Impact of Adenomyosis on Women’s Fertility and Its Management

What Is Adenomyosis?

When the endometrial tissue (the lining of the uterus) starts growing abnormally into the muscular wall of the uterus, this condition is termed adenomyosis. As a result of adenomyosis, the uterus gets thickened and enlarged. It can cause excessive bleeding and painful periods in women.

What Are the Causes, Symptoms, and Complications of Adenomyosis?

Causes- The exact causes of adenomyosis are not well known. Some theories explain the possible reasons, such as after baby delivery, developmental defects, or invasion of bone marrow stem cells into uterine muscles.

Symptoms- Painful cramps and prolonged menstrual bleeding, painful sexual intercourse, or pelvic pain. The symptoms of adenomyosis closely resemble that of endometriosis (where endometrial tissue grows outside the uterus).

Complications- Adenomyosis negatively impacts the overall life of women in day-to-day activities, depression, anxiety, irritability, increased risk of anemia, infertility, and other uterine conditions.

How Is Adenomyosis Diagnosed?

In the early days, it was difficult to diagnose the causes of infertility related to adenomyosis without hysterectomy (complete or partial removal of the uterus). It was a painful and invasive procedure. However now, with non-invasive and high-quality imaging techniques like magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS), it is much easier to achieve a diagnosis.

What Is the Connection Between Adenomyosis and Infertility?

Adenomyosis and its impact on women’s infertility were not very clear previously. Adenomyosis was primarily associated with multiparity (giving birth to more than one child). Due to improved imaging techniques like ultrasound, clinicians can now better diagnose and correlate infertility with adenomyosis.

Adenomyosis is primarily seen in middle-aged women over 35 years old or young women with endometriosis. Some studies show that infertility is more commonly diagnosed in cases where the woman has adenomyosis coexisting with other conditions like leiomyoma, polyps, or endometriosis. However, more research is still underway to find a direct association between adenomyosis and infertility.

How Does Adenomyosis Impact Fertility in Women?

Adenomyosis makes the uterus enlarged and bulky. Thus, it becomes inefficient to provide a fertile environment at various levels. The following reasons are thought to be responsible for infertility in women with adenomyosis-

1. Impaired Transportation of the Uterotubal Complex- Due to the distorted anatomy of the uterus, the uterotubal transport is blocked. This impairment results in blockage of sperm migration and embryo transport. Intrauterine peristalsis may also lead to abnormal sperm and oocyte transport through the uterine cavity, increasing intrauterine pressure.

2. Altered Endometrial Receptivity- Due to increased production of estrogen hormone and inflammation, the endometrial function and receptivity are altered.

3. Impaired Implantation- High chances of failed implantation are present due to reduced expression of adhesion molecules, implantation markers, and altered genetic function (gene-HOXA10) required for embryo development.

What is the effect of adenomyosis on In-Vitro Fertilization (IVF)?

Assisted reproductive technology (ART) includes IVF (in vitro fertilization) and ICSI (intracytoplasmic sperm injection); these are the procedures used for the treatment of infertility by the handling of either eggs, embryos, or sperms.

If a woman with adenomyosis is experiencing infertility, she may be a candidate for ART such as in vitro fertilization (IVF). From the ova of the female, the eggs are removed and then fertilized with sperm in a laboratory through a process called in vitro fertilization (IVF). The remaining embryos are placed into the uterus (womb) of the woman. While ART does not cure adenomyosis, it may help women with the condition to conceive.

Adenomyosis can impact IVF treatment adversely. Implantation is impaired due to the following reasons:

• Thickened myometrium (muscular outer layer of the uterus).

• Abnormal expression of adhesion molecules (integrins).

• Lower endometrial receptivity.

• Altered expression of gene HOXA10.

Is Natural Pregnancy Possible With Adenomyosis?

Adenomyosis causes symptoms that make the routine life of a woman very difficult. It is also thought to affect her ability to get pregnant negatively. But, if a woman with adenomyosis is able to conceive, there are still high chances of miscarriage.

What Are the Possible Treatments for Infertility With Adenomyosis?

The management of adenomyosis for infertility can vary from case to case, and healthcare providers should be consulted to narrow down on suitable treatment decisions. The appropriate treatment for adenomyosis depends on the severity of the symptoms, age, and reproductive goals of the patient. Either medical or surgical therapy can treat infertility in women with adenomyosis. A good strategic treatment can improve pregnancy outcomes and live birth rates.

Various therapies include-

1. Medical Management- These include:

• Medications- Ibuprofen or Acetaminophen, which are available without a prescription, can provide relief from the pain that is commonly associated with adenomyosis.

• Hormonal Therapy- Hormonal therapy, such as birth control pills, may help regulate the menstrual cycle and reduce pain and bleeding.

• Uterine Artery Embolization (UAE): Tiny particles are injected into the uterine arteries, blocking blood flow to the adenomyosis tissue, which can reduce pain and bleeding.

• GnRH Agonists- Gonadotropin-releasing hormone (GnRH) agonist treatment desensitizes the pituitary gland. It induces apoptosis, and decreases angiogenesis and inflammation.

GnRH agonist treatment causes pseudo menopause (a menopause-like condition characterized by reduced ovarian function, no menstruation, and a decrease in adenomyotic tissue).

GnRH agonist treatment and conservative or combination surgery have better results than GnRH alone. IVF treatment achieves better success when GnRH agonist treatment is also given. However, medical management does not necessarily improve the fertility.

2. Surgical Management- Various types of fertility-sparing surgery are conducted like:

Adenomyomectomy- Although hysterectomy is advised for severe adenomyosis, a less invasive and more effective technique known as adenomyomectomy is used if the uterus needs to be preserved. Surgical removal of only the abnormal tissues is performed.

It can be achieved by:

• H-Incision Method- H-shaped incision is placed to remove the adenomyotic tissue surgically.

• Triple-Flap Method- Reconstruction of the uterine wall is done using healthy uterine muscles.

• Laparoscopic Cytoreductive Surgery- Removal of the adenomyotic lesion by laparoscopic excision.

High-Intensity Focused Ultrasound Ablation (HIFU)- It is a non-invasive procedure used to treat focal and diffuse adenomyosis. The process includes ablation of the adenomyotic lesion using a very intense and focused beam of ultrasound radiation. The uterine lining is destroyed, reducing heavy bleeding and cramping associated with adenomyosis. It is a highly preferred procedure as it causes minor trauma, fewer complications, lower cost, and faster recovery. It decreases the painful symptoms and increases the potential to preserve fertility.

Hysterectomy: In severe cases, where other treatments do not work, removal of the uterus surgically by hysterectomy may be suggested to eliminate the symptoms of adenomyosis. This procedure is usually considered only in severe cases or in women who have crossed the childbearing age.

Conclusion

Adenomyosis is a gynecological disorder seen commonly in middle-aged women and sometimes in young women (with coexisting conditions). Due to abnormal growth of endometrial cells in the muscular lining of the uterus, the result is an enlarged bulky uterus with symptoms like- painful periods, heavy vaginal bleeding, and an altered lifestyle of the women. Adenomyosis alters the form and function of the uterus such that it may lead to infertility in some women.

In earlier times, hysterectomy was considered the only option, but in recent times doctors prefer conservative surgical interventions. The strategic combination of medical and surgical treatments can lead to a healthy pregnancy, a higher rate of live birth, and it has shown improvement in overall symptoms.