What are the best treatment options for a patient with primary infertility and adenomyosis?

Treatment of Primary Infertility with Adenomyosis

For patients with primary infertility and adenomyosis, medical management (GnRH agonists) or uterine artery embolization (UAE) should be the initial therapy, with cytoreductive surgery reserved for severe cases unresponsive to first-line treatments. 1

Initial Treatment Algorithm

First-Line: Medical Management

• GnRH agonists represent the primary medical therapy for adenomyosis in patients desiring pregnancy, as they suppress disease activity and can improve reproductive outcomes 2, 3
• Medical management should be trialed for 3-6 months before pursuing more invasive therapies 1
• After cytoreductive surgery (if performed), a 6-month course of GnRH agonist therapy is advisable before attempting conception, as adenomyosis tends to recur rapidly 3
• Oral contraceptive pills, progestins, and danazol temporarily suppress the menstrual cycle and are not appropriate for patients actively pursuing pregnancy 2

Second-Line: Uterine Artery Embolization

• UAE is usually appropriate for initial therapy in reproductive-age patients with adenomyosis and infertility 1
• A retrospective study demonstrated spontaneous pregnancy rates of 29.5% at 1 year and 40.1% at 2 years following UAE, with a live birth rate of 81% 1
• Long-term symptomatic relief ranges from 65% to 82% in patients with adenomyosis (median follow-up 27.9 months) 1
• UAE should be considered for patients with concomitant adenomyosis and uterine leiomyomas 1

Surgical Options for Refractory Cases

Cytoreductive Surgery (Adenomyomectomy)

• Cytoreductive surgery using Osada's approach should be reserved for severe adenomyosis unresponsive to medical management or UAE 4, 5
• This procedure normalizes menstrual cycles and restores reproductive function in patients with severe disease 4
• In one prospective study, spontaneous pregnancy occurred in 3 of 18 infertility patients (17%) after adenomyomectomy, with 2 delivering full-term babies 4
• Surgery should be performed only by experienced surgeons in dedicated centers due to complexity and risk of myometrial disruption 3, 5
• Delay pregnancy attempts for 4-6 months post-surgery to allow myometrial healing and complete GnRH agonist therapy 3

Important Surgical Considerations

• Cytoreductive surgery is highly effective in ameliorating abnormal uterine bleeding and pelvic pain, but carries post-operative risks and potential obstetric complications 5
• Major obstetric complications (uterine atony, rupture, placenta accreta) do not necessarily increase with adenomyosis during pregnancy, though cesarean delivery is typically recommended after extensive surgery 3
• Hysterectomy remains the only definitive treatment but is obviously not appropriate for patients desiring fertility 2, 5

Emerging Technologies

High-Intensity Focused Ultrasound (HIFU)

• HIFU may prove beneficial in adenomyosis patients planning pregnancy, though evidence remains limited 2
• This non-invasive option preserves the uterus while targeting adenomyotic tissue 2

MR-Guided Focused Ultrasound (MRgFUS)

• Evidence for MRgFUS in fertility enhancement is limited to case reports, and a randomized trial was terminated due to lack of enrollment 1
• This modality should not be considered standard therapy for infertility with adenomyosis at this time 1

Assisted Reproductive Technology Integration

Combined Treatment Approach

• Combined treatment with medical/surgical therapy before assisted reproductive techniques can prove beneficial in adenomyosis patients 2
• After failed conservative treatments, progression to IVF/ICSI should be considered, as female partner age is a critical factor in fertility outcomes 6
• Both partners should undergo concurrent assessment, as couple infertility may involve multiple factors 6, 7

Critical Pitfalls to Avoid

• Never prescribe testosterone to patients desiring fertility, as it completely suppresses spermatogenesis through negative feedback 6, 8
• Avoid delaying referral to assisted reproductive technology when conservative treatments fail, particularly in older patients 6
• Do not perform endometrial ablation or other procedures that exclude pregnancy planning 2
• Recognize that hormonal therapies (oral contraceptives, progestins, danazol) temporarily suppress menstruation and are not compatible with active conception attempts 2