In this commentary, we discuss the associations between adenomyosis, fertility, and obstetric outcomes. A recent meta-analysis on the impact of adenomyosis on reproductive outcomes found a 43% reduction in the odds ratio (OR) for clinical pregnancy and a threefold increase in the risk of miscarriage in women with adenomyosis compared with controls. Moreover, adenomyosis seems to be strongly associated with pre-eclampsia with an OR of almost 8. Also, the risk for small for gestational age was almost fourfold increased, whereas for preterm deliveries was threefold increased. The presence of deep infiltrating endometriosis and adenomyosis seems associated with particularly adverse obstetric outcomes, especially concerning natural conception. Some observations suggest that the probability of clinical pregnancy is considerably low in these cases, around 11.8%. Although several methodological drawbacks prevent definitive conclusions, all these elements should be considered in counseling women with adenomyosis seeking pregnancy, especially in cases of IVF.

Uterine rupture is a fatal medical complication with a high mortality rate. Most cases of uterine rupture occur in late pregnancy or during labor and are mainly related to uterine scarring due to previous surgical procedures. Adenomyosis is a possible risk factor for uterine rupture. However, spontaneous uterine rupture due to severe adenomyosis in a non-gravida-teenaged female has not been reported in the literature to date.A 16-year-old girl was referred to our hospital for acute abdominal pain and hypovolemic shock with a blood pressure of 90/50 mmHg. Radiologic studies revealed a huge endometrial mass with multiple nodules in the lung, suggesting lung metastasis. The patient underwent an emergency total hysterectomy and wedge resection of the lung nodules. Histologically, the uterus showed diffuse adenomyosis with glandular and stromal dissociation. Lung nodules were endometrioma with massive hemorrhage. Immunohistochemistry demonstrated that the tumor cells were positive for PAX8, ER, and PR expression, leading to a final diagnosis of pulmonary endometriosis and uterine adenomyosis. Following surgery, the patient remains in good condition without recurrence.This is the first case of spontaneous uterine rupture due to adenomyosis in a non-gravida adolescent.©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.

Spontaneous uterine rupture, although rare, is a life-threatening obstetric emergency with a high maternal and fetal mortality rate. It can occur without warning, leading to severe complications, including hemorrhage, shock, and fetal demise. The risk factors contributing to uterine rupture are diverse and include a history of uterine surgery (such as cesarean section), trauma to the uterus, abnormal uterine contractions during labor, and underlying conditions like adenomyosis. Identifying and understanding these risk factors are crucial for early detection, timely intervention, and improved outcomes in affected pregnancies.

Spontaneous uterine rupture is a rare, life‐threatening condition typically seen in gravid women with a history of uterine surgery or trauma. This report presents an unusual case of spontaneous uterine rupture in a 29‐year‐old virgin, highlighting the critical importance of early diagnosis and intervention, even in the absence of typical risk factors. A 29‐year‐old nulliparous woman presented with acute onset of severe lower abdominal pain during menstruation. She had no history of sexual activity, uterine surgery, or trauma. A high index of suspicion for spontaneous uterine rupture was raised following a computed tomography (CT) scan. An emergent exploratory laparotomy revealed a rupture at the uterine fundus with extensive necrosis, necessitating a total hysterectomy. Histopathological examination confirmed adenomyosis with significant hemorrhage and vascular thrombosis, without evidence of infection or malignancy. Subsequent investigations identified protein‐S deficiency, which may have contributed to a hypercoagulable state. This combination of factors led to localized ischemia and structural compromise of the uterine wall, ultimately leading to spontaneous rupture. This case underscores the importance of considering spontaneous uterine rupture in the differential diagnosis of acute abdominal pain in women, regardless of conventional risk factors. The coexistence of adenomyosis and protein‐S deficiency might have synergistically contributed to uterine wall compromise and rupture. Early recognition and prompt intervention are essential to prevent severe complications, and evaluation for underlying coagulopathies should be considered to guide management and reduce the risk of adverse outcomes.

Uterine rupture during pregnancy is a serious obstetric complication accompanied by a high incidence of maternal morbidity and mortality, and the presence of uterine scars is the main risk factor. In the present case, uterine rupture occurred in an unscarred uterus in a nonlaboring primigravida woman with adenomyosis and twin pregnancy in the third trimester.

Uterine adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Although adenomyosis was previously considered a disease of multiparous women, it is becoming increasingly evident that it also affects younger nulliparous women and may compromise their fertility potential. It is clear that hysterectomy, the standard approach to definitively manage the disease, is not an option for patients wishing to preserve their fertility, so there is an urgent need to develop novel conservative strategies. We searched the current literature for available methods for conservative management of adenomyosis, including both pharmacological and surgical approaches. There is no existing drug that can cure adenomyosis at present, but some off-label treatment options may be used to tackle disease symptoms and improve fertility outcomes. Adenomyosis in patients wishing to conceive can be ‘treated’ by conservative surgery, though these procedures require highly experienced surgeons and pose a considerable risk of uterine rupture during subsequent pregnancies. While currently available options for conservative management of adenomyosis do have some capacity for alleviating symptoms and enhancing patient fertility perspectives, more effective new options are needed, with gonadotropin-releasing hormone antagonists showing encouraging results in preliminary studies.

Adenomyosis is a chronic, debilitating condition characterised by the presence of endometrial- like glands and stroma within the myometrium. While hysterectomy remains the definitive treatment, uterus- sparing surgeries may be a possible option for patients desiring to maintain fertility. Surgical management, along with medical treatment and/or Assisted Reproductive Technology (ART), can improve outcomes.To provide a step-by-step video demonstration of robotic-assisted excision of diffuse adenomyosis affecting the posterior uterine wall.This video article describes the use of a robotic platform in conjunction with intracavitary indocyanine green (ICG) for the uterus-sparing excision of diffuse adenomyosis.Perioperative data, specifics of the surgical approach, and both objective and subjective outcomes of this surgical approach.A 38-year-old nulligravid patient with a history of chronic pelvic pain and infertility underwent surgical management of adenomyosis following two unsuccessful IVF cycles. The excisional surgery resulted in minimal blood loss (60 ml) and the patient was discharged on the same day of surgery with no complications.In select patients, robotic-assisted surgical management of diffuse adenomyosis can be advantageous. Leveraging the benefits of robotic technology, combined with appropriate surgical techniques, facilitates the performance of extensive surgeries with minimal morbidity and favourable outcomes.

The appropriate surgical treatment of adenomyosis, a benign invasion/infiltration of endometrial glands within the underlying myometrium, remains a subject of discussion. Since 1990, in place of the classical V-shaped resection method, various kinds of surgical management have been attempted, including a uterine muscle flap method that emphasizes fertility preservation, an asymmetric dissection method, and various modified reduction methods. Laparoscopic adenomyomectomy has also become an alternative to laparotomy for surgically managing the focal type of adenomyosis, although it seems to be associated with a higher risk of uterine rupture than laparotomy. This article reviews the surgical treatment of adenomyosis, including 23 uterine rupture cases that occurred during post-adenomyomectomy pregnancies, and provides an updated picture of the state of the field.Copyright © 2018 The Author. Published by Elsevier Inc. All rights reserved.

The treatment for severe adenomyosis has usually been hysterectomy, because there is no line of demarcation between diseased and normal tissue. Yet many such women wish to retain their uterus and some even wish to bear children. This report evaluates the efficacy of a new method of adenomyomectomy, where adenomyotic tissues are radically excised and the uterine wall is reconstructed by a triple-flap method, without overlapping suture lines, to prevent uterine rupture in subsequent pregnancies. This is a prospective case series followed for 10 years from June 1998 to August 2008 of 104 women with severe adenomyosis verified histologically and with magnetic resonance imaging. There was a dramatic reduction in both dysmenorrhoea and hypermenorrhoea and all patients returned to having normal menstrual cycles. Of 26 women who wished to conceive, 16 became pregnant, 14 (53.8%)went to term and delivered a healthy baby and there were no cases of uterine rupture. Adenomyosis symptoms recurred in only four out of 104 cases. The procedure thus resulted in a dramatic reduction in symptoms and allowed over half of women who wished to conceive to go to term without uterine rupture.Copyright © 2010 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Although many studies show that patients with diffuse adenomyosis who underwent fertility-sparing surgery can have a successful pregnancy, their pregnancy outcomes are still controversial. The objective of this study was to determine long-term pregnancy outcomes and possible influencing factors after double-flap adenomyomectomy for patients with diffuse adenomyosis. A total of 137 patients with diffuse adenomyosis who underwent double-flap adenomyomectomy between January 2011 and December 2019 were studied, and correlations between pregnancy outcomes and clinical data, including age and junctional zone measured by magnetic resonance imaging (JZmax-A), were analyzed. The results show that 56 patients (40.9%, 56/137) had 62 pregnancies, including 35 natural pregnancies and 27 assisted reproduction pregnancies, after operation. A univariate regression analysis showed that the pregnancy outcomes were related to age at surgery, visual analog scale (VAS) score of preoperative dysmenorrhea, parity experience, length of infertility, and postoperative JZmax-A. A multivariate regression analysis showed that age at surgery, VAS score of preoperative dysmenorrhea, and postoperative JZmax-A were the independent indicators correlated with pregnancy outcomes. A receiver operating characteristic curve analysis showed that postoperative JZmax-A was the most valuable indicator for predicting pregnancy outcomes. Cumulative pregnancy rates during the first 3 years were 70.1% and 20.9% in the postoperative JZmax-A ≤ 8.5 mm and the postoperative JZmax-A > 8.5 mm groups, respectively. In conclusion, double-flap adenomyomectomy could improve fertility for diffuse adenomyosis, and postoperative JZmax-A might be a promising indicator for predicting pregnancy outcomes.

High intensity focused ultrasound (HIFU) is an effective and safe non-invasive treatment method, widely used in the treatment of uterine fibroids and adenomyosis in the field of gynecology. The side effects in HIFU is low in incidence and mild. HIFU can significantly alleviate the symptoms of patients, reduce lesion volumes, improve quality of life, and has good cost-effectiveness. HIFU can accurately ablate the uterine fibroids and adenomyosis lesions, without destroying normal myometrium and endometrium, and thus HIFU is a promising alternative to myomectomy in uterine fibroids patients with fertility desire. Several studies have shown that in terms of ovarian endocrine function protection, HIFU treatment is superior to uterine artery embolization, and similar to myomectomy. Existing limited researches show that patients with uterine fibroids have a favorable pregnancy rate and live birth rate, as well as a lower natural abortion rate after HIFU treatment. Pregnancy rate after HIFU treatment for uterine fibroids is not lower than myomectomy, and higher than uterine artery embolization. HIFU may have significant advantages in shortening pregnancy interval compared with myomectomy. However, the proportion of cesarean section delivery after HIFU treatment is relatively high, and gestational uterine rupture after HIFU treatment exist in literature. Higher quality clinical data is needed to confirm the pregnancy outcomes and safety after HIFU treatment in future.© 2024. The Author(s).

The aim of this review was to describe the risk factors, diagnosis, and effects on pregnancy of the gynecologic condition adenomyosis.A PubMed, Web of Science, and CINAHL search was undertaken. Citations were limited to the past 30 years.There were 223 articles identified, with 31 articles being the basis of this review. Adenomyosis is a relatively common gynecologic condition that was previously thought to predominantly occur in older women, as it was diagnosed most commonly after a hysterectomy. As imaging techniques have advanced, this condition is now able to be diagnosed much earlier in life and is estimated to affect up to 20% of reproductive aged women. As studies have followed these women through subsequent pregnancies, an increased risk of adverse pregnancy outcomes has been observed. These include miscarriage, preterm birth, preterm prelabor rupture of membranes, small for gestational age, low birthweight, and preeclampsia, among others. This review is to examine the incidence, risk factors, and diagnostic criteria of adenomyosis and to then discuss its role in adverse pregnancy outcomes.Adenomyosis has been predominately a gynecologic condition, but now has been shown to adversely affect pregnancy outcomes. Diagnosis is made with histology, but may be suspected based on magnetic resonance imaging and ultrasound findings. Despite evidence of adverse pregnancy outcomes, there are no established strategies to risk, stratify, or prevent any of these outcomes.

Like endometriosis, uterine adenomyosis is another enigmatic disease and remains a source of controversy. Uterine adenomyosis is characterized by the presence of endometrial glands in the myometrium. Two main theories may explain its pathogenesis: adenomyosis may arise from invagination of the myometrial basalis into the myometrium; or an alternative theory maintains that it may result from metaplasia of displaced embryonic pluripotent müllerian remants or differentiation of adult stem cells. Uterine adenomyosis is responsible for pelvic pain, abnormal bleeding, and infertility. Its diagnosis may be improved by high quality imaging. This issue's Views and Reviews, authors stress the urgent need to establish some systematic classification. Medical and surgical strategies are discussed. It should be emphasized that treatment should be designed according to a patient's symptoms and an individual's needs. Surgical treatment remains a matter of debate. Indeed, the risk of uterine rupture during pregnancy after adenomyomectomy is a reality. Therefore, continued research into new molecules based on the pathogenic mechanisms is vital.Copyright © 2018. Published by Elsevier Inc.

To explore the risk factors, ultrasonic manifestations, clinical features, and maternal and neonatal outcomes associated with complete uterine rupture.

The risk of uterine rupture is a major concern for women who become pregnant after undergoing an adenomyomectomy.The aim of this study was to investigate the association of uterine wall thickness with pregnancy outcome.Uterine wall thickness was measured using sonography and/or magnetic resonance imaging in 23 pregnant women who underwent uterine-sparing surgery for diffuse uterine adenomyosis prior to conception.Of the 23 women, 10 (43.5%) had an early miscarriage and 13 (56.5%) proceeded to delivery. Of the ten early miscarriage cases, two had a uterine rupture caused by excision of the uterine wall to within 7 mm.Wall thickness of the excised uterus was highly associated with uterine rupture. We concluded that optimum wall thickness for conception and preventing uterine rupture during pregnancy may range from 9 to 15 mm.© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

To determine whether there is a correlation between stiffness measured by strain elastography and the severity of dysmenorrhea and to determine the value of elastography in evaluating severe dysmenorrhea in patients with adenomyosis.

The purpose of this study was to assess, if the biomechanical properties of the lower uterine segment (LUS) in women with a previous cesarean section (CS) can be determined by ultrasound (US) elastography. The first aim was to establish an ex-vivo LUS tensile-stress-strain-rupture(break point) analysis with the possibility of simultaneously using US elastography. The second aim was to investigate the relationship between measurement results of LUS stiffness using US elastography in-/ex-vivo with results of tensile-stress-strain-rupture analysis, and to compare different US elastography LUS-stiffness-measurement methods ex-vivo.An explorative experimental, in-/ex-vivo US study of women with previous CS was conducted. LUS elasticity was measured by point Shear Wave Elastography (pSWE) and bidimensional Shear-Wave-Elastography (2D-SWE) first in-vivo during preoperative examination within 24 h before repeat CS (including resection of the thinnest part of the LUS = uterine scar area during CS), second within 1 h after operation during the ex-vivo experiment, followed by tensile-stress-strain-rupture analysis. Pearson's correlation coefficient and scatter plots, Bland-Altman plots and paired T-tests, were used.Thirty three women were included in the study; elastography measurements n = 1412. The feasibility of ex-vivo assessment of LUS by quantitative US elastography using pSWE and 2D-SWE to detect stiffness of LUS was demonstrated. The strongest correlation with tensile-stress-strain analysis was found in the US elastography examination carried out with 2D-SWE (0.78, p < 0.001, 95%CI [0.48, 0.92]). The laboratory experiment illustrated that, the break point - as a surrogate marker for the risk of rupture of the LUS after CS - is linearly dependent on the thickness of the LUS in the scar area (Coefficient of correlation: 0.79, p < 0.001, 95%CI [0.55, 0.91]). Two extremely stiff LUS-specimens (outlier or extreme values) rupture even at less stroke/strain than would be expected by their thickness.This study confirms that US elastography can help in determining viscoelastic properties of the LUS in women with a previous CS. The data from our small series are promising. However whether individual extreme values of high stiffness and consecutive restricted biomechanical resilience can explain the phenomenon of rupture during TOLAC in cases of LUS with adequate thickness remains a question which prospective trials have to analyze before US elastography can be introduced into clinical practice.Copyright © 2018 Elsevier B.V. All rights reserved.

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

Is there a change in magnetic resonance imaging (MRI) criteria of diffuse and focal phenotypes of adenomyosis before and after pregnancy?A retrospective, monocentric, observational study in a single academic tertiary referral centre for endometriosis diagnosis and management. Women were followed for symptomatic adenomyosis, and without a prior history of surgery who give birth after 24+0 weeks. For each patient, pelvic MRI pre- and post-pregnancy was performed by two experienced radiologists with the same image acquisition protocol. Diffuse and focal adenomyosis MRI presentation were analysed before and after pregnancy.Between January 2010 and September 2020, of the 139 patients analysed, 96 (69.1%) had adenomyosis at MRI distributed as follow: 22 (15.8%) presented diffuse adenomyosis, 55 (39.6%) focal adenomyosis and 19 (13.7%) both phenotypes. The frequency of isolated diffuse adenomyosis on MRI was significantly lower before versus after pregnancy (n = 22 [15.8%] versus n = 41 [29.5%], P = 0.01). The frequency of isolated focal adenomyosis was significantly higher before pregnancy than after pregnancy (n = 55 [39.6%] versus n = 34 [24.5%], P = 0.01). The mean volume of all focal adenomyosis lesions on MRI decreased significantly after pregnancy, from 6.7 ± 2.5 mm to 6.4 ± 2.3 mm, P = 0.01.The current data indicate that, based on MRI, there is an increase in diffuse adenomyosis and a decrease in focal adenomyosis after pregnancy.Copyright © 2023 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Adenomyomectomy, a therapeutic option for women with adenomyosis who wish to preserve their fertility, has been reported to pose a risk of developing placenta accreta spectrum (PAS) and uterine rupture in future pregnancies. However, the specific clinical factors contributing to these occurrences remain elusive. This study aimed to explore the association between hysteroscopic findings after adenomyomectomy and the incidence of PAS in subsequent pregnancies. We conducted a retrospective analysis of 10 patients (11 pregnancies) who had undergone hysteroscopy following adenomyomectomy and had later delivered at our hospital. In 6/10 patients, postoperative hysteroscopy revealed endometrial defects. However, subsequent evaluations confirmed endometrial restoration within 7-21 months, with five patients achieving pregnancy afterward. The only other patient conceived naturally without waiting for endometrial restoration, resulting in uterine rupture from the site of the placenta percreta. The incidence of clinically diagnosed PAS during cesarean section was 100% (1/1) in pregnancies with preconceptional endometrial defects, 20% (1/5) in those with endometrial restoration, and 0% (0/5) in pregnancies without endometrial defects. Similarly, the incidence of pathologically diagnosed PAS was 100% (1/1), 60% (3/5), and 20% (1/5) in these groups, respectively. Thus, endometrial defects were frequently detected after adenomyomectomy and recovered over time, whereas one patient without endometrial restoration developed uterine rupture complicated by PAS. This study demonstrates that while the presence of an endometrial defect identified by postoperative hysteroscopy may be a risk factor for the occurrence of PAS in subsequent pregnancies, allowing sufficient recovery time for the endometrium may help reduce the risk of uterine rupture.© 2025. The Author(s).

Adenomyosis focus resection has always been the main surgical method for patients with uterine preservation, but its curative effect and surgical method are still controversial. We improved this method on the basis of the “double-flap method” and combined it with the levonorgestrel intrauterine delivery system (LNG-IUS) and gonadotropin-releasing hormone agonist (GnRH-a) sequential treatment to determine the clinical effect and feasibility of this scheme in the treatment of severe adenomyosis.

This study examined obstetric outcomes in patients diagnosed with uterine adenomyosis.