Adenomyosis and Fertility: Impact on Pregnancy Chances
Adenomyosis significantly reduces the likelihood of getting pregnant by impairing embryo implantation, altering uterine peristalsis, and creating an unfavorable endometrial environment. 1, 2
How Adenomyosis Affects Fertility
- Adenomyosis disrupts the myometrial junctional zone (JZ), leading to perturbed uterine peristalsis which interferes with sperm transport and embryo implantation 3
- Women with adenomyosis show reduced endometrial receptivity with defects in implantation markers 3, 1
- Adenomyosis causes abnormal concentrations of intrauterine free radicals and altered decidualization, creating a hostile environment for embryo development 3
- The condition is associated with lower pregnancy rates, lower live birth rates, and higher miscarriage rates in both natural conception and assisted reproductive technology (ART) 1, 2
Diagnostic Considerations
- Accurate diagnosis of adenomyosis can now be made through advanced imaging techniques including transvaginal ultrasound and MRI 3
- MRI can identify junctional zone disruption and thickening, which correlates with reproductive dysfunction 3
- Adenomyosis may be present alongside other fertility-affecting conditions like endometriosis, complicating diagnosis and treatment 4
Treatment Options to Improve Fertility
Medical Management
- GnRH agonists prior to attempting conception can improve fertility outcomes in women with adenomyosis 1, 2
- For women undergoing assisted reproductive technology (ART), pre-treatment with GnRH modulators before frozen embryo transfer may increase live birth and clinical pregnancy rates 2
- Progestin IUDs and combined oral contraceptives can help manage adenomyosis symptoms but are not compatible with conception attempts 5
Surgical Options
- Conservative surgical approaches via laparoscopy or laparotomy have been used to restore fertility in women with adenomyosis 6
- Pregnancy has been documented following excisional procedures, though these pregnancies may carry a higher risk of uterine rupture compared to pregnancy following myomectomy 2
- It remains unclear whether surgical ablation or resection increases pregnancy rates in women with adenomyosis 2
Other Interventions
- Uterine artery embolization (UAE) has shown promising results for symptom control in adenomyosis 5
- While successful pregnancy has been reported after UAE for adenomyosis, comprehensive data on fertility and pregnancy outcomes is lacking, and patients should be counseled accordingly 7
- MRI-guided focused ultrasound has potential but remains under-investigated for fertility preservation in adenomyosis 6
Fertility Outcomes After Treatment
- Both pharmaceutical and surgical treatments for adenomyosis appear to have a positive impact on reproductive outcomes 1
- GnRH agonist protocols show the most promising results for improving implantation rates in women with adenomyosis undergoing ART 1, 2
- Women with adenomyosis still have lower clinical pregnancy rates even after fertility treatments compared to women without adenomyosis 8
Pregnancy Complications in Adenomyosis
- Women with adenomyosis have increased risk of preterm delivery and pregnancy-induced hypertension 8
- The risk of other complications such as intrauterine fetal death and gestational diabetes remains controversial 8
- Close monitoring during pregnancy is recommended for women with adenomyosis 8
Clinical Approach
- For women with adenomyosis seeking pregnancy, consider GnRH agonist treatment for 3-6 months prior to conception attempts 1, 2
- For those undergoing ART, a long GnRH agonist protocol before embryo transfer shows the most promising results 1
- Conservative surgical approaches may be considered for focal adenomyosis (adenomyoma) when medical management fails 6, 3
- Patient counseling should include realistic expectations about reduced fertility potential and increased pregnancy complications 8