Management of Adenomyosis in Women Desiring Pregnancy
For women with adenomyosis who wish to become pregnant, conservative surgical treatment (adenomyomectomy) should be considered after failed medical management, as it can restore fertility with pregnancy rates of 30% and live birth rates of approximately 23% in severe cases. 1
Diagnostic Confirmation
Before initiating treatment, confirm the diagnosis using:
- Transvaginal ultrasound as the primary imaging modality, looking for echogenic nodules and striations radiating from the endometrium into the myometrium, myometrial thickening, and heterogeneous myometrium with blurring of the endometrial border 2
- MRI when ultrasound findings are inconclusive to better characterize the extent of adenomyosis and exclude other pathologies 3
Treatment Algorithm for Fertility Preservation
Step 1: Initial Medical Management (Trial Period)
While medical therapies do not eradicate adenomyosis lesions and provide only temporary symptom relief, they may improve the uterine environment before attempting conception 4:
- Avoid the levonorgestrel-releasing IUD (LNG-IUD) in women actively trying to conceive, as it provides contraception despite being first-line for symptomatic adenomyosis 5, 4
- Consider GnRH antagonists (elagolix, linzagolix, relugolix) with mandatory add-back therapy for 3-6 months to reduce adenomyosis burden before attempting pregnancy, as they reduce uterine volume and are highly effective for heavy menstrual bleeding 4
- Combined oral contraceptives can be used for symptom control during the preconception period, though they are less effective than other options 4
Critical caveat: No medical therapy has been proven to affect future fertility outcomes in women with adenomyosis, and there is no evidence that medical treatment improves pregnancy rates 3
Step 2: Conservative Surgical Management
When medical management fails or adenomyosis is severe:
- Adenomyomectomy (cytoreductive surgery) is the definitive fertility-preserving option, involving resection of adenomatosis lesions with a thin (≤0.5 cm) margin via wedge-shaped removal after sagittal incision in the uterine body 1
- This procedure achieved clinical pregnancy in 30% of patients (21 attempting naturally, 49 with assisted reproduction), with 16 full-term live births among 70 patients who attempted pregnancy 1
- Surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year after conservative surgery 3
- This surgery should only be performed by experienced surgeons in dedicated centers, particularly when concomitant endometriosis is present 6
Step 3: Assisted Reproductive Technology Considerations
- Uterine artery embolization (UAE) has limited data for fertility preservation and comprehensive data on pregnancy outcomes after UAE is lacking; patients must be counseled that this is not a standard fertility-preserving option 7, 3, 4
- One retrospective study showed spontaneous pregnancy rates of 29.5% at 1 year and 40.1% at 2 years following UAE, with a live birth rate of 81%, though this included patients with both fibroids and adenomyosis 7
- MR-guided focused ultrasound (MRgFUS) evidence is limited to case reports and a randomized trial was terminated due to lack of enrollment 7
Important Pitfalls and Caveats
- Adenomyosis may impair chances of successful pregnancy with assisted reproductive techniques, similar to severe endometriosis 8
- Post-adenomyomectomy patients require careful obstetric monitoring due to potential risks of uterine rupture and adhesions 1, 6
- Reconstruction technique is critical: use inverted sutures for the serosal layer ends and meticulous layer reconstruction to reduce rupture risk 1
- Only one patient in 103 had relapsed adenomyosis after adenomyomectomy in the largest prospective series, suggesting good long-term disease control 1