CASE SCENARIO

1. Adenomyosis associated
infertility
Case scenario
Prof. Aboubakr Elnashar
Dr. Mohamed Elsherbiny
Aboubakr ELNASHAR

2. An 32-year-old presented with primary infertility of
1.5 years
 Cycle: Regular 4-5 / 27-29
No history of infection, pelvic operation or pain apart
from mild primary dysmenorrhea
 Weight: 70 Kg Height: 163Cm BMI : 26.4Kg/ m2
Sexual relation 2-3 times / W.
.
Fertile Semen
•Count(M/ml): 18.7 Million/ml
•Total motility 44% N:42%
•progressive motility: 33.6%
•Normal forms: 23.2%Aboubakr ELNASHAR

3. HSG : Both tubes are patent
Aboubakr ELNASHAR

4. HSG : Both tubes are patent
Aboubakr ELNASHAR

5. Adenomyosis
Aboubakr ELNASHAR

6. What is ultrasonographic diagnosis?
A. Fibroid
B. Adenomyosis
Voting
Aboubakr ELNASHAR

7. What is ultrasonographic diagnosis?
A. Fibroid
B. Adenomyosis
Aboubakr ELNASHAR

8. TVS: 3 or more of the followings:
1. Globular uterus:
95% of cases.
2. Asymmetrical thickening:
Anterior or posterior myometrial wall appearing thicker
than its counterpart
3. Mottled heterogeneous myometrial texture:
All cases.
4. Small myometrial hypoechoic cysts:
cystic glands within ectopic endometrial foci: 82%.
5. “Shaggy” indistinct endometrial strips:
82%.
6. Striated projections extending from the
endometrium into the myometrium
(Mehasseb , Habiba, 2009)Aboubakr ELNASHAR

9. If there is still doubt how to differentiate
between adnomyosis and fibroid?
A. HSG
B. 3 DUS
C. Color Doppler US
D. MRI
Voting
Aboubakr ELNASHAR

10. If there is still doubt how to differentiate
between adnomyosis and fibroid?
A. HSG
B. 3 DUS
C. Color Doppler US
D. MRI
Aboubakr ELNASHAR

11. Color or power Doppler
Aboubakr ELNASHAR
AdenomyosisFibroid
Diffuse vascularityPeripheral vascularity

12. 3D US or MRI
Aboubakr ELNASHAR

13. Thickness of the junctional zone > 12 mm
Internal punctate foci of increased signal
T2 MRI confirm
the diagnosis
Aboubakr ELNASHAR

14. TVS Versus MRI
 TVS and MRI, especially T2-weighted images,
are increasingly used for clinical decision-
making.
 In a review of 23 articles, the sensitivity and
specificity of MRI for diagnosing adenomyosis
was 77 % and 89 %, as compared with 72 %
and 81 % for ultrasound
Champaneria etal . Acta Obstet Gynecol Scand Metanalysis2010;89:
1374–84.
Aboubakr ELNASHAR

15. MRI
More accurate in distinguishing adenomyosis from
fibroids in larger uteri.
1. Junctional zone:
Diffuse or focal widening
2. Areas of low signal intensity
{corresponding to smooth muscle hyperplasia}.
3. High signal intensity foci or
4. Linear striations
Aboubakr ELNASHAR

16. Patient asked is adenomyosis the cause
of delay of pregnancy?
A. Yes
B. No
.
Voting
Aboubakr ELNASHAR

17. ●Patient asked is adenomyosis the cause of
delay of pregnancy?
A. Yes
B. No
.
Aboubakr ELNASHAR

18. Adenomyosis and infertility
Strong association between adenomyosis and
fertility.
Infertile women should be evaluated for the
possibility of adenomyosis
[Vercellini et al, 2014 ].
Decreased CPR
Increased abortion rate
Aboubakr ELNASHAR

19. ● She received
2 cycles clomiphene citrate
One cycle letrozole
One cycle HMG &hCG
What is the next step in my delayed
pregnancy?
She asked ?
Aboubakr ELNASHAR

20. What is the best advice for this Patient?
A- Further 2 cycle COS with HMG
&hCG
B- IUI + COS using HMG
C- IUI + COS using HMG preceded by
Gt RH agonist
VotingAboubakr ELNASHAR

21. What is the best advice for this Patient?
A- Further 2 cycle COS with HMG
&hCG
B- IUI + COS using HMG
C- IUI + COS using HMG preceded by
Gt RH agonist
CAboubakr ELNASHAR

22. The patient underwent one failed IUI and
she asked for IVF Trial What is the advised
protocol?
A- Long agonist protocol
B- Short agonist protocol
C- Antagonist protocol
VotingAboubakr ELNASHAR

23. The patient underwent one failed IUI and
was disappointed .She inset to underwent
IVF Trial What is the advised protocol?
A- Long agonist protocol
B- Short agonist protocol
C- Antagonist protocol
CAboubakr ELNASHAR

24. Patient underwent one failed IVF trial and
was disappointed.
Is there any surgical solution?
A- No benefit of conservative surgery
B- Yes after one IVF failure
C- Yes after repeated IVF failure
VotingAboubakr ELNASHAR

25. Patient underwent one failed IVF trial and
was disappointed.
Is there any surgical solution?
A- No benefit of conservative surgery
B- Yes after one IVF failure
C- Yes after repeated IVF failure
Aboubakr ELNASHAR

26. Indications of uterine sparing surgery
Desire for pregnancy.
IVF failures
Age ≤39 years.
{No benefit on fertility ≥40 y
(Kishi et al, 2014)
CPR:
41.3% in those aged ≤ 39 y
3.7% in those aged 40 y}
[odds ratio (OR) 0.77, 95% CI 0.67e0.88, p ¼ 0.002]
Aboubakr ELNASHAR

27. Decision should be taken carefully after
1. Extensive counseling
2. Consideration of alternatives
3. Low index of suspicion with uterine rupture in
women who conceive after uterine sparing surgery
[Pepas et al, 2012 ].
Aboubakr ELNASHAR

28. Management of women with adenomyosis-
associated infertility
(Tsui et al, 2015).
1.Routine infertility investigation plus ORT
 Normal: long agonist protocol and natural
conception
 Abnormal: IVF
2. Failed natural conception or IVF:
repeat IVF
3. Failed IVF:
 conservative surgery
 IVF after 3 m
Aboubakr ELNASHAR

29.  Types (Horng et al, 2014)
Aboubakr ELNASHAR

30. Thanks
Aboubakr ELNASHAR