Adenomyosis and Infertility: is there a connection between them?

Adenomyosis is a gynaecologic disease characterized by the presence, in the myometrial tissue, of endometrial glands and stroma. The term was written for the first time by Franckl in 1925, but, already in 1860, Rokytansky identified the pathology, defining as „cystosarcoma adenoides uterinum“ the presence of endometrial elements in myometrial layer. The uterine posterior wall is the area most interested by adenomyosis. The ectopic elements are usually associated with a hyperplasia of the surrounding smooth muscle cells. Consequently the uterine volume is increased. The incidence of Adenomyosis varies between 5.7 and 69.6%, but foci of adenomyosis are present in 20-35% of uterus removed for benign disease. Adenomyosis is asymptomatic in 35% of cases. The symptoms, usually due to the increased volume of the uterus, are menorrhagia (40-50%), dysmenorrhoea (10-30%), metrorrhagia (10-12%) and dyspareunia. Is there a correlation between Adenomyosis and Infertility? Could the Adenomyosis be the lacking element in some cases of the Idiopathic Infertility? Adenomyosis is responsible of infertility in 53.8% of patients and of miscarriage in 11%-63%, but, due to the lack of large observational studies, the relation between them is not yet completely defined. We are still waiting some important answers and continuing to walk through a large number of hypotheses.

Surely, the presence of adenomyosis induces important changement in uterine contractility and in free radical production. The presence of atypical uterine activity is the one most important element responsible of the failure of the embryo-transfer. The Nitric Oxide, produced in greater quantity by the endometrial ectopic glands, would induce an endometrial edema. This condition should be responsible of the missed oocyte fecundation and of embryo implantation. How can we diagnose the adenomyosis? This pathology is still difficult to be identified. The first historical important marker is Ca-125, associated today with the seric evaluation of the cystine-aminopeptidase and the leucine-aminopeptidase. Ultrasonography with transvaginal probe presents in diagnosis of Adenomyosis a sensitivity of 86%, a specificity of 86% a positive and a negative predictive value of 71% and 94% respectively. At ultrasound evaluation, the adenomyosis is usually characterized by the presence of heterogeneous hypoechogenic areas with poorly defined margins in the myometrial layer. The hypoechogenicity of the myometrium is due to the hypertrophy of the smooth muscle cells. Small cystic areas are identifiable in 50% of patients. Sensitivity and a specificity of Magnetic Resonance vary from 86 to 100%. Adenomyosis is identified as low density area with a focal or a wide change of the endometrial-myometrial junction. Important diagnostic parameters in diagnosis of Adenomyosis were described for ultrasound and Magnetic Resonance. A myometrial biopsy can be performed hysteroscopically or laparoscopically, but, due to the number of attempts and the unclear deep of needle penetration the sensitivity of the technique is still low. Is there a therapy for adenomyosis in infertile patient? Obviously we need a conservative treatment, that can be reached with: vascular embolization, hormone therapy and surgery, combined or not. Vascular embolization is a quite new therapy of adenomyosis. The treatment is decisive in 92.3% of patients. The hormonal therapy can be done with progestins, estro-progestins, anti-estrogen like Danazol and Gn-RH analogues. The surgical treatment of the infertile patient should consider the residual tissue after the removal of the adenomyotic area. This is an important element to consider for a future pregnancy.