Adenomiosis uterina

Adenomyosis: A possible cause of infertility in women

Until a few years ago there was little knowledge about adenomyosis. What we already did know is, that is associated with heavy bleeding and severe menstrual pain, as well as a uterus with a larger size. Nowadays, thanks to advances in ultrasound techniques, it is easier for experts to diagnose adenomyosis.

This uterine alteration can cause fertility problems, affecting the successful implantation of an embryo, which leads to recurrent implantation failures.

What is adenomyosis and when does it occur?

Adenomyosis is a condition that occurs when tissue that covers the interior of the uterus (endometrium) penetrates the muscle layer of the uterus (myometrium). During menstruation, this tissue within the myometrium swells and bleeds the same way as the lining of the uterus does.

According to the World Health Organisation, one in 10 women between the ages of 35 and 50 suffer from adenomyosis. Furthermore, in recent years this condition has also been confirmed to appear in younger women.

What is the difference between endometriosis and adenomyosis?

In more than 10 per cent of cases, adenomyosis appears accompanied by endometriosis. Such is the relationship between them that in the field of gynaecology and reproductive medicine, adenomyosis is often also referred to as internal endometriosis.

To understand the difference between the two conditions, it is important to know that a woman’s uterus has two layers:

  1. The endometrium: the inner layer. Each cycle the endometrium prepares for the implantation of an embryo. If this does not occur, the inner layer is shed, causing menstruation.
  2. The myometrium: muscle layer of the uterus. It is responsible for uterine contractions during childbirth and menstruation.

At first glance, endometriosis and adenomyosis are similar gynaecological conditions that affect the tissues of the uterus and the endometrial lining. However, they should be known as two different conditions.

Endometriosis (one of the main causes of infertility in women) is the appearance of endometrial tissue outside the uterus, causing inflammatory lesions in other organs and complicating becoming pregnant through natural ways.

While adenomyosis is the appearance of endometrial cells in the myometrium only, the layer located between the endometrium and the outer layer of the uterus (also known as the perimetrium or serosa).


Types of Adenomyosis

Depending on how much it has spread and its location, we differentiate between two types of adenomyosis:

  • Focal: Also called adenomyoma, which appears in the form of tumours located within the myometrium.
  • Diffuse: This is the most common type of adenomyosis. It affects a large part of the myometrium, causing the uterus to the increase in size excessively.

On the other hand, depending on the location of the endometrial tissue within the myometrium, we differentiate between superficial adenomyosis and deep adenomyosis.

Main symptoms of adenomyosis

Many of the symptoms that adenomyosis causes also occur in other benign gynaecological diseases (such as endometriosis, uterine myomatosis and uterine polyps), leading to confusions in diagnosis. Furthermore, approximately 30% of women suffering from adenomyosis may be asymptomatic.

Although this condition is associated with a wide range of symptoms, the most common symptoms are:

  • Pelvic pain in the form of dysmenorrhoea (painful menstrual periods), dyspareunia (pain during sexual intercourse) and chronic pelvic pain.
  • Metrorrhagia or non-menstrual bleeding.
  • Reduced fertility
  • Infertility


How is adenomyosis diagnosed?

According to Dr Christos Roukoudis, gynaecologist at IVF-Life, the process of diagnosing adenomyosis should begin with “a specialist suspecting symptoms. Although reaching the exact diagnosis can be a challenge, the appearance of certain symptoms can help the expert reach a diagnosis”.

Imaging techniques are crucial for a good diagnosis. Through a 2D (and eventually a 3D) transvaginal ultrasound the expert will be able to diagnose an enlarged uterus caused by either diffuse or focal adenomyosis. Often it can be necessary to perform an MRI scan to confirm the condition.

How does adenomyosis affect a woman’s fertility?

Some studies show that up to 22% of women who are unable to become pregnant suffer from adenomyosis.

Furthermore, it has been confirmed that this condition can cause difficulties during pregnancy, leading to ectopic pregnancies or causing repeated miscarriages.

In addition, in some cases, it can also complicate the implantation of the embryo in the uterus, associating it with implantation failure.

The growth of endometrial tissue that generates adenomyosis may have its origin in the excessive amount of oestrogen produced by the woman’s body. This hormone is responsible for regulating the menstrual cycles and the female reproductive system. In such cases, a hyper-estrogenic and progesterone-resistant environment is created in the woman’s body, which alters endometrial receptivity.


What fertility techniques are recommended for women with adenomyosis?

In the cases of adenomyosis, the patient’s uterus must be adequately prepared for the treatment. For this reason, it is recommended to initially perform ovarian stimulation to obtain a number of oocytes and then perform in vitro fertilisation. The oocytes will be fertilised in the laboratory to later place the embryos with the highest chances of implantation in the woman’s uterus.

Another possibility would be to opt for egg vitrification and consider treatment of this condition at a later time.

The administration of contraceptives or oestrogen receptor drugs before starting a fertility treatment may be the best option to reduce the symptoms of this condition.

Generally, adenomyosis does not affect the outcome of in vitro fertilisation (IVF), but in some cases, patients must also be treated with gonadotropin-releasing hormone (GnRH) agonists, which can cause a temporary condition similar to menopause.

The importance of a good treatment strategy

Protocols for assisted reproduction treatment at IVF-Life are adapted to the needs of each individual patient. During the patient’s first visit we focus on obtaining an accurate diagnosis. Only in this way will we be able to determine from the start whether the existence of this condition is responsible for the patient’s infertility.

Adenomyosis is a condition that causes fertility problems for many women of childbearing age and its diagnosis is still as difficult to obtain as that of its “sister” endometriosis. Although adenomyosis occurs in a much smaller number (only 1% of the female population), any woman can suffer from adenomyosis; yet many of them are not even aware of it.

If you suspect you may be suffering from this condition, you may contact our team of experts. Pain impairing you from living a normal life is not normal and requires medical attention.