2. INTRODUCTION
Uterine adenomyosis (AD)
was thought to be
found only in parous women
final diagnosis was made at histology after
hysterectomy.
With
better imaging techniques
women attending clinics at older ages
adenomyosis is diagnosed with increasing
frequency in infertile women
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3. Uterine adenomyosis
± relevant factor for infertility
either
impairing implantation or
leading to early miscarriage
Conservative interventions have been advocated,
with variable reports of their impact on fertility.
This presents a dilemma for clinicians managing
such patients.
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4. II. AIM OF THE REVIEW
I. Prevalence in a subfertile population
II. Reproductive outcomes
III. Efficacy of fertility sparing treatment options
III. METHODS
Pub med search:
from 2000 to May 2019
Key words:
Systematic Reviews
Adenomyosis
Infertility
IVF/ICSI
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6. AUTHORS YEAR TITEL
I.
Mahesh et al 2012 Adenomyosis and subfertility: SR of prevalence, diagnosis,
treatment and fertility outcomes
II.
Vercellini et al 2014 Adenomyosis &reproductive performance after surgery for
rectovaginal and colorectal endometriosis: SR& MA.
III. IVF OUTCOME
Vercellini et al 2014 Uterine adenomyosis and IVF outcome
Younes,
Tulandi
2017 Effects of adenomyosis on IVF outcomes: MA.
IV. FERTILITY SPARING SURGERY
Younes ,
Tulandi
2018 Conservative Surgery for Adenomyosis and Results: SR.
Tan et al 2018 Reproductive Outcomes after Fertility-Sparing Surgery for
Focal and Diffuse Adenomyosis: SR
Rocha et al, 2018 Fertility-Sparing Treatment of Adenomyosis in Patients With
Infertility: SR
RESULTS
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7. I. Adenomyosis and subfertility: SR of prevalence,
diagnosis, treatment and fertility outcomes.
Mahesh et al, 2012
Prevalence:
present in a high proportion of women with
infertility
particularly those with
endometriosis and/ or
menorrhagia and dysmenorrhoea.
using MRI
79% with endometriosis
28% without endometriosis
(Kunz et al., 2005)
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8. Diagnosis:
MRI and ultrasound
non-invasive tests
equivalent accuracy
3 or more should be present
(Mehasseb , Habiba, 2009)
1. Blurring of endomyometrial interface
2. Echogenic nodules
3. Heterogeneous myometrial areas
4. Globular asymmetrical uterus
5. Irregular cystic spaces
6. Myometrial linear striations
7. Parallel shadowing
Sagittal TVS
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9. Treatment:
Most studies
Uncontrolled
case series.
The true impact of various treatments on fertility is
not known.
There are no fertility-sparing treatments of proven
effectiveness.
Currently, there is no evidence that
we should find and treat adenomyosis in
patients who wish to conceive.
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10. II. Adenomyosis and reproductive performance after
surgery for rectovaginal and colorectal
endometriosis: SR and MA.
Vercellini et al, 2014
Adenomyosis
often coexists with deep endometriosis
may have a detrimental effect on fertility more than
deep endometriosis
Surgery for deep endometriosis including colorectal resection
adopted as a fertility-enhancing procedure
lack of convincing evidence
may cause major complications.
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11. 5 observational studies
Screening for adenomyosis is recommended
before suggesting difficult and risky surgery
Surgery for deep endometriosis associated with
adenomyosis
have a marginal effect on the likelihood of conception.
Adenomyosis Without adenomyosis
CPR 11.9% 43%
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12. III. UTERINE ADENOMYOSIS AND IVF OUTCOME
1. Vercellini et al, 2014
1865 women in 9 selected studies
4 prospective observational studies: 665
5 retrospective studies: 1200
Heterogeneity: Qualitative and quantitative: high.
Women with adenomyosis had a 28% reduction in
CPR at IVF/ICSI compared with women without
adenomyosis.
After IVF/ICSI Adenomyosis Without adenomyosis.
CPR 40.5% 49.8%
Miscarriage 31.9% 14.1%
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13. CPR in infertile women with or without adenomyosis undergoing IVF/ICSI.
Forest plot showing individual and combined effect size estimates and 95% Cis
Horizontal lines indicate 95% CIs; boxes show the study-specific weight; diamond
represents combined effect size; dashed line indicates the overall estimate.ABOUBAKR ELNASHAR
14. Miscarriage rate in clinical pregnancies obtained at IVF/ICSI in women with
or without adenomyosis.
Forest plot showing individual and combined effect size estimates and 95% CIs)
Horizontal lines indicate 95% CIs; boxes show the study specific weight; diamond
represents combined effect size; dashed line indicates the overall estimate.ABOUBAKR ELNASHAR
15. 2. Effects of adenomyosis on in IVF outcomes: MA.
Younes, Tulandi, 2017
11 studies
519 with adenomyosis Vs.
1,535 without adenomyosis
significantly lower
Implantation rate
CPR
OPR
LBR
Significantly higher
Miscarriage rate
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17. CPR per embryo transfer in women without and with
adenomyosis.
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18. LBR per cycle in women without and with adenomyosisABOUBAKR ELNASHAR
19. Cumulative spontaneous CPR in women who underwent surgery
for adenomyosis and who did not (favoring surgery).
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20. Surgical treatment or
Treatment with GnRHa
increases the spontaneous CPR in women with
adenomyosis.
Adenomyosis has a detrimental effect on IVF clinical
outcomes.
Pretreatment with
long-term GnRHa or
long protocol could be beneficial.
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23. 1. Conservative Surgery for Adenomyosis and
Results: SR.
Younes, Tulandi , 2018
27 studies
10 prospective and 17 retrospective
1398 patients.
For preserving fertility and relieving symptoms:
Med TT is usually the first choice
Excisional surgery could be performed for refractory
adenomyosis.
Excision of adenomyosis is effective for
Symptom control: menorrhagia and dysmenorrhea
Most probably for adenomyosis-related infertility.
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24. After conservative surgery.
Over three-fourths of women will experience
symptom relief
Three-fourths of them conceived
Recurrence rates:
differ from no recurrence to almost one-half of
patients.
Conservative surgery for adenomyosis improves
Pelvic pain
AUB
Possibly fertility.
The best method of surgery is yet to be seen.
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25. 2. Fertility-Sparing Treatment of Adenomyosis in
Patients With Infertility: SR
Rocha et al,2018
6 studies evaluated surgical treatments of
adenomyosis
10 studies evaluated ART for infertility related to
adenomyosis
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26. Spontaneous CPR: very low (18.2%).
Using GnRH analogues for 24w after surgery, the pooled spontaneous CPR
was higher (40.7% vs 15.0%; P = .002).
No significant difference was observed in the other outcomes.
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27. long stimulation protocol had better outcomes compared to short stimulation
protocol
CPR (43.3% vs 31.8%; P = .0001)
LBR (43.0% vs 23.1%; P = .005)
Miscarriage rate (18.5% vs 31.1%; P < .0001)ABOUBAKR ELNASHAR
28. 3. Reproductive Outcomes after Fertility-Sparing
Surgery for Focal and Diffuse Adenomyosis: SR
Tan et al, 2018
18 studies
1396 infertile women with focal and diffuse AD.
focal AD
mean pregnancy and miscarriage rates of 52.7% and 21.1% , respectively
diffuse AD had mean pregnancy and miscarriage rates of 34.1% and 21.7%,
respectively.
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32. Diffuse AD Focal AD
PTL 4.5% 10.9%
Uterine rupture 6.8% 0%
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33. Surgery may be appropriate for women with
1. Pelvic pain or menorrhagia
2. Younger infertile women who have failed medical
management
3. Older women with infertility despite ART
4. RPL
5. RIF
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34. CONCLUSION
I. Prevalence
Presents in a high proportion of women with
infertility
Often coexists with deep endometriosis.
Screening for adenomyosis is recommended
II Outcome:
Had a 28% reduction in CPR at IVF/ICSI
compared with women without adenomyosis
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35. III. Treatment:
Med TT is usually the first choice
Excisional surgery could be performed for
refractory adenomyosis.
Pretreatment with long-term GnRHa or long
protocol could be beneficial.
Fertility sparing surgery:
effective for
symptom control such as menorrhagia and
dysmenorrhea
adenomyosis-related infertility
LBR after surgery for
Focal adenomyosis: 38%
Diffuse adenomyosis: 30%
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36. ABOUBAKR ELNASHAR
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