{"paper_id":"045d4441-8b9f-4cd1-a2ce-827266cc5a5f","body_text":"International Journal of Hyperthermia\nISSN: 0265-6736 (Print) 1464-5157 (Online) Journal homepage: www.tandfonline.com/journals/ihyt20\nCharacteristics of adenomyosis in secondary\ninfertility patients on MRI and factors associated\nwith fertility recovery after HIFU\nZhiyun Yang, Jinfeng Lin, Tao Tan, Yuan Li, Ying Chen, Meijie Yang, Zhibo Xiao\n& Jinyun Chen\nTo cite this article: Zhiyun Yang, Jinfeng Lin, Tao Tan, Yuan Li, Ying Chen, Meijie Yang, Zhibo\nXiao & Jinyun Chen (2025) Characteristics of adenomyosis in secondary infertility patients\non MRI and factors associated with fertility recovery after HIFU, International Journal of\nHyperthermia, 42:1, 2550633, DOI: 10.1080/02656736.2025.2550633\nTo link to this article:  https://doi.org/10.1080/02656736.2025.2550633\n© 2025 The Author(s). Published with\nlicense by Taylor & Francis Group, LLC\nPublished online: 26 Aug 2025.\nSubmit your article to this journal \nArticle views: 665\nView related articles \nView Crossmark data\nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=ihyt20\n\nInternatIonal Journal of HypertHermIa\n2025, Vol. 42, no . 1, 2550633\nCharacteristics of adenomyosis in secondary infertility patients on \nMRI and factors associated with fertility recovery after HIFU\nZhiyun Yang a, Jinfeng Lin a, Tao Tan a, Yuan Li a, Ying Chen a, Meijie Yang a, Zhibo Xiao b and \nJinyun Chen a,c\naf rom the State Key laboratory of ultrasound in m edicine and engineering, Chongqing m edical university, Chongqing, \nChina; bDepartment of r adiology, t he f irst a ffiliated Hospital of Chongqing m edical university, Chongqing, China; \ncultrasound a blation Center, t he f irst a ffiliated Hospital of Chongqing m edical university, Chongqing, China\nABSTRACT\nObjective: To study the MRI characteristics of adenomyosis in secondary infertility \npatients, and to analyze the factors affecting pregnancy after High-intensity focused \nultrasound (HIFU).\nMethods: Clinical data of 388 patients with adenomyosis were selected from January \n2014 to December 2019 treated with HIFU They were divided into the infertility group \nand the control group by the presence of secondary infertility. Then the patients in the \ninfertile group who had fertility requirements after HIFU were divided into the \npostoperative pregnancy group and the non-pregnant group, to assess the MRI \ncharacteristics of adenomyosis and the factors affecting infertility and to analyze the \nfactors affecting fertility recovery after HIFU.\nResults: Seventeen (28.81%) of the patients in the infertile group obtained pregnancy \nafter HIFU. Type II (exogenous) lesions, T2-weighted image(T2WI) high-signal spots \nmore than 30, pelvic adhesions, and dysmenorrhea may be related factors affecting the \nconception of patients with adenomyosis, among which T2WI high-signal spots more \nthan 30 (OR = 1.810, 95CI%: 1.071–3.058) was an independent risk factor for infertility \n(p < 0.05). There was no significant effect on whether fertilization in patients with pelvic \nadhesions, while age (OR = 0.844, 95CI%: 0.719–0.990) was an independent influence \non whether pregnancy occurred after HIFU ( p < 0.05), and the postoperative conception \nrate was high when the age was less than 37 years.\nConclusion: T2WI high-signal spots in lesions more than 30, type II (exogenous) lesions, \npelvic adhesions, and dysmenorrhea symptoms are risk factors for secondary infertility in \npatients with adenomyosis. HIFU treatment has the potential to enhance fertility in some \npatients with uterine adenomyosis. Age serves as an independent factor significantly \ninfluencing pregnancy outcomes following HIFU surgery. Consequently, early intervention \nis recommended for patients with uterine adenomyosis to optimize their fertility potential.\n1.  Introduction\nAdenomyosis (AM) is a common gynecological disease and frequentness in which endometrial glands \nand stroma with growth function invade the myometrium, resulting in localized or diffuse hyperplasia of \nthe myometrium, with an incidence rate of 7–23% [ 1]. In the investigation study of Vercellini [ 2] et  al. \ncompared with normal women, the successful pregnancy rate of patients with adenomyosis using \nassisted reproductive technology (ART) decreased by 8%. Women with adenomyosis are at increased risk \nof preterm birth and premature rupture of membranes [ 3], and adenomyosis is associated with decreased \npregnancy rates, decreased live birth rates, increased miscarriage rates, and adverse obstetric pregnancy \nand neonatal outcomes [ 4]. Due to the postponed of women’s childbearing age caused by social devel -\nopment, the prevalence of adenomyosis complicated with secondary infertility is increasing, which has \nbecome the key population of assisted reproduction and has attracted wide clinical attention.\n© 2025 t he a uthor(s). p ublished with license by taylor & f rancis Group, ll C\nCONTACT Jinyun Chen  chenjy@cqmu.edu.cn   f rom the State Key laboratory of ultrasound in m edicine and engineering, Chongqing \nmedical university, yixueyuan r oad, yuzhong District, Chongqing, 400016, China\nhttps://doi.org/10.1080/02656736.2025.2550633\nt his is an o pen a ccess article distributed under the terms of the Creative Commons a ttribution license ( http://creativecommons.org/licenses/by/4.0/), which \npermits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. t he terms on which this article has been \npublished allow the posting of the a ccepted m anuscript in a repository by the author(s) or with their consent.\nARTICLE HISTORY\nReceived 26 November \n2024\nRevised 12 August 2025\nAccepted 15 August 2025\nKEYWORDS\nAdenomyosis; infertility; \nfertility; high-intensity \nfocused ultrasound \n(HIFU); MRI; ultrasound \nablation\n\n2 Z. YANG ET AL.\nHIFU is an emerging treatment method for adenomyosis with few complications and no permanent dam -\nage [ 5]. It makes use of the biological effect of ultrasound to coagulative necrosis of the lesion cells and \npreserve the integrity of the uterus. There have been reports that the fertility of patients with adenomyosis \nimproved after HIFU ablation [6]. However, there is a lack of research reports on the factors affecting fertility \nin infertile patients with adenomyosis who receive ultrasound ablation. This study aims to analyze the char -\nacteristics of infertile patients with adenomyosis and the factors related to the improvement of fertility after \nHIFU treatment through clinical real-world data research, in order to provide a basis for preoperative evalua -\ntion, and it is expected to make a breakthrough in the fertility of infertile patients with adenomyosis.\n2.  Materials and methods\n2.1.  Study subjects\nPatients with adenomyosis treated in the ultrasound ablation center of the First Affiliated Hospital of \nChongqing Medical University from January 2014 to December 2019 were included. The clinical data of \nthe patients were collected from the electronic medical record database.\nInclusion criteria:(1) age 25–45 years old, diagnosed with adenomyosis by MRI; (2) the uterine wall where \nthe lesion was located was ≥30 mm; (3) those who met the diagnostic criteria of secondary infertility(Existing \nhistory of pregnancy and normal sex without contraception, not pregnant for more than one year.) were \nincluded in the infertility group; (4) those who had a history of pregnancy in the last 3 years and were diag-\nnosed with adenomyosis by MRI before the last pregnancy were included in the control group. Exclusion \ncriteria: (1) combined uterine fibroids ≥20mm, exclued type 0/type I myomas; (2) previous diagnosis of tubal \nocclusion or hydrosalpinx; (3) use of ovarian hormone modulators (e.g. GnRHa, dienogest, levonorgestrel intra-\nuterine system (Mirela), etc.) to affect estrogen and progesterone secretion in the 3 months prior to the oper-\nation; (4) It is known that male factors contribute to infertility, including azoospermia, oligospermia, and \nsperm morphology abnormalities, etc;The study was approved by the Ethics Committee of our hospital \n(HF2023-013) and verbal informed consent was obtained from the patients at the time of follow-up.\n2.2.  MRI evaluation and measurement\nThe MR images were evaluated and measured by a radiologist with 5 years of experience using a syngo \nfastView imaging system (Siemens AG) as follows:\n① Typing: According to the MRI-based classification of adenomyosis proposed by Kishi Y [ 7], adenomyosis \nwas typed based on MRI. Type I (endogenous type) The lesion is localized in the endometrium, preserving the \nexternal uterine structure. Type II (exogenous type): The lesion is situated in the serosal layer of the uterus, \nwithout affecting its internal architecture. Type III (intermuscular type): Lesions exist independently and are not \nassociated with either the outer or inner structures. Type IV (other type): Adenomyopathy that does not con -\nform to any of the aforementioned classifications. Refer to Figure 1 .\n② Volume and ablation rate (NPVR) calculation: the volume of the lesion measured on the preoperative T2WI image \nwas outlined with ITK-SNAP at each level of MR imaging, and the volume was summed up as the value of each level, \nwhich was automatically output by the system. The same method was used to obtain the non-perfused volume (NPV) \non postoperative enhanced MR images. The non-perfused volume ratio (NPVR) = NPV/lesion volume × 100%.\n③ The number of T2WI high-signal spots within the lesion was counted and grouped based on the level with \nthe highest number of high-signal spots, which was classified as 0-10; 11-30; and 30 +.\n④ Pelvic adhesions: on MR image, adhesions manifested as lack of a clear interface between adjacent organs, \nloss of fat layer, pinpoint low-signal tugging sensation between organs, and/or angulation and twisting of \nadjacent intestinal collaterals [ 8]. The main signs of MRI diagnosis of uterorectal trap closure were uterine \nretroflexion >180°, fibrous mass between uterorectals, displacement of intra-pelvic fluids, elevation of dome, \nand intestinal collaterals adherence [ 9].\n2.3.  HIFU ablation\nThe Focused Ultrasound Tumor Therapeutic System (Model-JC, Chongqing Haifu Medical Technology Co., \nLtd., China) was used, with a diameter of 20 cm ultrasound transducer. The physical focal region is \n\nINTERNATIONAL  JOURNAL  OF HYPERTHERMIA 3\n1.5 × 1.5 × 8 mm and the operating frequency is 0.5-1.5 MHz. The ablation procedure was guided with a fre -\nquency of 3.5 MHz ultrasonography device (Esao MyLab70, Italy). The patient was placed in the prone posi -\ntion with the anterior abdominal wall in full contact with the circulating degassed water, and in some \npatients a degassed water bladder could be placed to assist in pushing the bowel to obtain a safe acoustic \npathway. A spot scan is selected and the power is set between 350 and 400 W. The focus was at least \n10 mm away from the endometrium and 15 mm away from the extrauterine tissue structure. Intravenous \nfentanyl midazolam citrate is administered for sedation. Through real-time ultrasound monitoring, the \nchange of gray scale of the mass in the treatment area was used as a marker of ablation, and the treat -\nment dose was adjusted according to the patient’s tolerance and the change of gray scale of the target \narea, and the procedure was completed when the increase of the gray scale in the lesion covered the area \nto be planned, and the color Doppler flow imaging could assist in determining the disappearance of the \nblood flow signal in the lesion after the ablation. After the operation, patients were instructed to lie prone \nfor 2 h and return to the ward or be accompanied by family members to return home.\n2.4.  Follow-up\nA gynecologist and obstetrician performed telephone follow-up, including clinical symptoms and preg -\nnancy status. Loss of follow-up was recognized when multiple attempts to contact the patient failed \nwithin 3 days. The follow-up cutoff date was June 2024. Follow-up endpoints: pregnancy and delivery, \ntotal hysterectomy, or menopause.\n2.5.  Statistical methods\nSPSSv.29 was used to analyze the data, and the measurements conforming to normal distribution were \nexpressed as (x ± S), and the non-normally distributed measurements were expressed as (M ± Q), using \nANOVA and wilcoxon rank sum test, etc., and the count data were analyzed by χ2 test, and the influenc -\ning factors were analyzed by logistic regression analysis; p < 0.05 was statistically significant.\n3.  Results\n3.1.  Patient inclusion\nA total of 388 patients were included, with a mean age of 40.07 ± 5.44 years, 302 cases were successfully \nfollowed up and 86 cases (22.16%) were lost, among which 106 patients had fertility demands, 59 \n(55.66%) in the infertile group and 47 (44.34%) in the control group, with a median follow-up time of \n96 months (72–120 months). The flow chart is shown in Figure 2 .\n3.2.  Patient baseline data and HIFU ablation\nCompared with the control group, patients in the infertile group were younger (38.57 ± 5.80) years Vs. \n(41.34 ± 4.77) years ( p < 0.001); and more patients had significant dysmenorrhea 73.60% Vs. 63.33% \nFigure 1.  Classification of adenomyosis. t he classification of uterine lesions based on nuclear magnetic resonance \nshowed that a was endogenous type, b was exogenous type, c was intermuscular type, d was other types.\n\n4 Z. YANG ET AL.\n(p < 0.05). Comparison of NPVR obtained by HIFU ablation between the two groups showed that 43.09% \nin the infertile group was slightly lower than the control (47.02%) ( p < 0.05). The details of the data are \nshown in Table 1. The ablation after HIFU is shown in Figure 3 .\n3.3.  MRI characterization\nCompared with the control group, type I (endogenous) lesions were less in the infertile group 23.60% \nVs. 42.86%, type II (exogenous) lesions were more in the infertile group 23.60% Vs. 12.86%, the number \nof lesions with more than 30 high signal spots in T2WI was more in the infertile group 29.78% Vs. \n19.04%, and the thickness of the Junction zone (JZ)was less in the infertile group than in the control \ngroup 36.90 (IQR 13.20, 47.78) mm Vs. 41.10 (IQR 32.73, 50.38) mm. 13.20, 47.78) mm Vs. 41.10 (IQR \n32.73, 50.38) mm, the incidence of pelvic adhesions in the infertile group was 26.40%, which was higher \nthan that of the control group by 14.76%, and the differences present above were statistically significant \n(p < 0.05). The details of the data are shown in Table 2.\n3.4.  Pregnancy after HIFU treatment\nSuccessful follow-up was done in 302 cases (77.84%), of which 143 were in the infertile group and 159 \nin the control group. In the control group, 87 cases were fitted with Mirela and 29 cases underwent \nhysterectomy. In the infertile group, 41 cases were fitted with Mirela and 16 cases underwent hysterec -\ntomy. Among patients with fertility demands, the pregnancy rate after HIFU was 36.17% (17/47) in the \ncontrol group and 28.81% (17/59) in the infertile group.\nFigure 2.  f low chart.\n\nINTERNATIONAL  JOURNAL  OF HYPERTHERMIA 5\n3.5.  Analysis of factors affecting secondary infertility\nThe results of logistic regression analysis showed that T2WI high-signal spots in the lesions more than \n30, type II (exogenous) lesions, pelvic adhesions, and dysmenorrhea symptoms were the risk factors for \nsecondary infertility in adenomyosis ( p < 0.05). The details of the data are shown in Figure 4 .\n3.6.  Analysis of factors affecting pregnancy after HIFU treatment\nLogistic regression equation analysis showed that age, history of curettage, and NLR were risk factors for \npregnancy after HIFU for secondary infertility in adenomyosis ( p < 0.05), and age was an independent \ninfluencing factor. The details of the data are shown in Figure 5 .\n3.7.  The influence of age on pregnancy after HIFU\nThe relationship between patient’s age and pregnancy after HIFU was analyzed using the Receiver oper -\nating characteristic curve (ROC). The details of the data are shown in Figure 6 . The area under the curve \n(AUC) was 0.793 with a 95% confidence interval of 0.678–0.909, and the cut off value was 0.538 corre -\nsponding to the age of 37.50 years, with a sensitivity of 0.714 and a specificity of 0.824. That is, the rate \nTable 1. Baseline information of patients.\nVariable Infertile group ( n = 178) Control group ( n = 210) z/t/χ2 value p Value\nAge 38.57 ± 5.80 41.34 ± 4.77 5.08 <0.001*\nBMI (kg/m 2) 22.53(20.85, 24.61) 22.24(20.70, 24.03) 0.29 0.77\nCourse of disease 5(2, 10) 5(2, 8.25) 0.72 0.47\nHistory of pregnancy\n Frequency of vaginal \ndelivery\n64(35.96%) 151(74.76%) 50.39 <0.001*\n Cesarean section 51(28.65%) 60(28.57%) 0.00 0.986\n 2+ curettage times 56(31.46%) 88(42.11%) 4.66 0.031\nMenstrual condition\nMenstrual clots 119(66.85%) 147(70.00%) 0.25 0.613\nMenstrual changes 140(78.65%) 171(81.43%) 0.72 0.397\nChange in cycle 71(39.89%) 97(46.19%) 1.55 0.213\nIncreased menstrual flow 104(58.43%) 129(61.43%) 0.31 0.579\nProlonged periods 77(43.26%) 83(39.52%) 1.04 0.308\nDysmenorrhea 131(73.60%) 133(63.33%) 4.67 0.031 *\nNRS 6.41 ± 2.62 6.16 ± 2.52 0.95 0.172\nHematologic Indicators\nWBC (10^9/L) 5.69(4.68, 7.12) 5.46(4.77, 6.82) 1.35 0.178\nHGB (g/L) 123.50(105.00, 132.75) 121.00(103.00, 132.00) 2.15 0.032*\nPLT (10^9/L) 253.00(208.25, 300.75) 250.00(216.00, 316.00) 0.4535 0.651\nNLR (%) 2.15(1.74, 2.80) 1.97(1.45, 2.95) 1.0945 0.274\nHIFU ablation\nNPVR (%) 43.09 (29.80,60.56) 47.02 (33.72,64.57) 2.26 0.024*\nNote. *Indicates a statistically significant difference. Count data are expressed as median and quartiles or mean ± standard deviation, and \nmeasure data are expressed as frequency and percentage.\nNotes on abbreviations . WBC: White blood cell count; HGB: hemoglobin count; plt : platelet count; nlr: neutrophil lymphocyte ratio; plr: \nplatelet lymphocyte ratio; npVr: non-perfused volume ratio; nrS: numerical r ating Scale.\nFigure 3.  a blation after HIfu . Note. a and c preoperative t2WI lesions, b and d postoperative Ce- t1WI non-perfused \nvolume.\n\n6 Z. YANG ET AL.\nof post-HIFU pregnancy was higher ( p < 0.001) when the age was is lower than 37.5 years, the pregnancy \nrate after HIFU is higher ( p < 0.001).\n4.  Discussion\nAdenomyosis is an estrogen-dependent disease, the ectopic endometrium between the myometrial \nwall changes with the cycle, the tissue undergoes cyclic damage repair, platelet aggregation, myofi -\nbroblasts increase, causing myofibroblastic alterations, which shows uneven thickening of the myome -\ntrial layer, enlargement of the uterine cavity, distortion of anatomical morphology, endometrial \nperistalsis and uterine contractility abnormality, which interferes with the migration of spermatozoa \nand the transportation of embryos, and affects the rate of embryo implantation [ 10–12 ]. In this study, \nwe investigated the factors affecting secondary infertility in adenomyosis and the factors associated \nwith improved fertility in patients after HIFU treatment by using clinical real-world data, with a view \nto providing a basis for clinical decision-making in patients with adenomyosis who have fertility \nrequirements.\nTable 2. p atient mrI assessment and measurements.\nVariable Infertile group ( n = 178) Control group ( n = 210) z/t/χ2 Value p Value\nUterine position ( n, %)\n Anterior 95(53.37%) 122(58.10%) 2.561 0.278\n Posterior 60(33.71%) 71(33.81%)\n Median 23(12.92%) 17(8.09%)\nUterine measurements\n Volume (cm 3) 203.78(144.98,307.25) 222.17(164.58,298.76) 1.552 0.121\n Uterine cavity length (mm) 50.60(41.90,63.60) 49.35(41.20,59.24) 1.393 0.164\n JZ max (mm) 36.90(13.20,47.78) 41.10(32.73,50.38) 2.828 0.005*\nLesion measurements\n Lesion thickness (mm) 43.60(35.60,54.63) 43.90(35.45,52.93) 0.159 0.874\n Lesion volume (cm 3) 86.33.(51.59,158.15) 94.49(59.51,152.05) 0.619 0.536\nLesion typing (n,%)\n Type I (endogenous type) 42(23.60%) 90(42.86%) 15.924 <0.001*\n Type II (exogenous type) 42(23.60%) 27(12.86%) 7.598 0.006*\n Type III (intermural type) 5(2.80%) 2(0.95%) 1.875 0.171\n Type IV (other type) 89(50.00%) 91(43.33%) 1.722 0.189\nNumber of T2WI high signal spots in the lesion ( n, %)\n 0–10 67(37.64%) 100(47.62%) 3.913 0.048\n 11–30 58(32.58%) 70(33.33%) 0.024 0.876\n 30+ 53(29.78%) 40(19.04%) 7.426 0.007*\nPelvic adhesions ( n, %) 47(26.40%) 31(14.76%) 8.13 0.004*\nNote. Count data are expressed as median and quartiles or mean ± standard deviation, and measure data are expressed as frequencies and \npercentages. JZ: Junctional zone.\nFigure 4.  l ogistic analysis of infertility in adenomyosis patient. Note. *Indicates significance in multifactorial logistic \nanalysis ( p < 0.05). t2WI high-signal spots more than 30 ( or = 1.810, 95CI%: 1.071–3.058) was an influencing factor in \nmultifactorial analysis of infertility in adenomyosis ( p = 0.027).\n\nINTERNATIONAL  JOURNAL  OF HYPERTHERMIA 7\nAdenomyosis has different morphological features and is associated with clinical symptoms due to dif -\nferences in the development of adenomyosis. Kishi Y [ 7] staging is currently a common staging of adeno -\nmyosis, which correlates with clinical manifestations and can be used as a reference in the selection of \nclinical treatments. Comparing the different subtypes of adenomyosis in the present study, the difference \nbetween secondary infertility group and control group was not statistically significant for both type III \n(intermural) and type IV (other) ( p > 0.05), but type I (endogenous) was lower than the control group in the \ninfertility group, and type II (exogenous) was higher than the control group, which was in agreement with \nthe study of Exacoustos [ 13] et  al. Type I (endogenous type) lesions often involve women with a history \nof uterine cavity surgery, with the majority of localized injuries caused by uterine cavity surgery, which has \nrelatively little effect on sperm migration and embryo transport, uterine contractions, etc [ 7,13–16], and in \nthe present study, the percentage of deliveries and scrapings in the infertility group was lower than that \nin the control group. Type II (exogenous) adenomyosis is often combined with pelvic endometriosis, which \ncauses abnormalities in the morphology and structure as well as function of the patient’s oocytes, and \nexcessive oxidative stress occurs in the peritoneal fluid, which has a toxigenic effect on the spermatozoa, \nthus affecting the normal function of the spermatozoa [ 17]. Moreover, adhesions formed by severe endo -\nmetriosis cause changes in the pelvic structure, which may affect the process of ovulation and fertilization \nif the adhesions occur around the ovaries [ 18–20]. Thus it can lead to pelvic pain, dysmenorrhea and high \nFigure 5.  l ogistic analysis of pregnancy after HIfu for infertility. Note. *Indicates significance ( p < 0.05) in multifactorial \nbinary logistic analysis. a ge ( or = 0.822, 95CI%: 0.691–0.978) was an influential factor in the multifactorial analysis of \npregnancy secondary to infertility in adenomyosis after HIfu ( p = 0.027).\nFigure 6.  roC of patient age and pregnancy after HIfu treatment.\n\n8 Z. YANG ET AL.\nprobability of infertility [ 14,21]. The results of this study confirm that type II (exogenous) lesions, pelvic \nadhesions, and dysmenorrhea symptoms are risk factors for secondary infertility in adenomyosis. \nAdenomyosis of the uterus leads to ultrastructural changes in the binding zone, abnormal proliferation of \nmyoblasts as well as interruption of myofibrillar structure and disorganization of myofibrils occurs, which \nresults in impairment of the normal function of the JZ zone, thus causing abnormal uterine contractions \nand alterations of uterine cavity pressure, which reduces the success rate of pregnancy [ 22]. In this study, \nthe thickness of the JZ region in the infertile group with adenomyosis was less than that of the control \ngroup, and the incidence of dysmenorrhea in the infertile group was higher than that of the control group, \nthen it is suggested that the clinical symptoms of the patients in the infertile group were more severe. \nReinhold et  al. demonstrated that the histological features of uterine adenomyosis can be visualized on \nMRI, with high-signal lesions potentially representing ectopic endometrial tissue, endometrial cysts, or his -\ntological bleeding [ 23]. Studies by Gong Chunmei [ 24], Zhang Yan [ 25], and others revealed that the num -\nber of high-signal spots on T2WI correlates positively with the difficulty of ablation; specifically, a greater \nnumber of high-signal spots is associated with increased ablation complexity. Changes in JZ are accompa -\nnied by alterations in the uterine immune microenvironment and smooth muscle cell activity, as well as \nelevated levels of inflammatory factors [ 26]. In this study, the presence of high-signal spots within adeno -\nmyosis lesions may reflect higher cellular activity and invasiveness, leading to a higher incidence of T2WI \nsignals exceeding 30 in the secondary infertility group compared to the control group. Combined with \nelevated PLT levels, these findings suggest that periodic bleeding of ectopic endometrium may induce a \nhypercoagulable state, thereby affecting the embryo implantation microenvironment and offering new \ninsights into the pathophysiological mechanisms underlying infertility in uterine adenomyosis.\nHIFU, as a novel physical therapy modality [ 5], alleviates symptoms such as dysmenorrhea and men -\norrhagia through precise thermal ablation technology [ 27], while effectively improving the uterine ana -\ntomical environment. Leveraging its minimally invasive characteristics and relatively low complication \nrate [ 5], HIFU has emerged as an innovative treatment option for patients with adenomyosis-associated \ninfertility. Clinical observations indicate that successful pregnancies achieved post-treatment hold sub -\nstantial clinical significance [ 6]. In the present study, HIFU treatment restored fertility in 28.81% of \npatients with secondary infertility. Additionally, our findings indicated that lesion type II (exogenous), \nT2WI high signal spots exceeding 30, pelvic adhesions, and dysmenorrhea did not demonstrate statisti -\ncally significant associations with pregnancy outcomes following HIFU treatment. In principle, modifying \npelvic adhesions and exogenous lesions via HIFU remains challenging. Additionally, many patients expe -\nrience relief from pain symptoms after HIFU treatment, a finding that has been consistently supported \nby the published research [ 28]. Therefore, it is hypothesized that improvements in the pathological char -\nacteristics of the lesion and the pelvic microenvironment after HIFU ablation may contribute to the suc -\ncessful pregnancy outcomes observed in some infertile patients post-surgery.\nAge, history of curettage, and NLR are important factors affecting pregnancy after HIFU in patients with \ninfertility secondary to adenomyosis. NLR (Neutrophil Lymphocyte Ratio) is a novel inflammatory factor \nthat represents the balance between the body’s inflammatory response and the immune response [ 29,30], \nand has been proposed as a factor for assessing the severity of adenomyosis [ 31–33]. In the present study, \nwe found that the higher the NLR, the lower the postoperative conception rate. This suggests that patients \nwith fertility requirements can be treated with medication to reduce the NLR concentration preoperatively, \nreducing the inflammatory response in the body to provide a basis for postoperative pregnancy. Age is \nthe most important factor affecting conception in HIFU, and it is more difficult to restore fertility at age \nmore than 37.5 years, so it suggests that patients with adenomyosis should be intervened as early as \npossible to improve fertility. Regarding the parameters of HIFU treatment, the NPVR in the postoperative \npregnancy group was relatively lower. However, data analysis demonstrated that HIFU treatment did not \nadversely affect subsequent pregnancy outcomes. It can be inferred that following successful lesion abla -\ntion, the high-signal areas on T2WI either decreased or disappeared, indicating alterations in the uterine \ntissue structure. Therefore, HIFU ablation may significantly enhance fertility in some patients. Nevertheless, \nexcessive ablation could potentially impair endometrial repair or uterine blood perfusion. Thus, achieving \nan optimal balance between lesion control and fertility preservation is critical.\nThis study is a retrospective analysis. Patient recruitment was non-randomized, and patient attrition \nmay introduce bias into the results. MRI-based classification does not fully capture the histological \n\nINTERNATIONAL  JOURNAL  OF HYPERTHERMIA 9\ncharacteristics of lesions, and high-signal lesions were only quantified in the layer with the strongest \nsignal intensity. This approach may overlook lesions between layers, potentially leading to discrepancies \nin the number of high-signal spots and introducing result bias. Additionally, this study did not include a \ncomparison group of patients who did not undergo HIFU treatment, precluding definitive conclusions \nabout HIFU’s role in promoting pregnancy. Furthermore, patients with endometriosis were not excluded, \nwhich could introduce bias when assessing the impact of HIFU on pregnancy outcomes. In the future, a \nprospective trial will be conducted to validate the efficacy of HIFU in treating infertility caused by uterine \nadenomyosis and to provide improved management strategies for enhancing fertility in these patients.\n5.  Conclusion\nThe results of this study showed that T2WI high-signal spots in lesions more than 30, type II (exogenous) \nlesions, pelvic adhesions, and dysmenorrhea symptoms are risk factors for secondary infertility in patients \nwith adenomyosis. The reproductive outcomes of women have shown significant improvement following \nHIFU treatment for adenomyosis, particularly in those under the age of 37. In conclusion, the develop -\nment of secondary infertility in patients with uterine adenomyosis is closely associated with imaging \ncharacteristics, lesion types, and pelvic conditions. 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