Aboubakr Elnashar

1. Adenomyosis
associated infertility:
An Overview of Systematic
reviews
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt
ABOUBAKR ELNASHAR

2. INTRODUCTION
 Uterine adenomyosis (AD)
 was thought to be
 found only in parous women
 final diagnosis was made at histology after
hysterectomy.
 With
 better imaging techniques
 women attending clinics at older ages
 adenomyosis is diagnosed with increasing
frequency in infertile women
ABOUBAKR ELNASHAR

3.  Uterine adenomyosis
 ± relevant factor for infertility
 either
 impairing implantation or
 leading to early miscarriage
 Conservative interventions have been advocated,
with variable reports of their impact on fertility.
 This presents a dilemma for clinicians managing
such patients.
ABOUBAKR ELNASHAR

4. II. AIM OF THE REVIEW
I. Prevalence in a subfertile population
II. Reproductive outcomes
III. Efficacy of fertility sparing treatment options
III. METHODS
Pub med search:
from 2000 to May 2019
Key words:
 Systematic Reviews
 Adenomyosis
 Infertility
 IVF/ICSI
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5. WHAT IS THE BEST EVIDENCE?
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6. AUTHORS YEAR TITEL
I.
Mahesh et al 2012 Adenomyosis and subfertility: SR of prevalence, diagnosis,
treatment and fertility outcomes
II.
Vercellini et al 2014 Adenomyosis &reproductive performance after surgery for
rectovaginal and colorectal endometriosis: SR& MA.
III. IVF OUTCOME
Vercellini et al 2014 Uterine adenomyosis and IVF outcome
Younes,
Tulandi
2017 Effects of adenomyosis on IVF outcomes: MA.
IV. FERTILITY SPARING SURGERY
Younes ,
Tulandi
2018 Conservative Surgery for Adenomyosis and Results: SR.
Tan et al 2018 Reproductive Outcomes after Fertility-Sparing Surgery for
Focal and Diffuse Adenomyosis: SR
Rocha et al, 2018 Fertility-Sparing Treatment of Adenomyosis in Patients With
Infertility: SR
RESULTS
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7. I. Adenomyosis and subfertility: SR of prevalence,
diagnosis, treatment and fertility outcomes.
Mahesh et al, 2012
 Prevalence:
 present in a high proportion of women with
infertility
 particularly those with
 endometriosis and/ or
 menorrhagia and dysmenorrhoea.
 using MRI
 79% with endometriosis
 28% without endometriosis
(Kunz et al., 2005)
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8.  Diagnosis:
 MRI and ultrasound
 non-invasive tests
 equivalent accuracy
3 or more should be present
(Mehasseb , Habiba, 2009)
1. Blurring of endomyometrial interface
2. Echogenic nodules
3. Heterogeneous myometrial areas
4. Globular asymmetrical uterus
5. Irregular cystic spaces
6. Myometrial linear striations
7. Parallel shadowing
Sagittal TVS
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9.  Treatment:
 Most studies
 Uncontrolled
 case series.
 The true impact of various treatments on fertility is
not known.
 There are no fertility-sparing treatments of proven
effectiveness.
 Currently, there is no evidence that
we should find and treat adenomyosis in
patients who wish to conceive.
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10. II. Adenomyosis and reproductive performance after
surgery for rectovaginal and colorectal
endometriosis: SR and MA.
Vercellini et al, 2014
 Adenomyosis
 often coexists with deep endometriosis
 may have a detrimental effect on fertility more than
deep endometriosis
 Surgery for deep endometriosis including colorectal resection
 adopted as a fertility-enhancing procedure
 lack of convincing evidence
 may cause major complications.
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11. 5 observational studies
 Screening for adenomyosis is recommended
before suggesting difficult and risky surgery
 Surgery for deep endometriosis associated with
adenomyosis
have a marginal effect on the likelihood of conception.
Adenomyosis Without adenomyosis
CPR 11.9% 43%
ABOUBAKR ELNASHAR

12. III. UTERINE ADENOMYOSIS AND IVF OUTCOME
1. Vercellini et al, 2014
1865 women in 9 selected studies
 4 prospective observational studies: 665
 5 retrospective studies: 1200
 Heterogeneity: Qualitative and quantitative: high.
 Women with adenomyosis had a 28% reduction in
CPR at IVF/ICSI compared with women without
adenomyosis.
After IVF/ICSI Adenomyosis Without adenomyosis.
CPR 40.5% 49.8%
Miscarriage 31.9% 14.1%
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13.  CPR in infertile women with or without adenomyosis undergoing IVF/ICSI.
 Forest plot showing individual and combined effect size estimates and 95% Cis
 Horizontal lines indicate 95% CIs; boxes show the study-specific weight; diamond
represents combined effect size; dashed line indicates the overall estimate.ABOUBAKR ELNASHAR

14.  Miscarriage rate in clinical pregnancies obtained at IVF/ICSI in women with
or without adenomyosis.
 Forest plot showing individual and combined effect size estimates and 95% CIs)
 Horizontal lines indicate 95% CIs; boxes show the study specific weight; diamond
represents combined effect size; dashed line indicates the overall estimate.ABOUBAKR ELNASHAR

15. 2. Effects of adenomyosis on in IVF outcomes: MA.
Younes, Tulandi, 2017
11 studies
 519 with adenomyosis Vs.
 1,535 without adenomyosis
 significantly lower
 Implantation rate
 CPR
 OPR
 LBR
 Significantly higher
 Miscarriage rate
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16. Implantation rates in women without and with adenomyosis.
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17. CPR per embryo transfer in women without and with
adenomyosis.
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18. LBR per cycle in women without and with adenomyosisABOUBAKR ELNASHAR

19. Cumulative spontaneous CPR in women who underwent surgery
for adenomyosis and who did not (favoring surgery).
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20.  Surgical treatment or
 Treatment with GnRHa
 increases the spontaneous CPR in women with
adenomyosis.
 Adenomyosis has a detrimental effect on IVF clinical
outcomes.
 Pretreatment with
 long-term GnRHa or
 long protocol could be beneficial.
ABOUBAKR ELNASHAR

21. IV. FERTILITY SPARING SURGERY FOR
ADENOMYOSIS
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22. Diagrammatic depiction of the stages of the triple-flap
method.
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23. 1. Conservative Surgery for Adenomyosis and
Results: SR.
Younes, Tulandi , 2018
 27 studies
 10 prospective and 17 retrospective
 1398 patients.
 For preserving fertility and relieving symptoms:
 Med TT is usually the first choice
 Excisional surgery could be performed for refractory
adenomyosis.
 Excision of adenomyosis is effective for
 Symptom control: menorrhagia and dysmenorrhea
 Most probably for adenomyosis-related infertility.
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24.  After conservative surgery.
 Over three-fourths of women will experience
symptom relief
 Three-fourths of them conceived
 Recurrence rates:
differ from no recurrence to almost one-half of
patients.
 Conservative surgery for adenomyosis improves
 Pelvic pain
 AUB
 Possibly fertility.
 The best method of surgery is yet to be seen.
ABOUBAKR ELNASHAR

25. 2. Fertility-Sparing Treatment of Adenomyosis in
Patients With Infertility: SR
Rocha et al,2018
 6 studies evaluated surgical treatments of
adenomyosis
 10 studies evaluated ART for infertility related to
adenomyosis
ABOUBAKR ELNASHAR

26.  Spontaneous CPR: very low (18.2%).
 Using GnRH analogues for 24w after surgery, the pooled spontaneous CPR
was higher (40.7% vs 15.0%; P = .002).
 No significant difference was observed in the other outcomes.
ABOUBAKR ELNASHAR

27.  long stimulation protocol had better outcomes compared to short stimulation
protocol
 CPR (43.3% vs 31.8%; P = .0001)
 LBR (43.0% vs 23.1%; P = .005)
 Miscarriage rate (18.5% vs 31.1%; P < .0001)ABOUBAKR ELNASHAR

28. 3. Reproductive Outcomes after Fertility-Sparing
Surgery for Focal and Diffuse Adenomyosis: SR
Tan et al, 2018
 18 studies
 1396 infertile women with focal and diffuse AD.
 focal AD
 mean pregnancy and miscarriage rates of 52.7% and 21.1% , respectively
 diffuse AD had mean pregnancy and miscarriage rates of 34.1% and 21.7%,
respectively.
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29. ABOUBAKR ELNASHAR

30. ABOUBAKR ELNASHAR

31. ABOUBAKR ELNASHAR

32. Diffuse AD Focal AD
PTL 4.5% 10.9%
Uterine rupture 6.8% 0%
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33.  Surgery may be appropriate for women with
1. Pelvic pain or menorrhagia
2. Younger infertile women who have failed medical
management
3. Older women with infertility despite ART
4. RPL
5. RIF
ABOUBAKR ELNASHAR

34. CONCLUSION
I. Prevalence
 Presents in a high proportion of women with
infertility
 Often coexists with deep endometriosis.
 Screening for adenomyosis is recommended
II Outcome:
 Had a 28% reduction in CPR at IVF/ICSI
compared with women without adenomyosis
ABOUBAKR ELNASHAR

35. III. Treatment:
 Med TT is usually the first choice
 Excisional surgery could be performed for
refractory adenomyosis.
 Pretreatment with long-term GnRHa or long
protocol could be beneficial.
 Fertility sparing surgery:
 effective for
 symptom control such as menorrhagia and
dysmenorrhea
 adenomyosis-related infertility
 LBR after surgery for
 Focal adenomyosis: 38%
 Diffuse adenomyosis: 30%
ABOUBAKR ELNASHAR

36. ABOUBAKR ELNASHAR
You can get this lecture &424
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Aboubakr Elnashar Lectures.
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