ASSOCIATION OF ENDOMETRIOSIS AND ADENOMYOSIS WITH PREGNANCY AND INFERTILITY

We performed a comprehensive narrative synthesis of systematic reviews with meta-analysis published in the last five years on the association of endometriosis and adenomyosis with reproductive and obstetric outcomes. The aim was defining the information on which to base preconceptional counselling and clarifying whether and in which cases pregnant women with endometriosis and adenomyosis should be referred to tertiary care centers and followed as high-risk obstetric patients. Reduced pregnancy and live birth rates, and an increased miscarriage rate were observed in women with endometriosis and adenomyosis. The effect was larger in women with adenomyosis than in those with endometriosis. Women with superficial peritoneal and ovarian endometriosis do not appear to be at considerably increased risk of major obstetric and neonatal complications, whereas women with severe endometriosis, whether operated or not, are at several fold increased risk of placenta previa. Moreover, deep infiltrating endometriosis is a risk factor for spontaneous hemoperitoneum in pregnancy and is associated with surgical complications at cesarean section. Overall, women with adenomyosis are at increased risk for various adverse obstetric outcomes, including pre-eclampsia, preterm delivery, fetal malpresentation, postpartum hemorrhage, low birth weight, and small for gestational age. Most studies included in the considered systematic reviews are characterized by substantial qualitative and quantitative heterogeneity. This makes a reliable assessment of the available evidence difficult, and caution should be exercised when trying to derive clinical indications. Nevertheless, women with deep infiltrating endometriosis and severe adenomyosis should be considered at high obstetric risk and could benefit from referral to tertiary care centers where they can be safely followed through pregnancy and delivery. Whether the same should apply also to pregnant women with minimal endometriosis and adenomyosis forms is currently uncertain. Emerging evidence suggests that some adverse reproductive and obstetric outcomes observed in women with endometriosis may in fact be associated with coexisting adenomyosis.