{"paper_id":"0f9966db-9222-49fa-a569-01d4ca92f689","body_text":"Vol:.(1234567890)\nCurrent Obstetrics and Gynecology Reports (2024) 13:80–87\nhttps://doi.org/10.1007/s13669-024-00383-0\nREVIEW\nSurgical Treatment of Adenomyosis\nStavros Bischiniotis1 · Themistoklis Mikos1 · Grigoris F. Grimbizis1\nAccepted: 13 March 2024 / Published online: 22 March 2024 \n© The Author(s) 2024\nAbstract\nPurpose of Review Adenomyosis is defined as the presence of endometrial tissue within the myometrium. The aim of the \nreview is to describe contemporary surgical approaches for adenomyosis.\nRecent Findings Hysterectomy has been standard practice for the treatment of adenomyosis for many years. However, \nuterine-sparing interventions have emerged recently allowing patients to retain or even enhance their fertility. If there is no \nwish for further fertility and no desire for uterine preservation, hysterectomy with bilateral salpingectomy is the gold standard \ntreatment for symptomatic adenomyosis. Otherwise, the objectives of surgery are (a) to remove most (ideally the whole) of \nthe adenomyotic tissue, (b) to preserve the integrity of the endometrial cavity, (c) to reconstruct the uterus, and (d) to pre-\nserve the functionality of the ovaries and the tubes. The following surgical methods have been proposed for uterus-sparing \ntreatment of adenomyosis: classical excision of adenomyotic tissue after a single incision of the uterus, wedge resection, \ndouble- or triple-flap method, transverse H incision, and the PUSH technique. Post-operative clinical outcomes are in favor \nof fertility-sparing surgery of adenomyosis. The reduction of dysmenorrhea after uterus-sparing surgery for adenomyosis \nranges from 54.6 to 84.6%. The reduction of menorrhagia ranges from 50.0 to 73.7%. The total delivery rate in patients who \nhave undergone any uterus-sparing surgery for adenomyosis is 46.9%.\nSummary In conclusion, hysterectomy has traditionally been the primary treatment for adenomyosis in women. How -\never, contemporary medicine offers several excisional and non-excisional techniques for patients who wish to preserve \ntheir fertility.\nKeywords Adenomyosis · Adenomyoma · Fertility-sparing treatment · Uterine-sparing surgery · Reproductive outcome\nIntroduction\nUterine adenomyosis is the condition in which endometrial \nepithelial and stromal cells are located inside the myome -\ntrium [1]. Women suffering from adenomyosis present with \na variety of symptoms, most commonly dysmenorrhea, \nabnormal uterine bleeding (AUB-A according to FIGO), \nchronic pelvic pain, and infertility [2 –4]. In some cases, \nadenomyosis is asymptomatic and is incidentally suspected \nwith transvaginal sonography during a routine examination. \nAdenomyosis is often diagnosed while investigating patients \nfor causes of infertility; it is associated with lower pregnancy \nrates, higher rates of miscarriage as well as pregnancy com-\nplications such as preeclampsia, fetal growth restriction \n(FGR), and low birth weight [5].\nEtiology and Pathophysiology\nRecently, with the advances in radiology and magnetic \nresonance imaging in particular, it has been revealed that \nthere is a layer of cells called the inner myometrium (IM) or \njunctional zone (JZ) that separates the two layers of tissue. \nDuring the development of the embryo, the endometrium \nand the IM arise from the Mullerian ducts, while the outer \nmyometrium (OM) is of mesenchymal origin [6 ]. Differ -\nences in imaging (MRI or ultrasound) of the JZ are used \nin the diagnosis of adenomyosis. In the past, adenomyosis \nwas a histologic diagnosis in specimens of hysterectomy. \nNowadays, histologic diagnosis remains the gold standard; \nhowever, uterine-sparing surgical techniques allow us to \npreserve the fertility of the patient and even improve the \nreproductive outcome.\n * Themistoklis Mikos \n themis.mikos@gmail.com\n1 Department of Obstetrics and Gynecology, “Papageorgiou” \nGeneral Hospital, Aristotle University of Thessaloniki, Ring \nRoad, Nea Efkarpia, 56403 Thessaloniki, Greece\n\n81Current Obstetrics and Gynecology Reports (2024) 13:80–87 \nThe pathogenesis of adenomyosis is not perfectly under-\nstood; however, several mechanisms have been proposed \nalthough none of these have been definitively established. \nThere is the theory of the invasion of endometrial basalis into \nthe myometrium, crossing an abnormal JZ due to tissue injury/\nrepair and establishing adenomyotic lesions inside the myome-\ntrial wall [7]. Another theory suggests that adenomyosis forms \nwhere there is a trauma between the endometrial-myometrial \ninterface [8]. This theory is supported by the fact that adeno-\nmyosis is more common in women who have sustained uterine \ntrauma from curettage, uterine surgery, or cesarean section, but \nit does not explain adenomyosis in nulliparous women with no \nhistory of uterine trauma. The third theory suggests that the \nectopic endometrium derives from the metaplasia of embry-\nonic epithelial remnants [9]. Finally, like endometriosis, there \nis the theory that retrograde menstruation may also result in \nthe deposition of adult stem cells into the myometrium and \nresult in outside-to-inside invasion [10].\nEpidemiology\nThe prevalence of adenomyosis is difficult to pinpoint because \nthere is a large variation in the clinical manifestations of the \ndisease with patients ranging from asymptomatic to having \nsevere symptoms. In the past, the histological examination of \nthe specimens after hysterectomy was the only way to diag-\nnose the disease. As a result, the estimates are restricted to \nwomen undergoing hysterectomy, so their symptoms were \nlikely more severe, and they were probably of older age and \nhad no interest in preserving fertility. Even so, the estimated \nprevalence ranged from 8.8 to 61.5% [11••]. This wide range \nis the result of the lack of standardized criteria for diagnosis in \nhistopathologic specimens as well as in imaging techniques [12]. \nA study of 1252 hysterectomy histological reports in Maryland \nshowed uterine adenomyosis ranging from 12 to 58% and varied \nbetween pathologists from 10 to 88% [13]. These data show \nthat adenomyosis is either under or overdiagnosed. With the \nadvances in imaging techniques in recent years, it is now possi-\nble to diagnose adenomyosis in women prior to surgery. A study \nof 985 women who attended a general gynecological clinic in a \nuniversity teaching hospital in London showed that 206 of them \nhad sonographic findings consistent with adenomyosis (29.9%) \nusing transvaginal ultrasound [14]. This percentage however is \nlikely to be a bit higher than in the general population as these \nwere symptomatic women who entered the clinic.\nSurgical Treatment of Adenomyosis\nTherapeutic Options\nThe standard treatment for adenomyosis has been hyster -\nectomy, but, given the desire of many affected women to \nconceive, further medical and surgical approaches have \nslowly started to emerge.\nClassification of Surgical Techniques\nAfter diagnosis, there are two crucial issues that need to be \naddressed during the management of women with adeno-\nmyosis: (a) the wish to conceive, (b) the wish to preserve \nthe uterus. Time has proven that adenomyosis is a non-\nmalignant condition; therefore, this needs to be explic-\nitly communicated with the patient and then to proceed to \ninform decision-making [15].\nIf there is no wish for further fertility and no wish \nfor uterine preservation, hysterectomy with bilateral \nsalpingectomy is the gold standard treatment for \nsymptomatic adenomyosis (Fig.  1). The surgeon and \npatient will elect the method of choice (laparoscopic, \nrobotic, open laparotomy, or vaginal), and the treatment \nwill be definitive [16].\nIf the patient suffers from subfertility or wishes to \npreserve the uterus, the objective of the surgery is (a) to \nremove most (ideally tall) of the adenomyotic tissue, (b) \nto preserve the integrity of the endometrial cavity, (c) to \nreconstruct the uterus aiming to an anatomic result, and (d) \nto preserve the functionality of the ovaries and, if possible, \nthe tubes. The control of symptoms is mainly achieved by \nthe removal of the bulk of adenomyosis. The feasibility of \na spontaneous pregnancy is achieved by keeping the endo-\nmetrial cavity without permanent post-operative lesions. \nTherefore, the role of the technique is very important \nand the choice of it should depend on the pre-operative \nsonographic and MRI evaluation, as well as on the intra-\noperative findings [15].\nIn the majority of adenomyosis cases, the lesion typi-\ncally exhibits some level of myometrial infiltration, rang-\ning from minor to significant. During the excision of the \nlesion in these cases, the removal of healthy myometrial \ntissue is an inevitable consequence. It appears reasonable \nto propose that any categorization of the existing surgi-\ncal techniques for excising adenomyosis should primarily \nconsider the extent to which adjacent healthy myometrium \nis removed and the preservation of the structural integrity \nand, consequently, the functionality of the uterine wall. \nSurgical techniques can be classified into three main \ngroups: complete excision of the adenomyotic tissue, par -\ntial excision, and non-excisional techniques.\nComplete excision is typically possible in cases of focal \nadenomyosis, often in the form of adenomyomas. The pre-\nferred surgical method is adenomyomectomy, similar to \nleiomyomectomy, maintaining the integrity of the uterine \nwall as much as possible. Adenomyomectomy, a surgical \nprocedure first introduced by Hyams in 1952, has seen \n\n82 Current Obstetrics and Gynecology Reports (2024) 13:80–87\nthe development of various surgical approaches in order \nto reduce its complications. Unlike leiomyomectomy, the \nsurgical plane is not distinct between the adenomyoma \nand normal myometrium. Adenomyomectomy can be per -\nformed via laparotomy or laparoscopy, similar to leiomy -\nomectomy [15].\nComplete excision of lesions in cases of diffuse adeno-\nmyosis is generally not feasible due to the risk of removing \na significant portion of healthy myometrium. This can result \nin a weakened uterine wall and, consequently, lead to poor \npregnancy outcomes.\nThe following surgical methods have been proposed for \nuterus-sparing treatment of adenomyosis (Fig.  1).\n• Classical excision of adenomyotic tissue after a single \nincision of the uterus (longitudinal or else)\n• Wedge resection\n• Double- or triple-flap method\n• Transverse H incision\n• PUSH technique\nThe classic technique  (open, laparoscopic, or robotic) \ninvolves the recognition of the lesion’s location and bor -\nders by inspection, palpation, or intraoperative ultrasound \nwhen possible. A longitudinal incision at the uterine wall \nalong the adenomyotic region is performed, and the sur -\ngeon applies sharp and blunt dissection of the lesion with \nscissors, graspers, or diathermy in a fashion similar to the \nremoval of a leiomyoma. The seromuscular uterine wall is \nsutured in two or three layers with absorbable sutures. The \nendometrial cavity is similarly closed with sutures. Alter -\nnatively, during laparoscopy mainly, the uterine wall can \nbe reconstructed either with U-shape suturing, with the \nuse of overlapping flaps, or using the triple-flap method \n[17–19].\nThe wedge resection of the uterine wall is applied in dif-\nfuse lesions located mainly in a localized area of the uterus \n(i.e., adenomyosis restricted only in the anterior or only in \nthe posterior uterine wall). A typical cone-like resection \ninvolving the seromuscular uterine layer and the endouter -\nine adenomyotic lesion as far as adenomyosis reaches is \nperformed. The operation is completed with an anatomical \napproximation of the uterine wounds as described in the \nclassic technique of partial adenomyomectomy [17].\nThe triple-flap method has been described mainly for \nan open approach and involves the midline bisection of the \nuterus until the endometrial cavity is opened. The surgeon \nuses palpation with the index finger into the cavity to facili-\ntate maximum excision of adenomyotic tissue and grasping \nof adenomytic tissues with a Martin clamp to excise them \nfrom the surrounding myometrium leaving a myometrical \nthickness of 1 cm from serosa an endometrium. Then, the \nendometrium is initially closed, and the flaps of the uter -\nine wall are approximated from one side of the bisected \nuterus to the anteroposterior plane of the other side while \nthe contralateral side of the uterine wall is brought over the \nalready reconstructed part of the uterus in such a way as to \ncover it [19].\nThe transverse H incision technique is another laparoto-\nmic modification for diffuse adenomyosis, mainly described \nfor adenomyosis of the anterior uterine wall. A vertical inci-\nsion perpendicularly to the midline is initially made on the \nuterine wall, and two transverse secondary incisions are \napplied perpendicularly to the first incision along the upper \nFig. 1  Surgical classification of adenomyosis\n\n83Current Obstetrics and Gynecology Reports (2024) 13:80–87 \nand the lower parts of the uterus. The adenomyotic tissue \nunderneath the two flaps is removed with the use of scissors \nor diathermy until a healthy myometrium, preserving the \nintegrity of the endometrial cavity assessed with chromop-\nertubation during surgery. The closure of the uterine wall is \nperformed in multiple layers [20].\nThe asymmetric dissection of the uterus is a laparotomy \ntechnique, where the uterus is dissected longitudinally with \na surgical electric knife in an asymmetrical fashion to divide \nthe inside from the outside, preserving both the uterine cav-\nity and bilateral uterine arteries. The myometrium should be \ndissected diagonally, as if hollowing out the uterine cavity, \nand with a transverse incision, the uterine cavity is opened, \nthe index finger is inserted into the cavity, and adenomyotic \nlesions are removed using a loop electrode to a thickness of \n5 mm of the inner myometrium. Similarly, adenomyosis is \nexcised to a thickness of 5 mm of the serosal myometrium. \nThe endometrial cavity is then closed, and the uterine flaps \nare reconstructed in layers (muscle and serosa) [21].\nThe protection of uterine structure for healing  (PUSH) \noperation involves a full-layer mattress-type vertically pen-\netrating suture aiming to assist the surgical overlapping of \nresidual uterine muscle flaps [22]. An initial midline inci-\nsion along the uterus is performed reaching the uterine cav-\nity. Full excision of adnomyotic tissues is performed, and \nthe uterus (left–right/anterior–posterior walls) is left with 2 \nsubmucosal inner-muscle flaps (left–right) and 2 subserosal \nouter-muscle flaps (left–right). The reconstruction of the \nuterus takes place anatomically by overlapping the flaps on \neach side and fixing them with vertical mattress-type pen-\netrative sutures paying care not to remove any part of the \nouter flaps disregarding the size and their condition.\nOptimal Surgical Technique\nComplications after surgery are mostly associated with the \ntype of approach (laparoscopy or laparotomy) and are antici-\npated. There is not enough evidence to support that one tech-\nnique is superior to another and there does not seem to be a \ndifference between the flap methods. It is however impor -\ntant to note that these operations are generally performed \nin centers of excellence and by highly qualified surgeons \nfor the time being at least as they are beyond the scope of \nthe average gynecologist. There is still a lack of large, well-\ndesigned, randomized studies designed to directly compare \nthese methods. The treatment needs to be individualized \naccording to the patient’s needs. In general, single, well-\ndefined lesions should be removed with single incisions, \nlike myomas. Diffuse adenomyosis appears to be more chal-\nlenging for the surgeon, and optimal restoration of the uter-\nine wall is the most important factor. Optimal pre-operative \nimaging is of vast importance, as is communication with the \npatient and her needs. Treatment should be individualized \naccording to the patient’s needs and most importantly con-\nsidering her wish to conceive or not. The wall thickness of \nthe excised uterus should optimally range from 9 to 15 mm \nif the patient wishes to conceive which might reduce the \nrisk of uterine rupture, as suggested in the recent study of \nOtsubo et al. [23].\nDiscussion\nClinical Outcome After Fertility Sparing Surgery\nThe reduction of dysmenorrhea after uterus-sparing surgery \nfor adenomyosis ranges from 54.6 to 84.6%. The reduction \nof menorrhagia ranges from 50.0 to 73.7%. In prospective, \nwell conducted prospective studies, uterus-sparing surgery \nthe uterine volume appears to be decreased as much as 86%, \nthe post-operative dysmenorrhea is reduced as much as 83%, \nand the post-operative menorrhagia is reduced as much as \n71.3% (Table  1). Any systematic comparison between types \nof surgery is not possible because of the differences in the \nstudy methodology (different instruments of pain and bleed-\ning measurement), the small number of participants, and the \noverall poor quality of the available studies (retrospective \nnature, non-selected patients) [19, 24–28].\nReproductive Outcome After Fertility  \nSparing Surgery\nProspective, high-quality studies show a total delivery rate of \n46.9% (84/179) in patients who have undergone any uterus-\nsparing surgery for adenomyosis (Table  2). The total con-\nception rate, the miscarriage rate, and the preterm delivery \nrate are 58.1% (104/179), 8.9% (16/179), and 9.6% (10/104). \nMoreover, in these studies, no case of uterine rupture has \nbeen reported. As previously mentioned, the retrospective \nnature of most of the studies, the non-uniform methodol -\nogy of approaching the conception and pregnancy rates, and \nthe non-randomization of the included patients make any \ncomparison between surgical techniques inappropriate [19, \n24–28].\nSurgery for Adenomyosis and Infertility\nThe management of infertility in women with adenomyo-\nsis is a topic of ongoing debate, and there is no definitive \nanswer whether uterus-sparing surgery, with or without \nmedical interventions, improves the reproductive outcome. \nSystematic reviews and meta-analyses so far have clearly \nshown elevated risk of miscarriages and less favorable out-\ncomes in general in women suffering from adenomyosis, \nso finding the ideal therapy for these women is of utmost \nimportance [29 •]. The symptoms of adenomyosis, both in \n\n84 Current Obstetrics and Gynecology Reports (2024) 13:80–87\nterms of gynecological symptoms and in the reproductive \noutcome, seem to be due to the abnormal structure of the \nmyometrium both in terms of cell structure as well as molec-\nular factors that disrupt its normal function compared to that \nof the normal uterus. Increased myometrial thickness in par-\nticular may negatively affect the outcome of ART methods, \nalthough other studies have reported no association between \nadenomyosis and ART outcomes [30]. Most of the studies so \nfar have shown that removal of the adenomyotic lesions and \nthe subsequent reduction in myometrium thickness results \nin higher pregnancy rates as well as a reduction in the rate \nof miscarriage and pregnancy-related hypertensive disor -\nders like preeclampsia. Additionally, it is believed that com-\nplete excision of the disease (adenomyomectomy) in cases \nof focal adenomyosis shows the best pregnancy outcomes \nwith the least complications [31]. There is a large variance \nbetween the current studies in terms of methodology, and \nthus, there is an inherent bias in trying to find reliable data; \nhowever, the improved reproductive outcome after surgery \nseems to be consistent among studies. It is observed that the \nrates of conception are satisfactory, both natural as well as \nwith ART methods, and the rates of miscarriage are better. \nFurthermore, there is a reduction in hypertensive-related \ncomplications, and the rates of full-term deliveries are also \nconsidered acceptable. The incidence of uterine rupture also \nappears to be increased, and as a result, cesarean section is \nthe preferred method of delivery. There is a small number of \nstudies reporting patients with placenta previa and placenta \naccreta spectrum after surgical treatment of adenomyosis \nin the literature [32, 33]. A recent registry-based Japanese \nstudy, comparing 1204 pregnancies with a history of adeno-\nmyosis with 151,105 no adenomyotic women, described a \nrisk of 2.0% vs 0.5% for placenta accrete, respectively. Possi-\nbly, surgery for adenomyosis may increase the frequency and \nrisk of perinatal complications, as is in cases of myomec-\ntomy [34].\nAdenomyosis and ART \nIt is well established that adenomyosis alone is a cause of \nsubfertility. Although ASRM suggests that there remains \ninsufficient evidence that fibroids reduce fertility rates with \nor without ART, adenomyosis is often accompanied with lei-\nomyomata and/or endometriosis, drastically influencing the \nreproductive potential of these patients [35–37]. Most of the \nstudies noted the presence of endometriosis to some extent \nMoreover, surgery on the uterine body and the consequent \ndisruption of the myometrium in women who underwent \nsurgical treatments for adenomyosis further complicates the \nsituation, compared to women without uterine pathology. \nAll the above make these patients potential candidates for \nART. Not all the studies mention the method of conception \nTable 1  Pre-operative and post-operative uterine size, abnormal uterine bleeding, and pelvic pain/dysmenorrhea rates (only prospectively per -\nformed studies included)\nAuthor, year n Follow-up \n(months)\nAge Pre-op \nuterine \nvolume (cm3)\nPost-op \nuterine \nvolume (cm3)\nPre-op pain \nscore\nPost-op pain \nscore\nPre-op \nbleeding \nscore\nPost-op \nbleeding \nscore\nYoon et al. \n(2023)\n50 - 35.6 ± 3.3 - - 7.28 ± 2.30 1.56 ± 1.30 Pictogram: \n140 ± 91\nPictogram: \n66 ± 65\nTskhay et al. \n(2019)\n26 18 38.6 ± 8.2 455 63 - - - -\nKitade et al. \n(2018)\n76 36 36 (28–39) - - 9.3 (9–10) 3.5 (1–6) - -\nYang et al. \n(2017) (with \nplexus abla-\ntion)\n50 36 40.4 ± 3.7 200.4 ± 55.3 134.0 ± 28.6 8.3 ± 1.2 2.6 ± 0.9 PABC score: \n122.6 ± 34.2\nPABC score: \n62.2 ± 13.4\nYang et al. \n(2017)\n(without plexus \nablation)\n52 36 39.6 ± 4.0 202.3 ± 54.5 133.0 ± 35.1 8.3 ± 1.1 5.0 ± 1.4 132.6 ± 36.8 61.8 ± 13.5\nOsada et al. \n(2011)\n104 123 37.6 ± 6.9 - - 10 1.67 10 2.87\nWang et al. \n(2009) (sur-\ngery only)\n51 24 37.0 ± 4.8 - - 3.86 ± 0.51 1.14 ± 0.87 3.08 ± 1.44 0.91 ± 0.77\nWang et al. \n(2009) (sur-\ngery + GnRH)\n114 24 38.9 ± 3.8 - - 3.94 ± 0.43 0.78 ± 0.84 3.68 ± 1.03 0.91 ± 0.77\n\n85Current Obstetrics and Gynecology Reports (2024) 13:80–87 \nand even fewer mention how many IVF cycles were needed \nfor clinical pregnancy to be achieved. In a meta-analysis of \npublished data by Vercellini et al., women with adenomyosis \nhad a 28% reduction in the likelihood of clinical pregnancy \nat IVF/ICSI compared with women without adenomyosis \n[38]. Also, adenomyosis is more likely to be diagnosed in \na woman undergoing IVF as thorough examinations and \nimaging are performed more often than in healthy women. \nIt is fair to say however that since ART methods in general \nhelp women achieve pregnancy quicker than through natural \nconception, IVF might be preferable to natural conception, \nespecially if other infertility factors co-exist. In addition, \nsingle embryo transfers are recommended to minimize the \nrisk of uterine rupture.\nRisk of Uterine Rupture\nThere are several reports of uterine rupture in patients \nwith adenomyosis, even those without previous surgical \noperations [32]. In addition, the risk of rupture during \npregnancy, especially under labor, is inherent with every \nuterine surgery. This might be of particular importance \nafter surgery for adenomyosis, as there are cases of uterine \nrupture that occur prior to the onset of labor [33]. Even after \na single cesarian section, there is a reported 0.2 to 1% risk \nof rupture in vaginal birth, and the risk is even higher after \nmyomectomy. In some studies, the risk of uterine rupture is \nas high as 1 in 18 (almost 6%) after surgical treatment for \nadenomyosis. So, although vaginal delivery is possible, birth \nvia elective cesarian section appears to be the safest option.\nOptimal Time Between Surgery and Conception\nMost studies fail to report the time between surgery and \nconception, and there is not enough data to exclude useful \ninformation. The follow-up period in most studies is rarely \nadequate and is often not stated at all. However, a minimum \nof 3 months between the operation and the attempts to con-\nceive is suggested based on the limited data that is available \nas well as our experience with myomectomies, due to wound \nhealing and other factors.\nConclusion\nHysterectomy has traditionally been the primary treatment \nfor adenomyosis in women. However, contemporary medi-\ncine offers several excisional and non-excisional techniques \nfor patients who wish to preserve their fertility. Currently, no \nsingle surgical technique has been proven superior, and the \nlimited data and patient numbers restrict definitive conclu-\nsions. Patients must be informed about the risk of uterine \nrupture in subsequent pregnancies and should be considered \nTable 2  Pregnancy rates after fertility-sparing surgery for adenomyosis (only prospectively performed studies included)\nAuthor, year n Follow-up \n(months)\nAge (y) Patients wishing \nto conceive (n, %)\nTotal conceptions (n, %) Miscar-\nriages (n, \n%)\nPreterm (n, %) Full-term (n, %) Total deliveries (n, %) Uterine \nrupture in \npregnancy\nYoon et al. (2023) 50 35.6 ± 3.3 33/50\n(66.0%)\n18/33\n(54.5%)\n5/33\n(15.1%)\n3/33\n(9.1%)\n8/33\n(24.2%)\n10/33 (30/3%) 0/33\nTskhay et al. (2019) 26 18 38.6 ± 8.2 18/26\n(69.2%)\n3/18\n(17%)\n- - 2/18\n(11.0%)\n2/18\n(11.0%)\n0/18\nKitade et al. (2018) 76 36 36 31/76\n(40.7%)\n12/31\n(38.8%)\n3/31\n(9.7%)\n- - 9/31\n(29.0%)\n0/31\nOsada et al. (2011) 104 123 37.6 ± 6.9 26/104\n(25.0%)\n16/26\n(61.5%)\n2/26\n(7.6%)\n- - 14/26\n(53.8%)\n0/26\nWang et al. (2009)\n(surgery only)\n51 24 37.0 ± 4.8 27/51\n(52.9%)\n20/27\n(74.1%)\n3/27\n(11.1%)\n2/27\n(7.4%)\n15/27 (55.6%) 17/27 (74.1%) 0/27\nWang et al. (2009)\n(surgery + GnRH)\n114 24 38.9 ± 3.8 44/114\n(38.6%)\n35/44\n(79.5%)\n3/44\n(6.8%)\n5/44\n(11.4%)\n27/44\n(61.4%)\n32/44\n(79.5%)\n0/44\nTotal 507 18–123 35–38 181 104/179 (58.1%) 16/179\n(8.9%)\n10/104\n(9.6%)\n52/122 (42.6%) 84/179 (46.9%) 0/179\n(0.0%)\n\n86 Current Obstetrics and Gynecology Reports (2024) 13:80–87\nhigh-risk for complications, necessitating regular monitor -\ning. Moreover, further research is required to establish the \nsafety and effectiveness of these procedures. Non-excisional \ntechniques, like radiofrequency ablation, hold promise in \nenhancing patients’ quality of life and improving pregnancy \noutcomes [39].\nAuthor Contribution  SB: project development, manuscript writing, \nprepared tables; TM: protocol, project development, manuscript \nwriting, prepared figures, manuscript editing; GF Grimbizis: \nmanuscript editing.\nFunding Open access funding provided by HEAL-Link Greece.\nData Availability No datasets were generated or analyzed during the \ncurrent study.\nCompliance with Ethical Standards \nConflict of Interest The authors declare no conflict of interest.\nHuman and Animal Rights and Informed Consent This article does not \ncontain any studies with human or animal subjects performed by any \nof the authors.\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article’s Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article’s Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a \ncopy of this licence, visit http://creativecommons.org/licenses/by/4.0/.\nReferences\nPapers of particular interest, published recently, have \nbeen highlighted as:  \n• Of importance  \n•• Of major importance\n 1. Bird CC, McElin TW, Manalo-Estrella P. The elusive \nadenomyosis of the uterus—revisited. Am J Obstet Gynecol. \n1972;112(5):583–93.\n 2. Zymperdikas C, Mikos T, Grimbizis GF. Classification of uterine \nadenomyosis. Curr Obstet Gynecol Rep. 2022;11(3):186–97.\n 3. Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual \nDisorders Committee. 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A prospective study of \nprevalence using transvaginal ultrasound in a gynaecology \nclinic. Hum Reprod. 2012;27(12):3432–9.\n 14. Sampson JA. Perforating hemorrhagic (chocolate) cysts of the \novary. Arch Surg. 1921;3(2):245.\n 15. Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing operative \ntreatment for adenomyosis. Fertil Steril. 2014;101(2):472–87. \nThis is a review of the available surgical treatments for \nadenomyosis.\n 16. Gaba ND, Polite FG, Keller JM, Young AE. Clin Obstet \nGynecol. 2014;57:128–39.\n 17. Sun AJ, Luo M, Wang W, Chen R, Lang JH. Characteristics \nand efficacy of modified adenomyomectomy in the treat-\nment of uterine adenomyoma. Chin Med J (Engl). 2011;124:  \n1322–6.\n 18. Takeuchi H, Kitade M, Kikuchi I, Shimanuki H, Kumakiri J, \nKitano T, et al. Laparoscopic adenomyomectomy and hystero-\nplasty: a novel method. J Minim Invasive Gynecol. 2006;13:150–4.\n 19. 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Association of uterine wall thickness with pregnancy out-\ncome following uterine-sparing surgery for diffuse uterine \nadenomyosis. Aust N Z J Obstet Gynaecol. 2016;56(1):88–91.\n 24. Yoon SH, Lee GJ, Cho HJ, Kwon H, Yun BS, Lee CH, Park \nHS, Roh J-W. Clinical efficacy of a novel method of fertility-\npreserving adenomyomectomy in infertile women with diffuse \n\n87Current Obstetrics and Gynecology Reports (2024) 13:80–87 \nadenomyosis. Medicine. 2023;102(13):e33266. https:// doi. org/ \n10. 1097/ MD. 00000 00000 033266.\n 25. Tskhay VB, Schindler AE, Mikailly GT. Diffuse massive \nadenomyosis and infertility. Is it possible to treat this condition? \nHorm Mol Biol Clin Invest. 2019;37(1):20180026.\n 26. Kitade M, Jinsushi M, Shinichiro I, Murakami K, Ozaki R, Masuda \nA, Kuroda K, Kumakiri J. Surgical treatments for adenomyosis. \nIn: Sugino N, editor. Uterine fibroids and adenomyosis. \nComprehensive gynecology and obstetrics. Singapore: Springer; \n2018. p. 151–62. https:// doi. org/ 10. 1007/ 978- 981- 10- 7167-6_ 11.\n 27. Yang B, Wang L, Wan X, Li Y, Yu X, Qin Y, Luo Y, Wang F, \nHuang O. Elevated plasma levels of lysophosphatidic acid and \naberrant expression of lysophosphatidic acid receptors in adeno-\nmyosis. BMC Womens Health. 2017;17(1):118. https:// doi. org/ \n10. 1186/ s12905- 017- 0474-z.\n 28. Wang PH, Liu WM, Fuh JL, Cheng MH, Chao HT. Comparison \nof surgery alone and combined surgical-medical treatment in \nthe management of symptomatic uterine adenomyoma. Fertil \nSteril. 2009;92(3):876–85. https:// doi. org/ 10. 1016/j. fertn stert. \n2008. 07. 1744.\n 29.• Nirgianakis K, Kalaitzopoulos DR, Schwartz ASK, Spaanderman \nM, Kramer BW, Mueller MD, et al. Fertility, pregnancy and neonatal \noutcomes of patients with adenomyosis: a systematic review and \nmeta-analysis. Reprod Biomed Online. 2021;42(1):185–206. \nhttps:// doi. org/ 10. 1097/ MD. 00000 00000 033266. This is a review \nabout the fertility outcomes in patients with adenomyosis. \n 30. Youm HS, Choi YS, Han HD. In vitro fertilization and embryo \ntransfer outcomes in relation to myometrial thickness. J Assist \nReprod Genet. 2011; 28: 1135–40. https:// doi. org/ 10. 1007/  \ns10815- 011- 9640-7.\n 31. Tan J, Moriarty S, Taskin O, Allaire C, Williams C, Yong P, \net al. Reproductive outcomes after fertility-sparing surgery for \nfocal and diffuse adenomyosis: a systematic review. J Minim \nInvasive Gynecol. 2018;25:608–21.\n 32. Matsuzaki S, Yoshino K, Tomimatsu T, Takiuchi T, Kumasawa \nK, Kimura T. Placenta accreta following laparoscopic \nadenomyomectomy: a case report. Clin Exp Obstet Gynecol. \n2016;43(5):763–5. PMID: 30074335.\n 33. Kwack JY, Lee SJ, Kwon YS. Pregnancy and delivery outcomes \nin the women who have received adenomyomectomy: performed \nby a single surgeon by a uniform surgical technique. Taiwan J \nObstet Gynecol. 2021;60(1):99–102. https:// doi. org/ 10. 1016/j. \ntjog. 2020. 11. 015. PMID: 33495018.\n 34. Komatsu H, Taniguchi F, Harada T. Impact of adenomyosis \non perinatal outcomes: a large cohort study (JSOG database). \nBMC Pregnancy Childbirth. 2023;23(1):579. https:// doi.  \norg/ 10.  1186/  s12884- 023- 05895-w . PMID:37568120; \nPMCID:PMC10422787.\n 35. Practice Committee of the American Society for Reproduc-\ntive Medicine. Electronic address: ASRM@asrm.org; Practice \nCommittee of the American Society for Reproductive Medicine. \nRemoval of myomas in asymptomatic patients to improve fer -\ntility and/or reduce miscarriage rate: a guideline. Fertil Steril. \n2017;108(3):416–425.  https:// doi. org/ 10. 1016/j. fertn stert. 2017. \n06. 034. PMID: 28865538.\n 36. Cozzolino M, Cosentino M, Loiudice L, Martire FG, Galliano \nD, Pellicer A, Exacoustos C. Impact of adenomyosis on in vitro \nfertilization outcomes in women undergoing donor oocyte \ntransfers: a prospective observational study. Fertil Steril. \n2024;121(3):480–8. https:// doi. org/ 10. 1016/j. fertn stert. 2023. \n11. 034. PMID: 38043844.\n 37. Vercellini P, Viganò P, Bandini V, Buggio L, Berlanda N, \nSomigliana E. Association of endometriosis and adenomyosis \nwith pregnancy and infertility. Fertil Steril. 2023;119(5):727–\n40. https:// doi. org/ 10. 1016/j. fertn stert. 2023. 03. 018. PMID: \n36948440.\n 38. Vercellini P, Consonni D, Dridi D, Bracco B, Frattaruolo MP, \nSomigliana E. Uterine adenomyosis and in vitro fertilization \noutcome: a systematic review and meta-analysis. Hum Reprod. \n2014;29(5):964–77.\n 39. Dedes I, Kolovos G, Arrigo F, Toub D, Vaineau C, Lanz S, \nImboden S, Feki A, Mueller MD. Radiofrequency ablation for \nadenomyosis. J Clin Med. 2023;12(9):3069. https:// doi. org/ 10. \n3390/ jcm12 093069. PMID: 37176514; PMCID: PMC10179480.\nPublisher's Note Springer Nature remains neutral with regard to \njurisdictional claims in published maps and institutional affiliations.","source_license":"CC0","license_restricted":false}