have it surgically removed before I start treatment?

No, there is no robust evidence to suggest that this option increases the chances of success. Furthermore, surgery can lead to the weakening of the womb and increase the risk of uterine rupture during pregnancy, a life-threatening situation both for the mother and the baby. Also, there is risk of incomplete removal and recurrence.

3) I have adenomyosis. I am about to have IVF. Are my chances of success lower?

Adenomyosis has been associated with implantation failure, miscarriages, and lower live birth rates following IVF treatment. However, more well‐designed studies are needed before we can offer a definitive answer. Your doctor will take your history and test results into consideration and create a personalized treatment plan for you.

 

– Dr Andreas Athanasakis