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Adenomyosis associated infertility Case scenario

aboubakr elnashar

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Adenomyosis associated infertility Case scenario

  1. 1. Adenomyosis associated infertility Case scenario Prof. Aboubakr Elnashar Benha university, Egypt Aboubakr ELNASHAR
  2. 2. An 32-year-old presented with primary infertility of 1.5 years  Cycle: Regular 4-5 / 27-29 No history of infection, pelvic operation or pain apart from mild primary dysmenorrhea  Weight: 70 Kg Height: 163Cm BMI : 26.4Kg/ m2 Sexual relation 2-3 times / W. . Fertile Semen •Count(M/ml): 18.7 Million/ml •Total motility 44% N:42% •progressive motility: 33.6% •Normal forms: 23.2%Aboubakr ELNASHAR
  3. 3. HSG : Both tubes are patent Aboubakr ELNASHAR
  4. 4. HSG : Both tubes are patent Aboubakr ELNASHAR
  5. 5. Adenomyosis Aboubakr ELNASHAR
  6. 6. What is ultrasonographic diagnosis? A. Fibroid B. Adenomyosis Aboubakr ELNASHAR
  7. 7. What is ultrasonographic diagnosis? A. Fibroid B. Adenomyosis Aboubakr ELNASHAR
  8. 8. TVS: 3 or more of the followings: 1. Globular uterus: 95% of cases. 2. Asymmetrical thickening: Anterior or posterior myometrial wall appearing thicker than its counterpart 3. Mottled heterogeneous myometrial texture: All cases. 4. Small myometrial hypoechoic cysts: cystic glands within ectopic endometrial foci: 82%. 5. “Shaggy” indistinct endometrial strips: 82%. 6. Striated projections extending from the endometrium into the myometrium (Mehasseb , Habiba, 2009)Aboubakr ELNASHAR
  9. 9. If there is still doubt how to differentiate between adnomyosis and fibroid? A. HSG B. 3 DUS C. Color Doppler US D. MRI Aboubakr ELNASHAR
  10. 10. If there is still doubt how to differentiate between adnomyosis and fibroid? A. HSG B. 3 DUS C. Color Doppler US D. MRI Aboubakr ELNASHAR
  11. 11. Color or power Doppler Aboubakr ELNASHAR AdenomyosisFibroid Diffuse vascularityPeripheral vascularity
  12. 12. 3D US or MRI Aboubakr ELNASHAR
  13. 13. Thickness of the junctional zone > 12 mm Internal punctate foci of increased signal T2 MRI confirm the diagnosis Aboubakr ELNASHAR
  14. 14. TVS Versus MRI  TVS and MRI, especially T2-weighted images, are increasingly used for clinical decision- making.  In a review of 23 articles, the sensitivity and specificity of MRI for diagnosing adenomyosis was 77 % and 89 %, as compared with 72 % and 81 % for ultrasound Champaneria etal . Acta Obstet Gynecol Scand Metanalysis2010;89: 1374–84. Aboubakr ELNASHAR
  15. 15. MRI More accurate in distinguishing adenomyosis from fibroids in larger uteri. 1. Junctional zone: Diffuse or focal widening 2. Areas of low signal intensity {corresponding to smooth muscle hyperplasia}. 3. High signal intensity foci or 4. Linear striations Aboubakr ELNASHAR
  16. 16. Patient asked is adenomyosis the cause of delay of pregnancy? A. Yes B. No . Aboubakr ELNASHAR
  17. 17. ●Patient asked is adenomyosis the cause of delay of pregnancy? A. Yes B. No . Aboubakr ELNASHAR
  18. 18. Adenomyosis and infertility Strong association between adenomyosis and fertility. Infertile women should be evaluated for the possibility of adenomyosis [Vercellini et al, 2014 ]. Decreased CPR Increased abortion rate Aboubakr ELNASHAR
  19. 19. ● She received 2 cycles clomiphene citrate One cycle letrozole One cycle HMG &hCG What is the next step in my delayed pregnancy? She asked ? Aboubakr ELNASHAR
  20. 20. What is the best advice for this Patient? A- Further 2 cycle COS with HMG &hCG B- IUI + COS using HMG C- IUI + COS using HMG preceded by Gt RH agonist Aboubakr ELNASHAR
  21. 21. What is the best advice for this Patient? A- Further 2 cycle COS with HMG &hCG B- IUI + COS using HMG C- IUI + COS using HMG preceded by Gt RH agonist Aboubakr ELNASHAR
  22. 22. The patient underwent one failed IUI and she asked for IVF Trial What is the advised protocol? A- Long agonist protocol B- Short agonist protocol C- Antagonist protocol Aboubakr ELNASHAR
  23. 23. The patient underwent one failed IUI and was disappointed .She inset to underwent IVF Trial What is the advised protocol? A- Long agonist protocol B- Short agonist protocol C- Antagonist protocol Aboubakr ELNASHAR
  24. 24. Patient underwent one failed IVF trial and was disappointed. Is there any surgical solution? A- No benefit of conservative surgery B- Yes after one IVF failure C- Yes after repeated IVF failure Aboubakr ELNASHAR
  25. 25. Patient underwent one failed IVF trial and was disappointed. Is there any surgical solution? A- No benefit of conservative surgery B- Yes after one IVF failure C- Yes after repeated IVF failure Aboubakr ELNASHAR
  26. 26. Indications of uterine sparing surgery Desire for pregnancy. IVF failures Age ≤39 years. {No benefit on fertility ≥40 y (Kishi et al, 2014) CPR: 41.3% in those aged ≤ 39 y 3.7% in those aged 40 y} [odds ratio (OR) 0.77, 95% CI 0.67e0.88, p ¼ 0.002] Aboubakr ELNASHAR
  27. 27. Decision should be taken carefully after 1. Extensive counseling 2. Consideration of alternatives 3. Low index of suspicion with uterine rupture in women who conceive after uterine sparing surgery [Pepas et al, 2012 ]. Aboubakr ELNASHAR
  28. 28. Management of women with adenomyosis- associated infertility (Tsui et al, 2015). 1.Routine infertility investigation plus ORT  Normal: long agonist protocol and natural conception  Abnormal: IVF 2. Failed natural conception or IVF: repeat IVF 3. Failed IVF:  conservative surgery  IVF after 3 m Aboubakr ELNASHAR
  29. 29.  Types (Horng et al, 2014) Aboubakr ELNASHAR
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