{"paper_id":"063258ab-5816-4566-9e3d-b911651cf526","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nOur objective is to present hysteroscopic dissection and ablation \nof adenomyotic cysts as a method of surgical management of this \ncondition and discuss the implications and treatment in an infertile \npatient. Adenomyosis by definition is the benign invasion of \nendometrium into the myometrium producing a diffusely enlarged \nuterus which microscopically exhibits ectopic, non-neoplastic \nendometrial glands and stroma surrounded by hypertrophic and \nhyperplastic myometrium. Although it has been a histopathological \ndiagnosis, with current modalities of 2D, 3D sonography and MRI, it \nis possible to diagnose this condition in vivo. \nDiagnosis on TVS scan by the following distinctive \nfeatures\nAsymmetrical myometrial thickening, parallel shadowing, \nmyometrial cysts, hyperechoic islands, irregular endo-myometrial \njunction. On 3D USG, junctional zone-thickening and disruption \nin adenomyosis, under normal circumstances it is hypoechoeic, \nheterogenous myometrial echotexture, increased echogenicity or \nlinear striation due to ectopic endometrial tissue and presence of \nSubendometrial cysts. MRI criteria –thickness of Junctional zone \n>12mm, broadening of JZ is infiltrative (normal <5mm). High T2 \nsignal intensity linear striations radiating out of the endometrium.1,2\nDistinctive features of differentiation from fibroid are \nas in chart below\nFIBROIDS ADENOMYOSIS\nDefined margins Poorly defined margins\nRound shape Variable shape\nMass effect No mass effect\nCalcifications No calcification\nAttenuation with edge shadowing Multiple foci of attenuation\nPeripheral vascularization Rectilinear vascularization\nJZ intact Variable thickening of JZ\nBrosens classification of cystic adenomyosis (MUSCLE)\na. M, myometrial location (intramural, submucous, subserous)\nb. U, uterine site (midline,paramedian, lateral)\nc. S, structure (cystic, mixed, polypoid)\nd. C, contents (clear, hemorrhagic)\ne. L, level (fundus,body, cervix)\nEffects of adenomyosis on infertility\nI. Altered peristaltic activity- responsive to endocrine and paracrine \nstimuli – Estrogen due to aromatase P450 overexpression, \nconversion of androgen to estrogen and oxytocin, PGs, GF, \ncytokines dysperistalsis by Kunz.\nII. Altered endometrial function and receptivity-Colonisation of \nendometrium with macrophages by Leiva.\nIII. Impaired implantation –expression of integrins and pinopode \nformation is affected.\nIV . Altered decidualisation overexpression of cytochrome P450  \nestrogen receptor& lack of PR.\nV. Abnormal concentration of intrauterine free radicals –Nitic oxide, \nsuperoxide.\nVI. Gene dysregulation.\nVII. High risk of miscarriage. \nCase report\nMrs. X 32-year-old was referred to us as case of primary infertility \nof 5 years duration. She had regular and painful menses. Husband’s \nSemen analysis was normal. Her HysteroLaparoscopy 3 years back \nwas done which had normal findings and she had undergone 2 cycles \nof IUI with Clomifene stimulation previously without any resulting \npregnancy.\n General examination was normal\nPositive findings on TVS- Transverse dimensions were increased. \nPresence of 2 intramural subendometrial cysts of 1cm and 0.8cm \nInt J Pregn & Chi Birth. 2019;5(4):132‒133. 132\n© 2019 Saple et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nCase report: management of cystic adenomyosis \nVolume 5 Issue 4 - 2019\nShilpa Saple, Mukesh Agrawal, Simi Kawar \nAarush IVF and Endoscopy Centre, India\nCorrespondence: Shilpa Saple, Aarush IVF and Endoscopy \nCentre, India, T el 9819930643, Email \nReceived: May 18, 2019 | Published: July 05, 2019\nAbstract\nAdenomyosis has a negative impact on fertility owing to reduced likelihood of \nclinical pregnancy and implantation and increased risk of early pregnancy loss. \nUltrasound detection of adenomyotic changes include globular uterine enlargement, \nwall thickening, linear striations, thickened endomyometrial borders, junctional zone \nand cystic anechoic spaces in myometrium. The aim of the case report is to present \nhysteroscopic dissection and ablation of subendometrial adenomyotic cyst with good \nsubsequent ART outcome.\nInternational Journal of Pregnancy & Child Birth\nCase Report\n Open Access\n\n\nCase report: management of cystic adenomyosis \n133\nCopyright:\n©2019 Saple et al.\nCitation: Saple S, Agrawal M, Kawar S. Case report: management of cystic adenomyosis. Int J Pregn & Chi Birth. 2019;5(4):132‒133. \nDOI: 10.15406/ipcb.2019.05.00163\nabove the cervix on the posterior wall adjacent to each other and \nindenting the cavity. Her antral follicular count was 11. Her routine \ninvestigations and infection screen were done which were normal \nand AMH was 2.6. She was given one cycle of HMG 150 units x10 \ndays from 2nd day of menses and trigger at follicular size of 19-20mm \nand IUI was done on 12 th day with progesterone support post IUI. \nThe cycle was negative. She was counselled for an ICSI cycle and \nprecycle hysteroscopy was planned. Under General anesthesia, a \ndiagnostic hysteroscopy was done using 2.9mm hysteroscope with \nBettocchi operating sheath connected to a HD 3 chip Storz camera \nwith saline distention using hysteromat. Uterine cavity was normal \nand a bulge of 1cm was seen on the posterior wall just above cervix. \nUsing the same scope mounted on a bipolar resectoscope assembly \nusing normal saline as a distending medium, a linear incision was \nmade over the bulge with a Collin’s knife.3–5\na. bulge on posterior wall \nb. linear incision by Collins knife\nc. chocolate fluid \nd. base of the cyst\nICSI was planned with long protocol.\nA. Lupride 0.5mg starting 7days post ovulation in the same cycle. \nB. Stimulation with 300 units HMG was carried out after adequate \ndownregulation (10days). \nC. 6M2 eggs were obtained and transfer of 3 embryos on Day 3 yielded a \npositive Bhcg test.\nDifferential diagnosis\na) Cystic degeneration in fibroid\nb) Congenital anomaly- hematometra of horn\nOther modalities of treatment\ni. Scissors - open and resect the lesion with base. \nii. Fulgurate base with ball electrode \niii. Laparoscopic approach can be tried if lesions are in outer \nintramural part \niv. USG guided aspiration for large lesions \nv. Spirotome \nvi. Robotics \nConclusion \nHysteroscopic evaluation of the endometrial surface can detect \nchanges, subtle lesions of which the pathological value is not yet proven \nbut can be described as possible although not pathognomonic signs \nof adenomyotic changes in the myometrium. Endometrial changes \nlike hyper-vascularization, strawberry pattern, endometrial defects \nand submucosal hemorrhagic cysts are suggestive of adenomyosis \n(78, 80, 81) (Figure 1). A cystic translucent area in the fundal area \nvisualized by TVS, appearing as a bulging structure in the uterine \ncavity was described. Biopsy of the bed of the cyst was on histology \ndiagnosed as adenomyosis (81). With the increasing evidence of the \nimportance of the inner myometrium, uterine exploration in patients \nwith infertility, abnormal uterine bleeding and pain should not be \nrestricted to exploration of the uterine cavity but should include the \nexploration of the inner and outer myometrial structures.\n1. Adenomyotic sub endometrial cyst >5mm, which can be picked up \nas a bulge on hysteroscopy can be drained and base cauterized to \nimprove the pregnancy chances.\n2. Hysteroscopy – clear visualization of intracavitary lesions with \ndirect access \n3. Treatment by mechanical dissection or bipolar ablative surgery \nproduces minimal tissue damage. \n4. Further studies would be required to understand its impact on \nfertility and benefits of its surgical removal.\nAcknowledgments\nNone.\nConflicts of interest\nThe author declares there are no conflicts of interest.\nReferences\n1. Gordts S, Campo R, Brosens I. Hysteroscopic diagnosis and excision of \nmyometrial cystic adenomyosis. Gynecol Surg. 2014;11:273–278. \n2. Hiroyuki Takeuchi, Mari Kitade, Iwaho Kikuchi, et al. Diagnosis, \nlaparoscopic management, and histopathologic findings of juvenile \ncystic adenomyoma: a review of nine cases. Fertility and Sterility â. \n2010;94(3):863–868. \n3. Mi Ju Kim. A case of cystic adenomyoma of the uterus after complete \nabortion without transcervical curettage. Obstet Gynecol Sci . \n2014;57(2):176–179. \n4. Paolo Vercellini, Dario Consonni, Dhouha Dridi, et al. Uterine \nadenomyosis and in vitro fertilization outcome: a systematic review and \nmeta-analysis. Hum Reprod. 2014;29(5):964–977.\n5. Sebastiano Campo, Vincenzo Campo, Giuseppe Benagiano. Adenomyosis \nand infertility. Reproductive Biomedicine. 2012;24:35–46.","source_license":"CC0","license_restricted":false}