The role of hysteroscopy in patients with adenomyosis and infertility: bringing out the submerged.

Abstract

Objective: To describe how hysteroscopic treatment of adenomyotic cystic lesions of the innermyometrium, persisting after pharmacological treatment, can improve reproductive outcomes in patients with multiple IVF failures.

Design: Video case series demonstrating the infertility work-up and the hysteroscopic treatment of adenomyotic cystic lesions of the inner myometrium in infertile patients with multiple IVF failures.

Setting: University tertiary care hospital - Fertility Centre.

Patient(s): Out of a large experience of patients with infertility and inner myometrium(IM)/junctional zone (JZ) cystic adenomyosis undergoing IVF in the Fertility Centre of our University Hospital, we selected 3 patients for this case series. All three patients had personal history of repeated implantation failure (RIF) and sonographic evidence of adenomyosis (myometrial cysts).

Exposure: Patients underwent initial pelvic 2D and 3D sonographic assessment, according to the protocol of the Fertility Centre of our University Hospital. All patients were diagnosed with adenomyosis (myometrial cysts). The patients were treated with GnRH agonists for at least 2 months, to achieve hypoestrogenism (serum estradiol <40 pg/ml) and lesions shrinkage. If hypoestrogenism was not achieved, letrozole was added. In case of lesions persistence at ultrasound (i.e. cysts refractory to pharmacological treatment), patients underwent hysteroscopy and identified lesions were treated under sonographic guidance. One month after hysterosocopy, embryo transfer (ET) was performed.

Main outcome measure(s): Achievement of pregnancy in infertile women with multiple IVF failures and adenomyotic cystic lesions, undergoing medical and surgical treatment for adenomyosis.

Result(s): Not all cystic adenomyotic lesions of the inner myometrium regress after HPO suppressive treatment (GnRH agonist). When GnRH agonist treatment is not sufficient to achieve satisfactory hypoestrogenism, letrozole is an effective add-on. In cases of refractory lesions at ultrasound, hysteroscopic treatment can improve reproductive outcomes. Patients undergoing combined hysteroscopic and medical treatment achieved pregnancy.

Conclusion(s): The optimal management of adenomyotic cystic lesions in patients undergoing IVF is debated. This case series suggests the usefulness of hysteroscopic treatment of adenomyotic cystic lesions persistent after medical therapy, in infertile patients with personal history of multiple IVF failures. We propose a combined medical and surgical treatment strategy. Further studies are required to validate the proposed protocol.