Adenomyosis and fertility: from pathophysiology to optimizing reproductive outcomes

Adenomyosis is increasingly diagnosed in reproductive-aged patients, particularly those undergoing assisted reproductive technology, due to advances in imaging and standardized diagnostic criteria. Its association with infertility and adverse obstetric outcomes has prompted growing interest in understanding disease mechanisms, prognostic features, and optimal fertility-focused management strategies. This review summarizes recent evidence on the pathophysiology, diagnosis, and treatment of adenomyosis in the context of reproductive outcomes.

Emerging data highlight multifactorial mechanisms linking adenomyosis to impaired implantation and placentation, including hyperestrogenism, progesterone resistance, junctional zone disruption, immune dysregulation, and chronic inflammation. Studies evaluating imaging features suggest that disease phenotype, lesion size, uterine volume, and junctional zone involvement may influence reproductive outcomes, though findings remain inconsistent. Treatment strategies are evolving, with gonadotropin-releasing hormone agonists, levonorgestrel intrauterine systems, and aromatase inhibitors widely used, and growing evidence supporting pretreatment with prolonged gonadotropin-releasing hormone agonists. Adjunct approaches targeting inflammation, uterine contractility, and hormonal pathways are under investigation. Fertility-preserving procedures, including high-intensity focused ultrasound and adenomyomectomy, show promising but heterogeneous reproductive results.

Adenomyosis remains a clinically heterogeneous condition requiring individualized fertility management. Standardized diagnostic frameworks and well designed prospective studies are needed to clarify prognostic factors and optimize therapeutic strategies to improve reproductive outcomes.