What are the next steps for a patient with primary infertility and a poorly defined endometrial-myometrial (EMJ) junction after hysteroscopy with endometrial ploughing?

Management of Poorly Defined Endometrial-Myometrial Junction in Primary Infertility After Hysteroscopy

For a patient with primary infertility and poorly defined endometrial-myometrial (EMJ) junction after previous hysteroscopy with endometrial ploughing, the next step is to perform 3D transvaginal ultrasound or pelvic MRI to evaluate for adenomyosis, as this finding strongly suggests underlying adenomyosis which has a 24.4% prevalence in infertile women and significantly impacts reproductive outcomes.

Understanding the Clinical Significance

A poorly defined EMJ is one of the cardinal ultrasound features of adenomyosis, representing disruption of the junctional zone between endometrium and myometrium 1. This finding is particularly important because:

• Adenomyosis has a 24.4% prevalence in infertile women overall, rising to 29.7% in women aged ≥40 years 1
• The prevalence increases to 34.7% in women with previous ART failure and 38.2% in those with recurrent pregnancy loss 1
• Adenomyosis was diagnosed as a primary finding "de novo" in 80.6% of infertile patients, meaning it often goes unrecognized initially 1

Diagnostic Algorithm

Step 1: Complete Adenomyosis Assessment with 3D Ultrasound

Perform comprehensive 3D transvaginal ultrasound looking for all diagnostic criteria of adenomyosis 1:

• Globular uterine configuration
• Myometrial anterior-posterior asymmetry
• Heterogeneous myometrial echotexture
• Poor definition of the endometrial-myometrial interface (your current finding)
• Subendometrial cysts
• Assess endometrial cavity shape: normal triangular, moderate distortion, or "pseudo T-shaped" morphology 1

Step 2: Grade Severity of Adenomyosis Impact

If adenomyosis is confirmed, classify the impact on the uterine cavity as mild (63.7% of cases), moderate (22.6%), or severe (10.1%) 1. This severity grading directly influences treatment decisions and counseling about reproductive outcomes.

Step 3: Rule Out Concurrent Pathology

Perform diagnostic hysteroscopy with endometrial biopsy if not adequately done previously, as routine hysteroscopy should be a basic part of unexplained infertility workup 2:

• In 100 women with unexplained infertility, hysteroscopy detected abnormalities in 86%: endometrial polyps (31%), endometritis (14%), endometrial hyperplasia (15%), submucous myomas (6%), intrauterine synechiae (7%), and congenital anomalies (7%) 2
• Endometrial biopsy should be performed using Pipelle suction curette, though it may be non-diagnostic in 16% of cases 2
• Adenomyosis coexists with endometriosis in 35.1% of cases, so consider this association 1

Treatment Considerations Based on Findings

If Adenomyosis is Confirmed Without Other Pathology

The evidence does not provide specific guideline-based treatment for adenomyosis-related infertility, but the severity classification helps with counseling 1. Consider:

• Proceeding directly to ART if moderate-to-severe adenomyosis is present, as surgical intervention for adenomyosis (unlike fibroids) is not fertility-preserving
• Optimizing endometrial receptivity becomes critical in these cases

Novel Approach for Thin or Poorly Receptive Endometrium

If the poorly defined EMJ is associated with thin endometrium (<7 mm) or poor endometrial development:

• Hysteroscopic instillation of platelet-rich plasma (PRP) into the endomyometrial junction improved endometrial thickness to ≥7 mm in 75% of patients (24/32) who had previously canceled embryo transfers 3
• This resulted in clinical pregnancy rates of 41.7% (10/24) among those who achieved adequate thickness and underwent transfer 3
• The approach is based on histologically proven regeneration of endometrium from the endomyometrial junction 3

Critical Caveats and Pitfalls

Common Diagnostic Errors to Avoid

• Do not assume the poorly defined EMJ is simply a benign finding—it represents pathology in the majority of infertility cases 1
• Do not proceed with ART cycles without complete evaluation, as undiagnosed adenomyosis significantly impacts implantation and pregnancy outcomes 1
• Hysteroscopy alone may miss adenomyosis, which is primarily a myometrial disorder requiring imaging assessment 1

Important Considerations for Fertility Preservation

• Women with bilateral endometriomas or recurrent ovarian surgery should be counseled about oocyte cryopreservation before further interventions that might compromise ovarian reserve 4
• Age, ovarian reserve, and previous ovarian surgery are the main factors affecting fertility preservation success 4

When to Suspect Alternative Diagnoses

While rare, maintain high suspicion for endometrial stromal sarcoma in cases of submucosal lesions, even though it uncommonly presents as primary infertility 5. Any necrotic-appearing polyp or fibroid warrants careful histopathologic evaluation 5.

Prognosis and Counseling Points

• Adenomyosis severity correlates with reproductive outcomes, making accurate diagnosis and grading essential for realistic counseling 1
• The described severity criteria should guide future treatment decisions and help set appropriate expectations for ART success rates 1
• If adenomyosis is confirmed, patients should understand this is a chronic condition that may require multiple ART cycles or alternative approaches to achieve pregnancy 1