Fertility Topics Explained from the Experts at SFS
Adenomyosis is a condition where endometrial glands develop outside the uterine lining (endometrium), within the muscular wall of the uterus (myometrium). A definitive clinical diagnosis of adenomyosis is difficult to make. The condition should be suspected when a premenopausal woman (usually>25 years of age) presents with pelvic pain, heavy painful periods, pain with deep penetration during intercourse, “unexplained infertility” or repeated miscarriages and thereupon, digital pelvic examination reveals a smoothly enlarged (bulky) soft tender uterus. Previously, a definitive diagnosis was only possible after a woman had her uterus removed (hysterectomy) and it this was inspected under a microscope. However the use of uterine magnetic resonance imaging (MRI) now permits reliable diagnosis. Ultrasound examination of the uterus on the other hand , while not permitting definitive diagnosis, is a very helpful tool in raising a suspicion of the condition. Criteria used to make a diagnosis of adenomyosis on transvaginal ultrasound:
Since there is no proven independent relationship between adenomyosis and egg/embryo quality any associated reproductive dysfunction (infertility/miscarriages) might be attributable to an implantation dysfunction. It is tempting to postulate that this is brought about by adenomyosis-related anatomical pathology at the endometrial-myometrial junction. However, many women with adenomyosis, do go on to have children without difficulty. Given that 30%-70% of women who have adenomyosis also have endometriosis…. a known cause of infertility, it is my opinion that infertility caused by adenomyosis is likely linked to endometriosis where infertility is at least in part due to a toxic pelvic environment that compromises egg fertilization potential and/or due to an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa). Thus, in my opinion all women who are suspected of having adenomyosis-related reproductive dysfunction (infertility/miscarriages) should be investigated for endometriosis and for IID. The latter, if confirmed would make them candidates for selective immunotherapy (using intralipid/steroid/heparin) in combination with IVF. Surgery: Conservative surgery to address adenomyosis-related infertility involves excision of portions of the uterus with focal or nodular adenomyosis and/or excision of uterine adenomyomas. It is very challenging and difficult to perform because adenomyosis does not have distinct borders that distinguish normal uterine tissue from the lesions. In addition, surgical treatment for adenomyosis-related reproductive dysfunction is of questionable value and of course is not an option for diffuse adenomyosis. Medical treatment: There are three approaches.
Fortunately, not all women with adenomyosis are infertile. For those who are, treatment presents a real problem. Even when IVF is used and the woman conceives, there is still a significant risk of miscarriage. Since the condition does not compromise egg/embryo quality, women with adenomyosis-related intractable reproductive dysfunction who fail to benefit from all options referred to above…(including IVF) might as a last resort consider gestational surrogacy.
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