Ultrasonographic assessment of

adenomyosis in ART patients

dr.sc. Renato Bauman, prim.dr.med. Klinika za ginekologiju i porodništvo; KB “Sv.Duh”

Poliklinika BetaPlus, Zagreb, Croatia

The XIII Annual Meeting of the Mediterranean Society for Reproductive Medicine (MSRM); Ljubljana, 14.-16.05.2015.

Adenomyosis

Benign disease, hormonal dependent, unknown etiology Presence of heterotopic endometrial glands and

stroma within the myometrium, surrounded by hyperplastic islands of smooth musculature

70-80% women 40-60 yga; diagnosed on hysterectomy specimen

5-25% < 40 yga !!

In 64% with fibroids In 27-79% with endometriosis

Adenomyosis etiology theories Invagination of the deep basal part of

endometrium in the myometrium (estrogen dependent- promotes the process)

Originates from embriologically pluripotential mullerian remnants

Invagination of the basalis along the myometrial lymphatic system

From the bone marrow stem cells (displaced through the vasculature)

Adenomyosis

Junctional zone (JZ) - functional uterine zone between the endometrium and myometrium (norm. < 5 mm) . No changes in thickness during the menstrual cycle

JZ is hormonal dependent structure that governs uterine peristalsis (follicular and periovulatory phase – cervicofundal orientation; luteal phase –myometrial contractions are short – reduced activity helps blastocyst implantation)

trophoblast invasion involves the JZ

JZ in adenomyosis DISTORTED; thickened > 12 mm

Diagnostics

Anamnesis!!! US-TVS; TVCD; 3D HSG; SIS MR

“swiss cheese” appearance

US 2D useful in clinical practise Experience!

enlarged uterus, myometrial heterogenicity

distorted endometrial-myometrial border (JZ)

anterior-posterior miometrial assimetry (thicker

posterior layer)

hipoehogenic zones (“swiss cheese” appearance)

Hiperehogic dots in the myometrium “rain-in-the-forest”

“Swiss cheese”

JZ JZ

Adenomyosis uteri – 2D CD -

neovascularization

TVCD: neovascularization – “spaghetti” sign

Adenomyoma

3D, PD 3D+ GIS (gel infusion sonohysterography) – better

visualization of the borders of the JZ 3D coronal cross section - JZ JZ > 5 mm and JZ dif.≥4 mm (Exacoustos C et al. Ultrasound Obstet Gynecol 2011;37:471-479)

MR

MR: visualization JZ- endomyometrial junctional zone

MR criteria for adenomyosis: (1) JZ ≥12 mm, (2) JZ max./tot. max. Miometrial thickness ›40%, (3) JZ max.- JZ min.= JZ dif. › 5 mm

Novellas S et al. MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. Am J Roentgenol 2011;196:1206

Adenomyosis and reproduction

Indirect indicators linking adenomyosis and infertility

No epidemiological studies / incidence of adenomyosis in infertile population

Overlapping of adenomyosis and endometriosis (>70%)

Tomassetti C, et al. Adenomyosis and subfertility: evidence of association and causation. Semin Reprod Med 2013;31:101.

Possible influence of adenomyosis

No study on humans Negative impact of adenomyosis on

spontaneous conception in female baboons! (without endometriosis!)

Barrier BF, et al. Adenomyosis in the baboon is associated with primary infertility. Fertil Steril 2004;82(3):1091-4

Possible influence of adenomyosis

Changes of JZ – affects endometrial receptivity and function?!

Changes of endometrial vascularization?! Disturbed endometrial immune

response!?

Tomassetti C, et al. Adenomyosis and subfertility: evidence of association and causation. Semin Reprod Med 2013;31:101.

Influence of adenomyosis on ART results

Negative impact on reproductive outcome!

Maheshwari A, et al. Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. Human Reprod Update 2012;18:374 Salim R et al. Adenomyosis reduces pregnancy rates in infertile women undergoing IVF. Reprod Biomed Online 2012;25:273 Thalluri V et al. Ultrasound diagnosed adenomyosis has a negative impact on successful implantation following GnRH antagonist IVF treatment. Hum Reprod 2012;27:3487 Tomassetti C, et al. Adenomyosis and subfertility: evidence of association and causation. Semin Reprod Med 2013;31:101.

Adenomyosis and ART patients

Pre-treatment with aGnRH-agonists significantely increases the success rate!!

Dunselman GAJ et al. ESHRE guideline:management of women with endometriosis. Hum Reprod 2014;0:1-13 Niu Z et al. Long-term pituitary down-regulation before frozen embryo transfer improves pregnancy outcomes in women with adenomyosis. Gynecol Endocrinol 2013;29:1026 Tao T et al. Effects of uterine adenomyosis on clinical outcomes of infertility patients treated with in vitro fertilization/intracytoplasmatic sperm injection-embryo transfer (IVF/ICSI-ET). J South Med Univ 2015;35:248

Adenomyosis treatment

(ART patients)

Gestagens, OHC GnRH agonists Danazol IUS-LNG Uterine artery embolization Surgery – endometrial ablation, laparoscopy,

hysteroscopy, hysterectomy

Stimulation protocol?

Thank you !