Adenomyosis and Fertility: A Deep Dive into Diagnosis and Management – ARC Summit
Adenomyosis often poses diagnostic challenges, as it can sometimes be mistaken for fibroids during imaging studies. While there is no definitive imaging technique for diagnosing adenomyosis, certain ultrasound characteristics and MRI can suggest its presence. For instance, an ultrasound may initially interpret diffuse, unclear borders in the myometrium as a fibroid, but these could indicate infiltrative endometrial glands and stroma, typical of adenomyosis.
When adenomyosis is suspected, my approach is generally conservative. Despite some studies suggesting that adenomyosis may reduce fertility, I prefer to manage these cases non-surgically initially and provide thorough counseling to the patient. Blood flow patterns observed through Doppler flow can further support the diagnosis, showing dispersed, non-distinctive flow rather than the clear borders seen with fibroids.
During surgery, adenomyosis can be challenging to manage due to excessive bleeding and the difficulty in defining resection margins. For example, in a case where continuous resection was necessary, achieving a clear cavity was difficult, and the soft, glandular tissue complicated suturing, often causing sutures to pull through.
Post-surgically, it’s crucial to discuss with patients the impact adenomyosis may have on fertility. Meta-analyses suggest it is associated with decreased implantation rates, similar to the challenges faced with endometriosis. Patients need to understand that, like endometriosis, not all adenomyotic tissue can be removed, and this might affect their chances of pregnancy.
Regarding treatment, I usually proceed with IVF without initial use of Lupron, even when genetics are involved, placing one or two embryos based on the situation. If implantation fails, I then consider a course of Lupron, although the evidence supporting its effectiveness in improving outcomes for adenomyosis patients is limited. This approach underscores the importance of personalized care and the need to tailor treatment strategies to individual patient needs and conditions.
