infrequently touched topic in infertility . what can we offer in this talk is patient oriented view

1. Adenomyosis : An Update
Patient oriented approach

2. What is the problem?
• Diagnosis is difficult
• Management is more difficult
• So we need Patient orient way approach

3. Diagnosis : not easy
• up to 80% of adenomyotic uteri contain associated pathology, such as
myomas that could have similar clinical presentations
• about one-third ofwomen suffering from endometriosis have
concomitant adenomyosis, with overlapping and usually heavier
symptoms

4. Symptoms
• asymptomatic in about 35% of the cases
• whereas 50% of women with symptoms have menorrhagia, 30% have
dysmenorrhea, and 20% have metrorrhagia

5. What we know
• The definitive diagnosis of adenomyosis is based on histologic
examination after hysterectomy.

6. MCQ
• Do u think adenomyosis a disease of :-
a) Nulliparous
b) Multiparous
c) Low parity
d) All above

7. Is it related to parous women?!!!
• It was deemed that adenomyosis was a typical condition of parous
women. However, adenomyosis has become more relevant in the
setting of infertility

8. So why parous women??
• The incidence of adenomyosis is increased after uterine surgery,
cesarean section, postpartum endometritis, pregnancy, uterine
trauma, and surgery

9. So what about nulliparous women?
• because more and more women are delaying childbearing due to
social reasons and better imaging techniques have identified
adenomyosis in women labeled as having ‘‘unexplained infertility’

10. How to reach diagnosis??
• Clinical picture : not reliable
• Ultrasonography : may be
• MRI : Yes

11. Clinical picture
• Examination : inconclusive : ?? Enlarged tender uterus
• Especially during menses

12. TVUS: challenge
• 75% sensitive
• 84% specific
• 2D vs 3D !!!!

13. 2D : suggestive signs
• Asymmetrically enlarged uterus
• Round cystic areas within the myometrium
• Inhomogeneous, irregular myometrial echotexture in an indistinctly
defined myometrial area
• Myometrial hypoechoic linear striations
• Illdefined endometrial stripe

14. Should we do 3D?
• If only 1 of the typical TVS features associated with symptoms like
menometrorrhagia, dysmenorrhea, or infertility pls consider MRI for
accuracte diagnosis.

15. So What is the role of 3D?
• For evaluation of the JZ
• JZ thickness JZmax R 6 to 8 mm was significantly more associated with
histologically proven adenomyosis than other 2D features
• Exclude other pathologies

16. MRI : the gold standard
• The diagnostic accuracy of MRI in the diagnosis of adenomyosis has
long been established
• (1) thickening of the JZ to at least 8 to 12 mm
• (2) ratio JZ maximum-to-total myometrium over 40%
• (3) difference between the maximum and the minimum thickness of
the JZ = 5 mm
• Not during menstruation

18. Hysteroscopy: Is there a role?
• Seldom use in diagnosis of adenomyosis
• To evaluate uterine cavity

19. Adenomyosis & infertility : negative impact
• Uterine dysperistalsis
• Excess concentration of free radicals at endometrial level
• Altered ndometrial vasculature
• Associated pathology : myoma or endometriosis

20. IVF Outcome
• Less favourable outcome regarding pregnancy rate , live birth rate
• More miscarriage rate
• Should be clearly explained to the patients

21. In IVF
• Suppression of adenomyosis by long-term down-regulation with
GnRH agonists has to be considered to improve the outcome.

22. Best approach : long protocol
• ovarian hyperstimulation with high gonadotropin doses and embryo
freezing .
• The transfer could be postponed after 2 to 4 months of GnRH agonist
therapy with hormone replacement therapy used in frozen–thawed
cycles

23. If not seeking infertility : LUG
• The efficacy of levonorgestrel–intrauterine systems in the treatment
of adenomyosis-related pain and heavy menstrual bleeding could be
explained by different mechanisms:
• (1) a direct progestogenic effect on ectopic adenomyosis foci
• (2) decidualization and atrophy of the eutopic endometrium
• (3) modulation of endometrial factors altered in adenomyosis

24. LUG
• Effective
• Follow up by symptoms, CA125, TVS

25. GnRH a depot
• An alternative
• Not more than 6 month

26. HIFU
• Controversial
• No evidence till now

27. Why it may of value?
• Seeking to improve fertility outcomes in
patients with Localised Adenomyosis

28. Uterine sparing surgery
• Usually by hysteroscopy
• Resection of specific points
• Placenta accreta is a common complication
• Uterine rupture has been reported

29. MCQ
• Do u think adenomyosis a disease of :-
a) Nulliparous
b) Multiparous
c) Low parity
d) All above