Does Adenomyomectomy Preserve Fertility?
Yes, adenomyomectomy can preserve and improve fertility in carefully selected women with severe adenomyosis, with pregnancy rates of 30-54.5% reported in prospective studies, though the procedure carries significant risks including uterine rupture during pregnancy and requires highly experienced surgeons. 1, 2
Evidence for Fertility Preservation
The strongest recent evidence comes from prospective clinical trials demonstrating that fertility-preserving adenomyomectomy achieves meaningful reproductive outcomes:
In a 2023 prospective trial of 45 infertile women with severe diffuse adenomyosis, 54.5% (18/33) of those attempting pregnancy conceived after adenomyomectomy, with 30.3% (10/33) achieving viable pregnancies. 1
A 2014 prospective study of 103 women with severe adenomyosis showed that 30% of the 70 patients attempting pregnancy (either naturally or via assisted reproduction) achieved clinical pregnancy, with 16 reaching full-term live birth. 2
Both studies demonstrated significant improvement in dysmenorrhea and menorrhagia symptoms post-operatively, with numeric rating scale scores dropping from 7.28 to 1.56 (p<0.001) and menstrual blood loss decreasing from 140.44 mL to 66.33 mL (p<0.05). 1
Patient Selection Criteria
Not all women with adenomyosis are appropriate candidates for adenomyomectomy:
The procedure is most appropriate for women with severe, symptomatic adenomyosis who have failed medical management and desire fertility preservation. 3, 4
Women presenting with infertility (55.34%), IVF failure (16.50%), recurrent abortion (8.74%), or abnormal uterine bleeding (19.42%) represent the typical candidate profile. 2
The procedure should be reserved for focal or nodular adenomyosis when possible, as diffuse adenomyosis involving the entire uterus makes complete excision nearly impossible. 3, 4
Surgical Technique Considerations
The technical approach significantly impacts outcomes:
The most successful technique involves T- or transverse H-incision of the uterine serosa, preparation of a serosal flap, excision of adenomyotic tissue (ideally with ultrasound guidance), and specialized suturing between residual myometrium and the serosal flap. 1
Alternative approaches include wedge-shaped removal with thin (≤0.5 cm) margins after sagittal incision, with careful layer reconstruction using inverted sutures for the serosal layer. 2
The procedure is technically demanding and requires surgeons with extensive experience in complex uterine reconstruction to minimize complications. 5
Critical Risks and Limitations
Several important caveats must be discussed with patients:
Spontaneous uterine rupture during subsequent pregnancy is a significant risk, as the procedure involves deep myometrial excision and reconstruction. 5, 2
Complete removal of all adenomyotic tissue is often impossible because adenomyosis typically involves the myometrium diffusely, making this a "debulking" or "cytoreductive" procedure rather than curative surgery. 3, 4
Recurrence rates remain a concern, though one study reported only 1/103 patients (0.97%) with relapsed adenomyosis during follow-up. 2
Miscarriage rates remain elevated even after surgery, with 8/18 pregnancies (44%) ending in miscarriage in one series. 1
Adhesion formation is a recognized complication that may further compromise fertility. 2
Alternative Fertility-Preserving Options
When adenomyomectomy is not feasible or desired:
Uterine artery embolization (UAE) provides 94% short-term and 85% long-term symptom improvement in women with adenomyosis, though comprehensive fertility data remain limited. 6
Medical management with levonorgestrel-releasing IUDs or GnRH antagonists provides temporary symptom relief but does not cure the disease or improve fertility outcomes. 6
Combined oral contraceptives reduce bleeding and pain but are less effective than hormonal IUDs and should not be used in women actively attempting conception. 6
Post-Operative Management
After adenomyomectomy, specific protocols are essential:
Patients should be counseled that attempting pregnancy via assisted reproductive technology (IVF-ET or frozen embryo transfer) may be necessary, as 49/70 (70%) of pregnancies in one series required ART. 2
Close obstetric monitoring during pregnancy is mandatory due to uterine rupture risk, with delivery planning requiring high-risk obstetric consultation. 5
Regular follow-up with ultrasound monitoring is needed to detect adenomyosis recurrence, which can occur despite initially successful surgery. 4
When to Avoid Adenomyomectomy
Certain clinical scenarios make adenomyomectomy inappropriate:
Women who have completed childbearing should undergo hysterectomy rather than adenomyomectomy, as hysterectomy provides definitive treatment with approximately 90% patient satisfaction. 6
Diffuse adenomyosis involving the entire uterus without focal lesions makes complete excision impossible and significantly reduces success rates. 3, 4
Patients unable to accept the risks of uterine rupture, recurrence, and potential need for emergency hysterectomy during pregnancy should consider alternative options. 5