Adenomyosis & IVF

Adenomyosis is a condition in which tissue similar to the endometrium invades the muscular wall of the uterus. In the past it was diagnosed only after hysterectomy; today it is identified with ultrasound and MRI.

It often coexists with endometriosis and can cause heavy periods and pain. The question that concerns couples is how much it affects IVF — and what we can realistically do about it.

What is adenomyosis and how common is it in infertility?

In adenomyosis, endometrial glands and stroma are found within the myometrium, the muscular wall of the uterus. This causes enlargement of the uterus, chronic inflammation and disruption of its normal contractions.

Its frequency in women with infertility is estimated at roughly 20–25%, with substantial variation depending on the diagnostic criteria and age. It is more common in women of older reproductive age.

How does adenomyosis affect IVF?

The data are not entirely uniform, but taken together adenomyosis is associated with lower implantation rates, higher miscarriage rates and ultimately a lower live-birth rate compared with women without adenomyosis.

The likely mechanisms include the inflammatory environment of the uterus, reduced endometrial receptivity and abnormal, excessive uterine contractions that may hinder implantation.

How strong is the scientific evidence?

Here honesty is needed. The evidence on adenomyosis and IVF is limited: the studies are mostly retrospective, with small numbers of patients and differing diagnostic criteria. In addition, adenomyosis often coexists with endometriosis and older age, which make interpretation difficult.

For that reason, while the general trend points to less favourable outcomes, we do not have strong randomized trials that establish the optimal management with certainty. Decisions are made on the basis of existing, imperfect knowledge.

What is the role of the “ultra-long” GnRH-agonist protocol?

One strategy used in selected cases is prior “down-regulation” of the uterus with GnRH agonists for two to three months before embryo transfer — the so-called ultra-long protocol. The aim is to reduce inflammation and the size of the uterus before implantation.

Some studies, mostly retrospective, show improved pregnancy rates and reduced miscarriage with this approach in women with adenomyosis. The evidence remains limited, so the protocol is applied on an individual basis and not as a general rule.

Are there other treatment options?

The “freeze-all” strategy, with a later frozen-embryo transfer once the uterine environment has been optimized, is often used in women with adenomyosis. In severe, focal forms, some centres consider surgical removal, but this carries risks for the uterus and is not standard practice.

It is important to stress that many women with adenomyosis do achieve pregnancy through IVF. The condition lowers the chances, it does not eliminate them, and management is planned individually.

What should I discuss with my doctor?

Ask for a clear picture: how extensive the adenomyosis is on ultrasound or MRI, whether endometriosis coexists, and how these affect your own prognosis given your age and ovarian reserve.

Ask, too, to have it explained honestly where the evidence is strong and where it is limited. A realistic, individualized plan is better than promises unsupported by data.

Summary

Adenomyosis is associated with lower implantation rates, more miscarriages and a lower birth rate in IVF, although the evidence is limited and often confounded by endometriosis and age. The ultra-long GnRH-agonist protocol and the freeze-all strategy are used in selected cases, with encouraging but not definitive data. Many women with adenomyosis do have a baby through IVF; management is individualized and honest about the limits of current knowledge.

Sources: Systematic reviews on the impact of adenomyosis on IVF outcomes (Human Reproduction Update, Reproductive BioMedicine Online); cohort studies of the ultra-long GnRH-agonist protocol in adenomyosis (Frontiers in Endocrinology).

⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340

ARTICLE 22 · FEMALE CONDITIONS & FERTILITY