Medical or Surgical Treatment of Adenomyosis Before IVF/ICSI? Is It Really Necessary?

Mustafa BAHÇECİ, MD President and Medical Director of Bahçeci Medical Health Group

Diagnosis of Adenomyosis/MRI Diagnosis of Adenomyosis/TVUSG Agenda

• Does adenomyosis have a causative effect on infertility? • Does adenomyosis have detrimental effect on IVF/ICSI outcome? • Does medical treatment of adenomyosis prior to IVF/ICSI improve outcome? • Is it necessary to make a conservative surgical treatment prior to IVF/ICSI?

Possible Pathological Causes of Infertility Due to Adenomyosis

• Abnormal uterotubal transport (peristaltic activity) Kissler et.al. 2007 • Altered endometrial function and receptivity Ulukus et.al. 2006 Fisher et.al.2011 • Abnormal concentrations of intrauterine free radicals Ota et.al. 1998 Igarashi et.al. 2002 • Impaired implantation Mikolajvick et.al. 2006 Xiao et.al. 2010 • Altered decidualization Wicherek et.al 2009 Adenomyosis - Infertility Adenomyosis-IVF/ICSI Outcome Adenomyosis-IVF/ICSI Outcome

Results: -Patient characteristics are similar

-Higher spontaneous abortion rate (66.7%) than controls (P < 0.04; odds ratio = 7.5;95% confidence interval, 1.16-48.56) Adenomyosis-IVF/ICSI Outcome

Results: -Junctional zone thickness increase was significantly correlated with implantation failure Adenomyosis-IVF/ICSI Outcome

Results: -There was no difference in the primary outcome of live birth rate per patient. Adenomyosis-IVF/ICSI Outcome Adenomyosis-IVF/ICSI Outcome Adenomyosis-IVF/ICSI Outcome

Results: -Clinical pregnancy rate of 23.6% compared with 44.6% in the non- adenomyosis group (P=0.017) Adenomyosis-IVF/ICSI Outcome Results -RR of clinical pregnancy ranged from 0.37 (95% CI,0.15–0.92) to 1.20(95%CI,0.58- 2.45),with a significant heterogeneity among studies. Pooling of the results yielded a common RR of 0.72 (95% CI, 0.55 – 0.95). -The RR of miscarriage ranged from 0.57 (95% CI, 0.15 –2.17) to 18.00 (95% CI, 4.08–79.47) Pooling of the results yielded a common RR of 2.12 (95% CI, 1.20–3.75) Adenomyosis-IVF/ICSI Outcome

Results: -Ongoing pregnancy, and live birth among women with adenomyosis were significantly lower than among those without adenomyosis. -The presence of adenomyosis was associated with a 41% decrease in live birth rate (OR 0.59, 95% CI 0.42–0.82).

Adenomyosis-Medical Treatment Prior to IVF/ICSI

Results: -No significant differences were found for any of the IVF/ICSI outcomes between women with and without adenomyosis. Adenomyosis-Medical Treatment Prior to IVF/ICSI Adenomyosis-Medical Treatment Prior to IVF/ICSI

Results: -Treatment with GnRH-a increases the spontaneous pregnancy rate in women with adenomyosis. Adenomyosis-Medical Treatment Prior to IVF/ICSI Bahçeci Experience

601 euploid embryo transfer

47 TV-USG diagnosed adenomyosis cases. Adenomyosis has no detrimental effect!!! Adenomyosis-Surgical Treatment Prior to IVF/ICSI Clinical/Histologic Classification of Adenomyosis • Diffuse adenomyosis • Focal adenomyosis -Adenomyoma -Cystic adenomyosis • Polypoid adenomyomas -Typical polypoid adenomyomas -Atypical polypoid adenomyomas. Uterine-Sparing Techniques Uterine-Sparing Techniques

Adenomyosis-Surgical Treatment Prior to IVF/ICSI Laparotomy or Laparoscopy for Adenomyosis Surgery • Laparotomy remains the ability of the surgeon to palpate and recognize the adenomyotic lesions intraoperatively. • Depending on the extension of the disease within the myometrium and the difficulty in suturing the remaining uterine wedges after the excision by laparoscopy. • The adenomyotic lesion can be clearly outlined via MRI, TV-USG laparoscopy is feasible either for ablation of the foci or excision of adenomyomas. CONCLUSION-I

• There is evidence to support a causal association between adenomyosis and subfertility . • Implantation, clinical pregnancy, and ongoing pregnancy rates are reduced, whereas first- trimester miscarriage rates are increased after ART in women with adenomyosis. • Prolonged downregulation regimens in ART may improve pregnancy rates in women with adenomyosis. CONCLUSION-II

• Definitive conclusions about the efficacy of any of surgical treatments of adenomyosis for subfertility and for implantation failure before IVF are not possible. • Limited data supports uterine-sparing operative treatment of adenomyosis and its variants appear to be feasible for subfertility and before IVF. • Well- designed, RCTs are urgently needed to answer these questions.

Thank You For Your Attention!!