T İMUR GURGAN MD
G U R G A N C L I N I C W O M E N ’ S H E A LT H , I N F E R T I L I T Y A N D I V F C E N T E R A N K A R A , T U R K E Y
Adenomyosis
What are the diagnostic and Therapeutic Options
in Infertile Patients ?
Adenomyosis
The benign invasion of endometrium into the myometrium, producing a diffusely
enlarged uterus which microscopically exhibits ectopic, non‐neoplastic,
endometrial glands and stroma
surrounded by the hypertrophic and
hyperplastic myometrium
Risk Factors and Typical Symptoms
Pelvic pain,
Dysmenorrhea,
Menorrhagia unresponsive to hormonal therapy or uterine curettage.
Subfertility
Advancing age Multiparity
Early menarche
Previous uterine surgery
Clinical/Histologic Classification
Diffuse adenomyosis
Focal Adenomyosis
adenomyoma
cystic adenmyosis
Polypoid adenomyosis
typical polypoid adenomyomas atypical polypoid adenomyomas
Other forms
adenomyomas of the endocervical type retroperitoneal adenomyomas
Adenomyosis associated pathologies
Parazzini F et al, EJOG 2009
Adenomyosis
Leiomyomas
35-55%
3-7%
1.4% 2.3%
Adenocarcinoma
Endometrial hyperplasia
Endometrial polyps
6-20%
Endometriosis
Diagnosis
Transvaginal ultrasonography
‐2D US
‐3D US
‐Doppler US
MRI
Ca ‐125
HSG
USG
1. Subjective enlargement of the uterine corpus
2. Heterogeneity of myometrium/hypo‐echoic striations
3. Asymmetrically thickened myometrium between anterior and posterior walls
4. Myometrial cysts
5. Poor definition of endo‐myometrial junction
(Junctional Zone )
MRI
MR imaging have equal sensitivity but a higher specifity (sensitivity:MR 0.7 and TVS 0.68 (P:0.66);
specifity: MR 0.86 and TVS 0.65 (p:0.03))
Dueholm M. Fertility and Sterility 2001
MRI, typically presents as either diffuse or focal thickening of inner myometrium or an ill‐defined myometrial nodule and characterized by a homogeneous thickening of JZ.
Bazot M et al., 2001; Hum Reprod 16:2427‐33
永友美輝
JUNCTIONAL ZONE
Junctional zone myometrium is a functional layer forcing endometrial glands into direct contact with the
myometrium.
Undergoes cyclical changes ,
Max growth between days 8‐16
Myometrial distrinct contraction waves(peristaltic activity) originates exclusively from JZ
During follicular and periovulatory phases, contraction
waves have a cervicofundal orientation and their amplitude and frequency increase significantly towards the time of ovulation
These waves are probably implicated in many aspects of the physiological reproductive process: endometrial
differentiation, menstruation, sperm transport and implantation.
Undefinited junctional zone in diffuse adenomyosis
Thickness and infiltration of junctional zone in focal adenomyosis
Exacoustos C. et al, Ultrasound Obstetr Gynecol 2011
Irregular endometrium with pitting endometrial defects, altered vascularization, and cystic hemorrhagic lesions may be associated with the process
Fernandez, 2007
Adenomyosis: WHAT IS THE IMPACT ON FERTILITY
Different peristaltic activity due to;
Structural and functional defects of the uterine JZ Altered desidualisation due to;
Existance of several dysregulated proteins
The presence of abnormal levels of intrauterine free radicals Abberant endometrial development throughout the menstrual cycle Lack of expression of some implantation markers
Altered consentrations of implantation markers
Classification of Uterine-Sparing Techniques
Complete exicission of adenomyosis
Used in the cases of localized adenomyosis and selected cases of difuse adenomyosis
adenomyomectomy cystectomy
Cytoreductive surgery/partial adenomyomectomy
Used in the cases of diffuse adenomyosis,including the partial removal of the clinically recognizable non‐microscopic lesions
Nonexcissional techniques
interventions where removal of adenomyotic tissue not included
Avaible Methods of Uterine-Sparing Surgical Treatment
Complete excission of Adenomyosis/Adenomyomectomy
Classic Technique Grimbizis 2008,Wangethal 2009
Modicification in wall reconstruction : U‐shaped suturing Sun et al.,2011
Modicification in wall reconstruction : Overlapping flaps Tacheshi et ai.,2006
Tripple flap method Osada et al.,2011
Cytoreductive Surgery/Partial Adenomyomectomy
Classic technique:exicission of diffuse adenomyosis Fujishita et al.,2004
Transverse H incission Fujishita et al.,2004
Wedge resection of the uterine wall Sun et al.,2011
Asymmetric dissection of uterus Nishida et al.,2010
Laparoscopically assisted vaginal excission
Non ‐excissional Techniques
Complete adenomyomectomy classic and
Overlaping Flaps Techniques
永友美輝 44
Surgery for Severe Cases of Adenomyosis
Wedge ‐resection of the uterine tissue,
ｆollowed by the approximation of the remaining myometrium and serosa.
3
Thin 1ayer of uterine wall
After Wedge‐resection
The approximated site is depressed
Management of adenomyosis by the triple‐flap method
1 month(s) after surgery
Contrast-MRI
Recovery of blood flow After surgery ?
avascular area
After the uterine blood flow is recovered
untill almost normal flow may be allowed conceive
avascular area
Conservative Surgical Intervention
Improve the symptoms from diffuse adenomyosis
In cases of focal adenomyosis there is a good possibility of permanent treatment
In diffuse adenomyosis who are interested future pregnancy agressive excission of the lession with secure restoration of the uterine wall thickness migth offer best results
Preoperative diagnosis and assessment of the location and size of the adenomyosis using MRI outmost important to remove completely each focus of the adenomyosis
Grimbizis G et al., Fertil Steril,2014
Adenomyosis and Conservative Surgery
Tubal patency must be retained in order to assure fertilization
The uterine cavity environment must be retained in order to assure implantation
The uterine wall must be constructed property so that it can sustain a normal pregnancy
The rate of spontaneous abortion (38.8%) were
reported to be higher than in the general population
after the excisional procedures due to uterine scar
tissue formation.
Fedele, 1993L/S vs L/T & Which Technique is Better ?
L/T has been of choice in adenomyosis surgery because of the extension of the disease within the myometrium and the difficulty in suturing the remaining uterine
wedges after the excision .Gives ability to the surgeon to palpate and recognize the adenomyotic lesions
intraoperatively
However; when the adenomyotic lesions can be clearly outlined via MRI , L/S is feasible either for ablation of the adenomyotic foci or excision of adenomyomas
Grimbizis G et al., Fertil Steril,2014
Preoperative and postoperative use of GnRH agonist thearpy
Can be used 4‐6 months prior and/or after surgery
Preoperative use of GnRH treatment ; advantages :
*reduction of uterine vascularity
*reduction of operative bleeding(favor L/S) disadvantages :
* demarcation between adenomyosis and normal myometrium is difficult
increased endometrial perforation risk
*difficulty in removing large amounts of adenomyotic lesions
Fujishita A, Gynecol Obstet Invest, 2004;Wang PH, Fertil Steril , 2000
Adenomyosis and Uterine Rupture
There is a slightly increased risk in isolated case reports with no prior cytoreductive surgery for adenomyosis
The uterine rupture risk increases significantly after conservative surgery for adenomyosis
The risk is reported as high as one out of eight women experiencing uterine rupture in pregnancy/labour after cytoreductive surgery for adenomyosis
Wang et al., 2006
Non-Excissional Techniques
Combination of excissional and non‐excissional techniques
Hysteroscopic non‐excissonal techniques /operative
hysteroscopy,rollerball endometrial ablation,transerviacal resection of endometrium,endomyometrial resection
Laparoscopic non‐excisssional techniques
Laparoscopic electrocoagualtion of the adenomyosis and laparoscopic uterine artery ligation
Other techniques
Ablation of focal adenomyosis with high frequency ultrasound
Alchol instillation under ultrasound quidiance for cystic denomyosis Radiofrequency ablation of focal adenomyosis
Microwave endometrial ablation
Baloon thermoablation of diffuse adenomyosis
Fertility After Treatment
Surgical techniques involve to modify the anatomy of the uterus that contribute to enhance postoperative pregnancy rates
There is a trend for increased fertility after surgery for adenomyosis in the complete excision group ,but more data are needed to elicit safe results for clinical practice
After complete excision, the dysmenorrhea reduction,
menorrhagia control, and pregnancy rate were 82.0%, 68.8%, and 60.5%, respectively.
After partial excision, the dysmenorrhea reduction,
menorrhagia control, and pregnancy rate were 81.8%, 50.0%, and 46.9%, respectively.
Ultrasound evidence of adenomyosis is found in a significant number of women presenting with infertility and has a negative impact on the outcome of IVF/ICSI
Of the 17 articles assessed in detail, 9 were finally
selected based on diagnosis of adenomyosis at magnetic resonance imaging or transvaginal ultrasonography.
A total of 1865 women were enrolled in the 9 selected studies, 665 of whom in 4 prospective observational studies, and 1200 in 5 retrospective studies.
Adenomyosis and IVF/ICSI
Adenomyosis associated with a 28% reduction of clinical pregnancy in IVF/ICSI cycles
There is no signifcant reduction if selecting the studies with only one IVF/ICSI cycles ??
Double risk of miscariages
30% reduction of in the live birth rate
Severe forms may be associated with higher detrimental effect
Confounding effect of endometriosis should be assessed
Preterm birth,IUGR,preexlempsia,red degenaration, ectopic pregnancy, postpartum haemorrhage may result in defective remodeling of spiral arteries
Vercelini P et al., 2014
CONCLUSSION
Screening for endometriosis before embarking on
medically assisted reproductive technologies should be encouraged
Surgery may be an option in selected cases prior ART’
The potentiellay productive role of down regulation protocols needs further evaluation
