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Adenomyosis associated infertility: Review of systematic reviews

Aboubakr Elnashar

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Adenomyosis associated infertility: Review of systematic reviews

  1. 1. Adenomyosis associated infertility: An Overview of Systematic reviews Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  2. 2. INTRODUCTION  Uterine adenomyosis (AD)  was thought to be  found only in parous women  final diagnosis was made at histology after hysterectomy.  With  better imaging techniques  women attending clinics at older ages  adenomyosis is diagnosed with increasing frequency in infertile women ABOUBAKR ELNASHAR
  3. 3.  Uterine adenomyosis  ± relevant factor for infertility  either  impairing implantation or  leading to early miscarriage  Conservative interventions have been advocated, with variable reports of their impact on fertility.  This presents a dilemma for clinicians managing such patients. ABOUBAKR ELNASHAR
  4. 4. II. AIM OF THE REVIEW I. Prevalence in a subfertile population II. Reproductive outcomes III. Efficacy of fertility sparing treatment options III. METHODS Pub med search: from 2000 to May 2019 Key words:  Systematic Reviews  Adenomyosis  Infertility  IVF/ICSI ABOUBAKR ELNASHAR
  5. 5. WHAT IS THE BEST EVIDENCE? ABOUBAKR ELNASHAR
  6. 6. AUTHORS YEAR TITEL I. Mahesh et al 2012 Adenomyosis and subfertility: SR of prevalence, diagnosis, treatment and fertility outcomes II. Vercellini et al 2014 Adenomyosis &reproductive performance after surgery for rectovaginal and colorectal endometriosis: SR& MA. III. IVF OUTCOME Vercellini et al 2014 Uterine adenomyosis and IVF outcome Younes, Tulandi 2017 Effects of adenomyosis on IVF outcomes: MA. IV. FERTILITY SPARING SURGERY Younes , Tulandi 2018 Conservative Surgery for Adenomyosis and Results: SR. Tan et al 2018 Reproductive Outcomes after Fertility-Sparing Surgery for Focal and Diffuse Adenomyosis: SR Rocha et al, 2018 Fertility-Sparing Treatment of Adenomyosis in Patients With Infertility: SR RESULTS ABOUBAKR ELNASHAR
  7. 7. I. Adenomyosis and subfertility: SR of prevalence, diagnosis, treatment and fertility outcomes. Mahesh et al, 2012  Prevalence:  present in a high proportion of women with infertility  particularly those with  endometriosis and/ or  menorrhagia and dysmenorrhoea.  using MRI  79% with endometriosis  28% without endometriosis (Kunz et al., 2005) ABOUBAKR ELNASHAR
  8. 8.  Diagnosis:  MRI and ultrasound  non-invasive tests  equivalent accuracy 3 or more should be present (Mehasseb , Habiba, 2009) 1. Blurring of endomyometrial interface 2. Echogenic nodules 3. Heterogeneous myometrial areas 4. Globular asymmetrical uterus 5. Irregular cystic spaces 6. Myometrial linear striations 7. Parallel shadowing Sagittal TVS ABOUBAKR ELNASHAR
  9. 9.  Treatment:  Most studies  Uncontrolled  case series.  The true impact of various treatments on fertility is not known.  There are no fertility-sparing treatments of proven effectiveness.  Currently, there is no evidence that we should find and treat adenomyosis in patients who wish to conceive. ABOUBAKR ELNASHAR
  10. 10. II. Adenomyosis and reproductive performance after surgery for rectovaginal and colorectal endometriosis: SR and MA. Vercellini et al, 2014  Adenomyosis  often coexists with deep endometriosis  may have a detrimental effect on fertility more than deep endometriosis  Surgery for deep endometriosis including colorectal resection  adopted as a fertility-enhancing procedure  lack of convincing evidence  may cause major complications. ABOUBAKR ELNASHAR
  11. 11. 5 observational studies  Screening for adenomyosis is recommended before suggesting difficult and risky surgery  Surgery for deep endometriosis associated with adenomyosis have a marginal effect on the likelihood of conception. Adenomyosis Without adenomyosis CPR 11.9% 43% ABOUBAKR ELNASHAR
  12. 12. III. UTERINE ADENOMYOSIS AND IVF OUTCOME 1. Vercellini et al, 2014 1865 women in 9 selected studies  4 prospective observational studies: 665  5 retrospective studies: 1200  Heterogeneity: Qualitative and quantitative: high.  Women with adenomyosis had a 28% reduction in CPR at IVF/ICSI compared with women without adenomyosis. After IVF/ICSI Adenomyosis Without adenomyosis. CPR 40.5% 49.8% Miscarriage 31.9% 14.1% ABOUBAKR ELNASHAR
  13. 13.  CPR in infertile women with or without adenomyosis undergoing IVF/ICSI.  Forest plot showing individual and combined effect size estimates and 95% Cis  Horizontal lines indicate 95% CIs; boxes show the study-specific weight; diamond represents combined effect size; dashed line indicates the overall estimate.ABOUBAKR ELNASHAR
  14. 14.  Miscarriage rate in clinical pregnancies obtained at IVF/ICSI in women with or without adenomyosis.  Forest plot showing individual and combined effect size estimates and 95% CIs)  Horizontal lines indicate 95% CIs; boxes show the study specific weight; diamond represents combined effect size; dashed line indicates the overall estimate.ABOUBAKR ELNASHAR
  15. 15. 2. Effects of adenomyosis on in IVF outcomes: MA. Younes, Tulandi, 2017 11 studies  519 with adenomyosis Vs.  1,535 without adenomyosis  significantly lower  Implantation rate  CPR  OPR  LBR  Significantly higher  Miscarriage rate ABOUBAKR ELNASHAR
  16. 16. Implantation rates in women without and with adenomyosis. ABOUBAKR ELNASHAR
  17. 17. CPR per embryo transfer in women without and with adenomyosis. ABOUBAKR ELNASHAR
  18. 18. LBR per cycle in women without and with adenomyosisABOUBAKR ELNASHAR
  19. 19. Cumulative spontaneous CPR in women who underwent surgery for adenomyosis and who did not (favoring surgery). ABOUBAKR ELNASHAR
  20. 20.  Surgical treatment or  Treatment with GnRHa  increases the spontaneous CPR in women with adenomyosis.  Adenomyosis has a detrimental effect on IVF clinical outcomes.  Pretreatment with  long-term GnRHa or  long protocol could be beneficial. ABOUBAKR ELNASHAR
  21. 21. IV. FERTILITY SPARING SURGERY FOR ADENOMYOSIS ABOUBAKR ELNASHAR
  22. 22. Diagrammatic depiction of the stages of the triple-flap method. ABOUBAKR ELNASHAR
  23. 23. 1. Conservative Surgery for Adenomyosis and Results: SR. Younes, Tulandi , 2018  27 studies  10 prospective and 17 retrospective  1398 patients.  For preserving fertility and relieving symptoms:  Med TT is usually the first choice  Excisional surgery could be performed for refractory adenomyosis.  Excision of adenomyosis is effective for  Symptom control: menorrhagia and dysmenorrhea  Most probably for adenomyosis-related infertility. ABOUBAKR ELNASHAR
  24. 24.  After conservative surgery.  Over three-fourths of women will experience symptom relief  Three-fourths of them conceived  Recurrence rates: differ from no recurrence to almost one-half of patients.  Conservative surgery for adenomyosis improves  Pelvic pain  AUB  Possibly fertility.  The best method of surgery is yet to be seen. ABOUBAKR ELNASHAR
  25. 25. 2. Fertility-Sparing Treatment of Adenomyosis in Patients With Infertility: SR Rocha et al,2018  6 studies evaluated surgical treatments of adenomyosis  10 studies evaluated ART for infertility related to adenomyosis ABOUBAKR ELNASHAR
  26. 26.  Spontaneous CPR: very low (18.2%).  Using GnRH analogues for 24w after surgery, the pooled spontaneous CPR was higher (40.7% vs 15.0%; P = .002).  No significant difference was observed in the other outcomes. ABOUBAKR ELNASHAR
  27. 27.  long stimulation protocol had better outcomes compared to short stimulation protocol  CPR (43.3% vs 31.8%; P = .0001)  LBR (43.0% vs 23.1%; P = .005)  Miscarriage rate (18.5% vs 31.1%; P < .0001)ABOUBAKR ELNASHAR
  28. 28. 3. Reproductive Outcomes after Fertility-Sparing Surgery for Focal and Diffuse Adenomyosis: SR Tan et al, 2018  18 studies  1396 infertile women with focal and diffuse AD.  focal AD  mean pregnancy and miscarriage rates of 52.7% and 21.1% , respectively  diffuse AD had mean pregnancy and miscarriage rates of 34.1% and 21.7%, respectively. ABOUBAKR ELNASHAR
  29. 29. ABOUBAKR ELNASHAR
  30. 30. ABOUBAKR ELNASHAR
  31. 31. ABOUBAKR ELNASHAR
  32. 32. Diffuse AD Focal AD PTL 4.5% 10.9% Uterine rupture 6.8% 0% ABOUBAKR ELNASHAR
  33. 33.  Surgery may be appropriate for women with 1. Pelvic pain or menorrhagia 2. Younger infertile women who have failed medical management 3. Older women with infertility despite ART 4. RPL 5. RIF ABOUBAKR ELNASHAR
  34. 34. CONCLUSION I. Prevalence  Presents in a high proportion of women with infertility  Often coexists with deep endometriosis.  Screening for adenomyosis is recommended II Outcome:  Had a 28% reduction in CPR at IVF/ICSI compared with women without adenomyosis ABOUBAKR ELNASHAR
  35. 35. III. Treatment:  Med TT is usually the first choice  Excisional surgery could be performed for refractory adenomyosis.  Pretreatment with long-term GnRHa or long protocol could be beneficial.  Fertility sparing surgery:  effective for  symptom control such as menorrhagia and dysmenorrhea  adenomyosis-related infertility  LBR after surgery for  Focal adenomyosis: 38%  Diffuse adenomyosis: 30% ABOUBAKR ELNASHAR
  36. 36. ABOUBAKR ELNASHAR You can get this lecture &424 lectures from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277 44884091351/ 2.Slide share web site 3.elnashar53@hotmail.com 4.My clinic: Elthwara St. Mansura
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