Adenomyosis and Its Effect on Reproductive Outcomes

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Background: Adenomyosis was historically diagnosed on histological examination of the uterus after hysterectomy in older parous women. However, it is becoming more prevalent in women wishing to conceive due to the social trend towards delaying fertility alongside improved imaging techniques. This has led to a dilemma regarding whether adenomyosis should be actively diagnosed and treated in the fertility setting. This review aims to present the current controversies in the evidence with regards to (i) prevalence of adenomyosis in the sub-fertile population (ii) its effects on fertility, (iii) its effects on assisted reproduction techniques (ART), (iv) its effects on obstetric outcomes, (v) the efficacy of fertility sparing treatments in the sub-fertile population. Methods: Searches of Medline and Pubmed were searched independently by the reviewers using the key words ‘adenomyosis’, ‘adenomyoma’, ‘reproductive outcomes’, ‘obstetric outcomes’, ‘miscarriage’, ‘ART’, ‘assisted reproductive technique’. Animal studies were excluded and studies were limited to the English language. Results: The prevalence of adenomyosis in the sub-fertile population is difficult to determine due to a lack of robust epidemiological studies. There are conflicting and variable reports in the literature regarding the effects of adenomyosis on fertility and ART with the majority of studies supporting no association. There is some evidence to suggest that the condition does increase the incidence of preterm labour and premature rupture of membranes once pregnancy is achieved. Most of the fertility sparing treatment options for adenomyosis are cited in case series and reports from limited populations, hence their true effect on conception remains unclear. Conclusion: Further epidemiological studies are needed to evaluate the prevalence and impact of adenomyosis in the sub-fertile population. Currently the existing literature on the effect of the disease on fertility is inconclusive; hence, actively diagnosing and treating the condition is debateable in women wishing to conceive. However, once pregnancy is achieved, the evidence suggests a detrimental effect on delivery rate, with an increased risk of miscarriage and preterm labour. There is some success seen in treating women undergoing assisted reproduction. Clinicians could consider a long course of pituitary down regulation prior to ART in appropriately informed sub-fertile women.