2. DEFINITION
• Adenomyosis is defined by the presence
of ectopic endometrial glands and stroma
within the myometrium.
• The presence of ectopic endometrial
glands and stroma induces a hypertrophic
and hyperplastic reaction in the
surrounding myometrial tissue.
3. • It usually occurs in 4th
or 5th
decade.
• Associated with high parity
• usually associated with other
conditions, such as myoma,
endometrial polyps and endo
metriosis.
5. • adenomyoma describes a
focus of adenomyosis within a
leiomyoma.
• Both conditions are common
so it is not surprising that this
overlap condition may occur
7. Adenomyosis & subfertility
• It thought to be a condition of
parous women, with the final
diagnosis made after
hysterectomy.
• Thus, an association between
adenomyosis and subfertility has
not been fully established.
8. • Some believe that adenomyosis is
not common in subfertile women,
while others think that adenomyosis
plays a critical role in subfertility.
9. • The hypothesis of a possible link between
adenomyosis and infertility is becoming
more and more plausible.
• There is observation that adenomyosis is
present even in younger women and can
be associated with pelvic endometriosis
and infertility.
• (Kissler et al., 2007; Kunz et al.,2005).
10. Possible mechanism
1-Altered uterine peristaltic activity.
Kissler et al. (2006) placed into the
posterior vaginal fornix radio-labelled
macro-albumin aggregates (with a size of
5–20 um mimicking sperm size) and
scanned with a gamma camera
immediately after application and at
various time intervals up to 30 min.
11. • Fertile women. Positive, uni- and
ipsilateral transport of radionuclides to the
side bearing the dominant follicle.
• Diffuse adenomysis & infertility.
– 70% remain in uterus.
– 22% transport to contralateral side.
– 8% to ipsilateral side of dominant follicle.
13. DIAGNOSIS
• The sure diagnosis of adenomyosis
is made on a pathologic specimen.
• The pathologic diagnosis is
dependent on the visualization of
endometrial glands and stroma in
more than 1 low-power field from the
endometrial basalis layer.
• Katz VL. Benign gynecologic lesions. 5th Edition. 2007:419–471.
14. TVS
• Operator dependent.
• meta-analysis on the accuracy of
sonography in the diagnosis of
adenomyosis showed that it had
sensitivity of 82.5% (77.5–87.9) and
specificity of 84.6% (79.8–89.8).
Meredith SM et al, 2009.
15. • Uterine enlargement.
• Cystic anechoic spaces or lakes in
the myometrium.
• Heterogeneous echo texture.
• Obscure endometrial/myometrial
border.
• Subendometrial halo thickening.
16. • Globular uterine enlargement with an obscure
endometrial/myometrial border (arrow).
17. • Anechoic cystic lacunae in the posterior uterine
wall (arrow) with a heterogeneous echo texture.
18. • Linear striations (arrows) in the presence of a
heterogeneous echo texture
19. MRI
• More accurate.
• Findings
– Diffuse or local widening of junctional
zones on T2 weighted images >12 mm.
– Low intensity lesion (ill-defined).
– Uterine enlargement.
– Small hypointense myometrial spots.
20. Sagittal T2-weighted MR image shows diffuse, even
thickening of the junctional zone (arrows), a finding
consistent with diffuse adenomyosis
25. MANAGEMENT OF INFERTILITY.
• Data available on treatment of
infertility associated with
adenomyosis are still fairly limited
and mostly confined to case reports
or uncontrolled small series.
33. Other options
A- GnRH analogue:
Few case reports (Silva et al.,1994)
published the first term pregnancy in
a patient with a 10-year history of
secondary infertility, after 5 months of
therapy with GnRHa.
34. B- IUD containing danazol.
• a Japanese group (Igarashi et al.,
2000) have published results of 14
women with symptomatic
adenomyosis that had relapsed after
previous medical therapy.
• There was good relief of the
symptoms.
• Three of the four infertile women
conceived after removal.
35. C- Uterine artery embolization.
few case series
D- MRI-assisted high-intensity focused
ultrasound (HIFU). Only one case of
successful treatment of adenomyosis
associated infertility with HIFU has been
published. (Rabinovici et al., 2006b)