Adenomyosis may also impair chances for IVF success

1. Ultrasonographic
assessment of
adenomyosis in ART
patients
dr.sc. Renato Bauman, prim.dr.med.
Klinika za ginekologiju i porodništvo; KB “Sv.Duh”
Poliklinika BetaPlus, Zagreb, Croatia
The XIII Annual Meeting of the Mediterranean
Society for Reproductive Medicine (MSRM);
Ljubljana, 14.-16.05.2015.

2. Adenomyosis
 Benign disease, hormonal dependent, unknown etiology
 Presence of heterotopic endometrial glands and
stroma within the myometrium, surrounded by
hyperplastic islands of smooth musculature
 70-80% women 40-60 yga; diagnosed on
hysterectomy specimen
 5-25% < 40 yga !!
 In 64% with fibroids
 In 27-79% with endometriosis

3. Adenomyosis etiology theories
 Invagination of the deep basal part of
endometrium in the myometrium (estrogen
dependent- promotes the process)
 Originates from embriologically pluripotential
mullerian remnants
 Invagination of the basalis along the
myometrial lymphatic system
 From the bone marrow stem cells (displaced
through the vasculature)

4. Adenomyosis
 Junctional zone (JZ) - functional uterine zone between the
endometrium and myometrium (norm. < 5 mm) . No changes in
thickness during the menstrual cycle
 JZ is hormonal dependent structure that governs uterine
peristalsis (follicular and periovulatory phase – cervicofundal
orientation; luteal phase –myometrial contractions are short –
reduced activity helps blastocyst implantation)
 trophoblast invasion involves the JZ
 JZ in adenomyosis DISTORTED; thickened > 12 mm

5. Diagnostics
 Anamnesis!!!
 US-TVS; TVCD; 3D
 HSG; SIS
 MR
“swiss cheese” appearance

6. US
 2D useful in clinical practise
 Experience!
 enlarged uterus, myometrial heterogenicity
 distorted endometrial-myometrial border (JZ)
 anterior-posterior miometrial assimetry (thicker
posterior layer)
 hipoehogenic zones (“swiss cheese” appearance)
 Hiperehogic dots in the myometrium “rain-in-the-forest”

8. “Swiss cheese”

9. JZJZ

10. Adenomyosis uteri
– 2D CD -
neovascularization

11.  TVCD:
neovascularization
– “spaghetti” sign

12. Adenomyoma

14. 3D, PD
 3D+ GIS (gel infusion sonohysterography) – better
visualization of the borders of the JZ
 3D coronal cross section - JZ
 JZ > 5 mm and JZ dif.≥4 mm
(Exacoustos C et al.
Ultrasound Obstet Gynecol
2011;37:471-479)

16. MR
 MR: visualization JZ-
endomyometrial junctional
zone
 MR criteria for
adenomyosis: (1) JZ ≥12 mm,
(2) JZ max./tot. max.
Miometrial thickness ›40%,
(3) JZ max.- JZ min.= JZ
dif. › 5 mm
Novellas S et al. MRI characteristics of the uterine junctional zone: from
normal to the diagnosis of adenomyosis. Am J Roentgenol 2011;196:1206

17. Adenomyosis and reproduction
 Indirect indicators linking adenomyosis
and infertility
 No epidemiological studies / incidence
of adenomyosis in infertile population
 Overlapping of adenomyosis and
endometriosis (>70%)
Tomassetti C, et al. Adenomyosis and
subfertility: evidence of association and
causation. Semin Reprod Med 2013;31:101.

18. Possible influence of
adenomyosis
 No study on humans
 Negative impact of adenomyosis on
spontaneous conception in female
baboons! (without endometriosis!)
Barrier BF, et al. Adenomyosis in the
baboon is associated with primary
infertility. Fertil Steril
2004;82(3):1091-4

19. Possible influence of adenomyosis
 Changes of JZ – affects endometrial
receptivity and function?!
 Changes of endometrial vascularization?!
 Disturbed endometrial immune
response!?
Tomassetti C, et al. Adenomyosis and
subfertility: evidence of association and
causation. Semin Reprod Med
2013;31:101.

20. Influence of adenomyosis on
ART results
 Negative impact on reproductive outcome!
Maheshwari A, et al. Adenomyosis and subfertility: a systematic review
of prevalence, diagnosis, treatment and fertility outcomes. Human
Reprod Update 2012;18:374
Salim R et al. Adenomyosis reduces pregnancy rates in infertile women
undergoing IVF. Reprod Biomed Online 2012;25:273
Thalluri V et al. Ultrasound diagnosed adenomyosis has a negative
impact on successful implantation following GnRH antagonist IVF
treatment. Hum Reprod 2012;27:3487
Tomassetti C, et al. Adenomyosis and subfertility: evidence of
association and causation. Semin Reprod Med 2013;31:101.

21. Adenomyosis and ART patients
 Pre-treatment with aGnRH-agonists
significantely increases the success rate!!
Dunselman GAJ et al. ESHRE guideline:management of women
with endometriosis. Hum Reprod 2014;0:1-13
Niu Z et al. Long-term pituitary down-regulation before
frozen embryo transfer improves pregnancy outcomes in
women with adenomyosis. Gynecol Endocrinol 2013;29:1026
Tao T et al. Effects of uterine adenomyosis on clinical
outcomes of infertility patients treated with in vitro
fertilization/intracytoplasmatic sperm injection-embryo
transfer (IVF/ICSI-ET). J South Med Univ 2015;35:248

22. Adenomyosis treatment
(ART patients)
 Gestagens, OHC
 GnRH agonists
 Danazol
 IUS-LNG
 Uterine artery embolization
 Surgery – endometrial ablation, laparoscopy,
hysteroscopy, hysterectomy
 Stimulation protocol?

23. Thank you !