Fertility in adenomyosis: surgery or IVF?

Area of Science:

• Reproductive Medicine
• Gynecology
• Infertility Research

Background:

• Adenomyosis, a chronic condition where endometrial tissue invades the myometrium, significantly impairs female fertility.
• Current diagnostic tools like MRI and 3D ultrasound have advanced, yet optimal fertility management strategies remain debated.
• The optimal timing and choice between uterus-sparing surgery and in vitro fertilization (IVF) are subjects of ongoing discussion.

Purpose of the Study:

• To review and analyze current evidence on fertility management in women with adenomyosis.
• To explore the relationship between uterine morphology, treatment responses, and IVF/intracytoplasmic sperm injection (ICSI) outcomes.
• To propose a pragmatic, evidence-based framework for individualized treatment planning.

Main Methods:

• A narrative review of studies sourced from PubMed, Scopus, and Web of Science.
• Focus on uterine morphology, hormonal and surgical interventions, and assisted reproductive technology outcomes.
• Analysis of prognostic markers and their correlation with fertility outcomes.

Main Results:

• Infertility in adenomyosis is linked to junctional zone (JZ) remodeling, inflammation, hypercontractility, and reduced endometrial receptivity.
• Poor prognostic markers include JZ thickness ≥8.5 mm, uterine volume 90-130 mL, and specific MUSA features, correlating with lower live birth rates and higher miscarriage risk.
• Larger uterine volumes (>130 cm³) and thicker JZ significantly predict pregnancy failure and reduced cumulative live birth rates.

Conclusions:

• Assessment of JZ morphology, uterine volume, and MUSA features is critical for personalized fertility treatment in adenomyosis.
• A proposed framework suggests medical therapy (GnRH agonists) followed by IVF for moderate uterine volumes and JZ thickness.
• Uterus-sparing surgery followed by IVF or direct IVF are options for specific uterine/JZ measurements, guiding clinical decision-making.