Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Effect of pretreatment with a levonorgestrel-releasing intrauterine system on IVF and vitrified-warmed embryo transfer outcomes in women with adenomyosis

RESEARCH QUESTION

Does the use of a levonorgestrel-releasing intrauterine system (LNG-IUS) improve the ongoing pregnancy rate of vitrified-warmed embryo transfer in women with adenomyosis undergoing IVF?

DESIGN

This retrospective study included 358 women with adenomyosis undergoing IVF. Of these, 134 women were enrolled in the LNG-IUS group and another 224 women were in the control group. All women were screened for adenomyosis by transvaginal ultrasound and magnetic resonance imaging (MRI). There was no significant difference in the ages of women, FSH, cause of infertility, body mass index, total dose of gonadotrophin used and number of oocytes collected between the two groups. All comparisons performed were between patients undergoing vitrified-warmed embryo transfer.

RESULTS

Statistical differences were found in the ongoing pregnancy rates (41.8% vs 29.5%, P = 0.017) between the LNG-IUS group and control group. Logistic regression analysis showed that the odds ratio (OR) of ongoing pregnancy was significantly increased with LNG-IUS usage (adjusted OR = 1.628, 95% confidence interval 1.011-2.622). Also, differences were found in implantation rates (32.1% vs 22.1%, P = 0.005) and clinical pregnancy rates (44% versus 33.5%, P = 0.045) between the LNG-IUS group and control group.

CONCLUSIONS

The results of this study offer some support for evaluating the effect of pretreatment with LNG-IUS in women with adenomyosis in future randomized controlled trials.

P21-Activated Kinase 1 Overactivates in Eutopic Endometrium of Adenomyosis

Adenomyosis is a common gynecological disease, characterized by the existence of endometrium in the myometrium. The pathogenesis of adenomyosis is not fully understood. P21-activated kinase 1 (PAK1) is an effector of small Rho GTPases including CDC42 and RAC1 and plays various roles in cellular biology, especially cytoskeletal remodeling. This study aimed to evaluate whether the expression and activation of PAK1 in adenomyosis were different from normal. Immunohistochemistry was performed to evaluate the expression of PAK1 and its active form phosphorylated-PAK1 (pPAK1) semi-quantitatively in women with and without adenomyosis. Immunofluorescence was performed to locate the distribution of pPAK1. This study found that PAK1 in eutopic endometrium of adenomyosis was overactivated compared to normal. Phosphorylated-PAK1 assembled along the apical surface of glandular cell membrane. In ectopic lesions, PAK1 expression decreased and its activation returned to the baseline. The expression of pPAK1 correlated with the frequency of reproduction. These findings suggest that PAK1 overactivation in the endometrium may be an important event during the development of adenomyosis, meanwhile, decreased phosphorylation may assist to form lesions.

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD). A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE). This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.

Current and Future Medical Treatment of Adenomyosis

Adenomyosis is a benign gynecological disorder associated with abnormal uterine bleeding, dysmenorrhea, dyspareunia and infertility, requiring a life-long management plan through medical or surgical treatment. The choice depends on woman's age, reproductive status and clinical symptoms. However, until now no drug labelled for adenomyosis is available; thus, the present review will focus on medical treatments currently used for adenomyosis and those in development.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. The use of gonadotropin-releasing hormone agonists (GnRH-a) for treating adenomyosis is described blocking the hypothalamic-pituitary-gonadal axis; however, it has long been associated with frequent and intolerable hypoestrogenic side effects. An antiproliferative effect of progestins suggests their use for treating adenomyosis, reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to inducing regression of adenomyosis, relief pain and reduce bleeding. The use of vaginal danazol has therapeutic effect on adenomyosis combining progestogenic and anti-inflammatory activity. The intrauterine device releasing levonorgestrel (Lng-IUD) is widely assessed in menorrhagia, and has been shown to be extremely effective in resolving pain and bleeding symptoms associated with adenomyosis. Recent data show a therapeutic effect of dienogest on adenomyosis symptoms.

New drugs are under development for the treatment of adenomyosis, such as aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs), that produce a hypoestrogenic environment reducing pain, but are correlated with some adverse effects and a recurrence of symptoms after discontinuation of treatment. Selective progesterone receptor modulators (SPRMs) may reduce adenomyosis-associated pelvic pain, by inhibiting endometrial proliferation and suppressing adenomyotic lesion growth, as shown in animal models; however, the long-term effect with SPRMs needs further determination.