This document discusses a case of a 32-year-old woman presenting with primary infertility of 1.5 years. Ultrasound findings show adenomyosis. Adenomyosis can be associated with infertility by decreasing clinical pregnancy and increasing abortion rates. The patient underwent failed ovulation induction and IUI cycles. IVF using an antagonist protocol is recommended as the next step. If IVF fails, conservative surgery may be considered to treat the adenomyosis, followed by another attempt at IVF after 3 months of recovery.

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