Can adenomyomectomy be offered to a reproductive‑age woman with symptomatic adenomyosis who wishes to preserve fertility?

Adenomyomectomy for Fertility Preservation in Adenomyosis

Adenomyomectomy can be offered to reproductive-age women with symptomatic adenomyosis who desire fertility preservation, but only after medical therapy has failed and only in centers with highly experienced surgeons, as this is not standard-of-care and carries significant risks including uterine rupture during pregnancy. 1, 2

Treatment Algorithm for Adenomyosis with Fertility Preservation Goals

First-Line: Medical Management (Mandatory Initial Step)

• Start with levonorgestrel-releasing IUD (20 μg/day) as first-line therapy, which provides superior symptom control compared to oral contraceptives and reduces menstrual blood loss by 71-95% 3
• If LNG-IUD fails or is not tolerated, trial combined oral contraceptives, though these are less effective than hormonal IUDs 4
• GnRH antagonists (elagolix, linzagolix, relugolix) with mandatory low-dose estrogen-progestin add-back therapy can be used as second-line medical therapy for heavy bleeding, but these suppress fertility during treatment 3, 4
• Tranexamic acid serves as a nonhormonal alternative for bleeding symptoms 4

Critical Limitation of Medical Therapy

• No medical therapy eradicates adenomyotic lesions—all provide only temporary symptom relief with rapid recurrence after discontinuation 3
• Up to 44% of patients experience symptom recurrence within one year after stopping GnRH therapy 3

Second-Line: Surgical Options (Only After Medical Failure)

Adenomyomectomy Candidacy Criteria

• Reserve adenomyomectomy for patients who are refractory to long-term medical treatment or those with focal adenomyoma 1
• Requires centers with surgical expertise in this technically demanding procedure 5
• Best suited for focal/localized adenomyosis rather than diffuse disease 6

Adenomyomectomy Outcomes

• Symptom relief occurs in over 75% of women after conservative surgery 1
• Pregnancy rates: 30% of patients attempting conception achieved clinical pregnancy, with approximately 23% (16/70) resulting in full-term live birth 2
• Among those attempting pregnancy (naturally or with ART), approximately 75% conceived after surgery with or without adjuvant medical treatment 1
• Dysmenorrhea and menorrhagia are significantly reduced post-surgery 2

Surgical Technique Considerations

• The modified technique involves resection of adenomyotic lesions with a thin (≤0.5 cm) margin via wedge-shaped removal after sagittal incision in the uterine body 2
• Reconstruction requires meticulous layer closure with inverted sutures for the serosal layer 2

Major Risks and Complications

• Spontaneous uterine rupture during subsequent pregnancy is a considerable risk 7
• Adhesion formation can occur 2
• Recurrence rates vary from no recurrence to almost 50% of patients, depending on follow-up duration 1
• Only 1% recurrence was reported in one prospective series of 103 patients, but longer follow-up shows higher rates 2

Alternative Fertility-Preserving Interventions (Limited Evidence)

Uterine Artery Embolization (UAE)

• Limited evidence supports UAE for fertility preservation in adenomyosis; comprehensive pregnancy outcome data are lacking 3
• One retrospective cohort (mixing fibroids and adenomyosis cases) reported 29.5% spontaneous pregnancy at 1 year, 40.1% at 2 years, with 81% live-birth rate, but applicability to adenomyosis-only cases is uncertain 3
• Patients must be counseled that UAE is not a standard fertility-preservation option 3

MR-Guided Focused Ultrasound (MRgFUS)

• Evidence is confined to isolated case reports; a randomized trial was terminated due to insufficient enrollment 3
• This modality cannot be recommended for fertility preservation in adenomyosis 3

Common Pitfalls to Avoid

• Do not perform myomectomy alone for adenomyosis—it does not address the disease and is ineffective 4
• Do not assume adenomyomectomy is low-risk—it requires highly experienced surgeons and poses rupture risk 7
• Do not skip medical management—surgery should only follow documented medical treatment failure 1
• Ensure endometrial biopsy has been performed to rule out endometrial cancer or hyperplasia, especially in perimenopausal women 4
• Counsel patients that hysterectomy remains the definitive treatment, and conservative surgery has high recurrence rates 1

Patient Counseling Points

• Adenomyomectomy is not standard-of-care for adenomyosis 7
• Pregnancy outcomes are modest: only 23% achieved full-term live birth in the largest prospective series 2
• Risk of uterine rupture in subsequent pregnancy requires close obstetric monitoring 7
• Symptom recurrence is common and may necessitate eventual hysterectomy 1
• Medical management should be exhausted first unless focal adenomyoma is present 1