The Role of Hysteroscopy in Patients with Adenomyosis and Infertility: Bringing out the Submerged

Objective: To describe how hysteroscopic treatment of adenomyotic cystic lesions of the inner myometrium (IM), persisting after pharmacologic treatment, can improve reproductive outcomes in patients with multiple in vitro fertilization (IVF) failures.

Design: Video case series demonstrating the infertility workup and the hysteroscopic treatment of adenomyotic cystic lesions of the IM in patients with infertility with multiple IVF failures.

Setting: University tertiary care hospital-Fertility Center.

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

Exposure: Patients underwent initial pelvic 2-dimensional and 3-dimensional sonographic assessment, according to the protocol of the Fertility Center of our university hospital. All patients were diagnosed with adenomyosis (myometrial cysts). The patients were treated with gonadotropin-releasing hormone (GnRH) agonists 3.75 mg for at least 2 months to achieve hypoestrogenism (serum estradiol level, <40 pg/mL) and lesions shrinkage. If hypoestrogenism was not achieved, letrozole 2.5 mg/daily was added. In case of lesions persistence at ultrasound (i.e., cysts refractory to pharmacologic treatment), patients underwent hysteroscopy, and identified lesions were treated under sonographic guidance. One month after hysteroscopy, embryo transfer was performed.

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

Result(s): Not all cystic adenomyotic lesions of the IM regress after hypothalamic-pituitary-ovarian axis-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 patients with infertility with a personal history of multiple IVF failures. We propose a combined medical and surgical treatment strategy. Further studies are required to validate the proposed protocol.