{"paper_id":"7ef6aa3a-77dc-4948-a0b7-7685c598261d","body_text":"Clin. Exp. Obstet. Gynecol. 2026; 53(8): 51376\nhttps://doi.org/10.31083/CEOG51376\nCopyright: © 2026 The Author(s). Published by IMR Press.\nThis is an open access article under the CC BY 4.0 license .\nPublisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nOriginal Research\nThe Impact of Laparoscopic Versus Open Conservative Surgery for\nAdenomyosis on Subsequent In Vitro Fertilization Outcomes: A\nRetrospective Cohort Study\nXia Li1,2\n , Jianmin Chen 1,2\n , Liaobing Xin 1,2\n , Y anqing Hao1,2\n , Jie Y ang1,2\n ,\nY uyang Chen1,2\n , Weijie Y ang1,2\n , Xiu Liu 1,2\n , Anning Zhao 3\n , Dong Huang 1,2,*\n1Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 310016\nHangzhou, Zhejiang, China\n2Zhejiang Provincial Clinical Research Center for Reproductive Health and Disease, 310016 Hangzhou, Zhejiang, China\n3School of Medicine, Zhejiang University, 310028 Hangzhou, Zhejiang, China\n*Correspondence: 3198049@zju.edu.cn (Dong Huang)\nAcademic Editors: Bruce McLucas and Michael H. Dahan\nSubmitted: 1 March 2026 Revised: 25 April 2026 Accepted: 15 May 2026 Published: 19 August 2026\nAbstract\nBackground: With the widespread adoption of fertility-preserving conservative surgery for adenomyosis in clinical practice, the impact\nof different surgical approaches on subsequent reproductive outcomes has become a key clinical concern. This study aimed to investigate\nthe impact of laparoscopic versus open conservative surgery for adenomyosis on subsequent in vitro fertilization (IVF) outcomes. Ade-\nnomyosis is a recognized cause of female infertility; yet, the optimal surgical approach for patients seeking to preserve fertility remains\ndebated, and comparative data on their effect on subsequent IVF outcomes are limited. Methods: This single-center retrospective cohort\nstudy included 162 infertile women with adenomyosis who underwent primary conservative surgery (98 laparoscopic, 64 open) between\nJanuary 2018 and December 2023. Diagnosis was confirmed by imaging and histopathology. Strict exclusion criteria were applied to\nminimize confounding. The primary outcome was live birth rate following postoperative IVF. Multivariate logistic regression was used\nto evaluate the independent effects of surgical approach and intraoperative factors on live birth. Results: Baseline characteristics were\ncomparable between groups, except for a higher proportion of diffuse adenomyosis in the open surgery group (65.6% vs. 28.6%, p <\n0.001). As expected, open surgery was associated with longer intraoperative blood loss (103 [55–140] vs. 61 [30–80] mL, p < 0.001),\nand larger resected lesion volume (40 [22–58] vs. 23 [12–32] cm 3, p < 0.001). However, postoperative IVF parameters and pregnancy\noutcomes showed no significant differences. Clinical pregnancy rates (laparoscopic vs. open: 48.0% vs. 50.0%, p = 0.795) and live\nbirth rates (36.7% vs. 37.5%, p = 0.917) were similar. Multivariate analysis confirmed that surgical approach was not an independent\npredictor of live birth (adjusted odds ratio [OR] = 1.05, 95% confidence interval [CI]: 0.54–2.04, p = 0.882). Intraoperative blood loss\nand resection volume were likewise not significantly associated with live birth. Conclusions: Within the limitations of this retrospective\ndesign, the choice between laparoscopic and open conservative surgery in infertile patients with adenomyosis was not found to signif-\nicantly affect subsequent IVF live birth outcomes. Surgical decisions may therefore be guided by individual lesion characteristics and\nsurgeon expertise, as the approach alone does not appear to compromise fertility potential based on the available evidence.\nKeywords: adenomyosis; infertility; conservative surgical treatment; pregnancy outcome\n1. Introduction\nAdenomyosis is a common benign gynecological con-\ndition affecting approximately 20% of women of reproduc-\ntive age. Its main clinical manifestations include abnor-\nmal uterine bleeding, pelvic pain, and infertility [ 1,2]. The\npathological hallmark of adenomyosis is the invasion of en-\ndometrial glands and stroma into the myometrium, lead-\ning to uterine enlargement, disruption of myometrial ar-\nchitecture, and functional impairment of the endometrio-\nmyometrial junctional zone, which may subsequently inter-\nfere with embryo implantation and early pregnancy main-\ntenance [ 3,4]. In recent years, advances in imaging tech-\nniques and growing emphasis on fertility preservation have\nled to the widespread adoption of conservative surgical\ntreatment for adenomyosis in clinical practice [ 5,6].\nThe primary surgical approaches include laparoscopic\nsurgery and open abdominal surgery. The choice between\nthese procedures typically depends on the extent and loca-\ntion of the lesions, symptom severity, and the patient’s fer-\ntility goals [ 7,8]. For diffuse adenomyosis or extensive le-\nsions involving the posterior uterine wall, open abdominal\nsurgery is often preferred to achieve more complete lesion\nresection. In contrast, laparoscopic surgery is generally fa-\nvored for focal adenomyosis or cases with mild pelvic ad-\nhesions, due to its minimally invasive nature and faster re-\ncovery [ 9,10]. Nevertheless, the two surgical approaches\nmay differ in terms of intraoperative blood loss, extent of\nlesion resection, and postoperative uterine healing, all of\nwhich could potentially impact outcomes following assisted\nreproductive technology (ART) [11,12].\n\nCurrent studies have investigated natural conception\nand in vitro fertilization (IVF) outcomes in infertile patients\nwith adenomyosis following conservative surgery, suggest-\ning that postoperative reductions in uterine volume and\nsymptom improvement may be associated with higher fer-\ntility success rates [ 13,14]. However, comparative studies\nspecifically examining the impact of different surgical ap-\nproaches, laparoscopic versus open surgery, on subsequent\nIVF outcomes remain relatively limited [ 15,16]. Further-\nmore, the existing literature lacks a systematic evaluation\nof the relationship between intraoperative variables, such\nas blood loss and resection volume, and live birth outcomes\nfollowing IVF.\nTherefore, this study retrospectively analyzed clinical\ndata from infertile patients with adenomyosis who under-\nwent conservative surgical treatment at our center. The ob-\njectives were to compare intraoperative indicators and post-\noperative IVF outcomes between laparoscopic and open ab-\ndominal surgery, to explore whether the surgical approach\nand associated intraoperative factors influence live birth\nrate, and to provide evidence to inform clinical decision-\nmaking regarding the choice of surgical technique.\n2. Methods\n2.1 Study Design and Participant Selection\nThis was a single-center retrospective cohort study.\nPatients with infertility and adenomyosis who attended the\nreproductive center of Sir Run Run Shaw Hospital be-\ntween January 2018 and December 2023 were systemati-\ncally screened for eligibility. All participants underwent\nprimary conservative surgical treatment (laparoscopic or\nopen surgery). The diagnosis of adenomyosis was con-\nfirmed by preoperative transvaginal ultrasonography and/or\npelvic magnetic resonance imaging and subsequently ver-\nified by postoperative histopathological examination. In-\nfertility was defined according to international standards as\nthe failure to achieve a clinical pregnancy after at least 12\nmonths of regular unprotected intercourse.\n2.2 Inclusion and Exclusion Criteria\nThe inclusion criteria were as follows: (1) age be-\ntween 20 and 45 years; (2) meeting the diagnostic cri-\nteria for both adenomyosis and infertility as previously\ndescribed; (3) undergoing first-time conservative surgical\ntreatment for adenomyosis; and (4) receiving postoperative\nIVF treatment at our center.\nTo minimize the interference of confounding factors\non the outcomes, strict exclusion criteria were applied: (1)\nmale factor as the primary cause of infertility; (2) pres-\nence of other gynecological conditions significantly affect-\ning fertility, such as uncontrolled ovulatory disorders, poly-\ncystic ovary syndrome (PCOS), or other uterine anomalies\n(e.g., uncorrected uterine septum); (3) comorbid major sys-\ntemic diseases (e.g., malignant neoplasm, autoimmune dis-\neases); (4) history of prior uterine surgery (e.g., myomec-\ntomy, prior adenomyosis resection); and (5) incomplete sur-\ngical records or postoperative follow-up data. Of 215 pa-\ntients initially screened, 162 were included after applying\nthe exclusion criteria. Patient allocation at each stage is de-\ntailed in Fig. 1.\n2.3 Clinical Definitions and Outcome Measures\nBased on histopathological findings, adenomyosis\nwas classified as diffuse or focal. The diffuse type was de-\nfined as widespread infiltration of endometrial glands and\nstroma throughout the myometrium, whereas the focal type\n(adenomyoma) presented as relatively well-circumscribed\nnodular lesions within the myometrium. Primary infertility\nwas defined as never having achieved a clinical pregnancy,\nand secondary infertility referred to the inability to conceive\nfollowing at least one previous clinical pregnancy.\nThe primary outcome measure of this study was the\nlive birth rate following postoperative IVF cycles. Sec-\nondary outcome measures included clinical pregnancy rate\n(confirmed by the presence of an intrauterine gestational sac\nand fetal cardiac activity on ultrasound), biochemical preg-\nnancy rate (elevated serum human chorionic gonadotropin\n(hCG) not meeting clinical pregnancy criteria), miscarriage\nrate, and incidence of postoperative complications. All\npregnancy outcomes were calculated per patient who under-\nwent at least one embryo transfer cycle after surgery. Ac-\ncordingly, the denominators for live birth rate and clinical\npregnancy rate were based on the number of patients who\nreceived at least one embryo transfer following postopera-\ntive IVF. In this cohort, all 162 included patients underwent\nat least one embryo transfer cycle after surgery.\n2.4 Surgical Intervention and Data Collection\nSurgical indication was determined based on a com-\nprehensive assessment encompassing: (1) clinical symp-\ntoms (e.g., severe dysmenorrhea or heavy menstrual bleed-\ning poorly controlled by medication); (2) imaging findings\nsuggestive of significant uterine enlargement (uterine vol-\nume equivalent to ≥8 weeks of gestation) or lesions poten-\ntially compromising the uterine cavity environment; and (3)\ncoexisting symptomatic pelvic endometriosis.\nThe surgical approach was determined by senior at-\ntending physicians based on lesion characteristics, in accor-\ndance with routine clinical practice rather than a random-\nized allocation. Open abdominal surgery was preferred for\npatients with diffuse lesions, lesions predominantly involv-\ning the posterior uterine wall, or those for whom preopera-\ntive assessment indicated severe pelvic adhesions, with the\naim of achieving more complete lesion resection and reli-\nable uterine closure. Laparoscopic surgery was prioritized\nfor patients with focal disease or mild adhesions. This non-\nrandomized selection process introduced potential selection\nbias, which is addressed in the statistical analysis and dis-\ncussion.\n2\n\n\nFig. 1. Flowchart of patient selection .\nAll surgeries were performed or supervised by experi-\nenced senior surgeons. Standardized techniques were used\nfor both approaches: following lesion excision, the uterine\nwall was reconstructed in multiple layers using delayed ab-\nsorbable sutures (e.g., Vicryl) to ensure adequate myome-\ntrial closure. For focal adenomyosis, complete excision of\nthe adenomyoma with preservation of surrounding healthy\nmyometrium was attempted. For diffuse adenomyosis, a\ncytoreductive approach was used to reduce adenomyotic\nvolume while maintaining uterine integrity. With the ex-\nception of the access method and suturing instrumentation,\nthe surgical technique did not differ substantially between\nthe laparoscopic and open approaches.\nIntraoperative data, including operative time and es-\ntimated blood loss, were recorded. The volume of re-\nsected lesions was calculated using the prolate ellipsoid for-\nmula (volume = 0.52 × length × width × height), based\non measurements obtained from preoperative imaging or\npostoperative specimens. When endometriosis was iden-\ntified intraoperatively, it was staged according to the re-\nvised American Fertility Society (rAFS) classification and\ntreated accordingly. Concurrent tubal pathologies (e.g., hy-\ndrosalpinx) and intrauterine pathologies (e.g., polyps de-\ntected during hysteroscopy) were also addressed at the time\nof surgery. Postoperatively, patients were advised to defer\npregnancy for 3 to 12 months based on the depth of myome-\ntrial involvement and extent of resection. The timing of the\nfirst postoperative IVF cycle was recorded.\nPostoperative IVF protocol: Following the recom-\nmended waiting period, patients underwent controlled ovar-\nian stimulation using a gonadotropin-releasing hormone\n(GnRH) antagonist or agonist protocol, selected accord-\ning to individual ovarian reserve and prior response at\nthe discretion of the treating reproductive endocrinologist.\nEmbryo transfer was performed as either fresh or frozen-\nthawed, with frozen-thawed embryo transfer being pre-\nferred when endometrial preparation was required or to re-\nduce the risk of ovarian hyperstimulation syndrome. The\nnumber of embryos transferred followed national guide-\nlines based on patient age and embryo quality. Live birth\nwas defined as delivery of a live infant beyond 24 weeks\nof gestation. Data on IVF cycles, including the number of\ncycles per patient, were collected. For patients who under-\nwent multiple cycles, only the first postoperative cycle was\nincluded to avoid within-patient clustering effects.\n2.5 Statistical Analysis\nStatistical analyses were performed using IBM SPSS\nStatistics version 27.0 (IBM Corp, Armonk, NY , USA).\nNormality of continuous variables was assessed using the\n3\n\nShapiro-Wilk test. Normally distributed variables are pre-\nsented as mean ± standard deviation (SD) and were com-\npared using the independent samples t-test. Non-normally\ndistributed variables are presented as median (interquartile\nrange, IQR) and were compared using the Mann-Whitney U\ntest. In the current manuscript, some continuous variables\nthat deviated from normality are presented as median (IQR)\nin the tables, and the text descriptions have been aligned ac-\ncordingly. Categorical variables are described by frequency\n(percentage) and were compared using the chi-square test or\nFisher’s exact test.\nTo assess the independent effect of the surgical ap-\nproach on live birth outcomes, multivariate logistic regres-\nsion analysis was performed. V ariables with a p-value <0.2\nin univariate analysis, including age, surgical approach,\nintraoperative blood loss, resected lesion volume, adeno-\nmyosis type, coexisting endometriosis, duration of infer-\ntility, and prior ART attempts, were considered for inclu-\nsion. The final multivariable model included the follow-\ning variables based on observed data: age, preoperative\nanti-Müllerian hormone (AMH), adenomyosis type (diffuse\nvs. focal), duration of infertility, and prior ART attempts.\nSurgical approach (open vs. laparoscopic), intraoperative\nblood loss, and resected lesion volume were also retained\nin the model to test their independent effects. A stepwise\nforward selection method (likelihood ratio) was used for\nvariable selection. Adjusted odds ratios (ORs) and their\n95% confidence intervals (CIs) were calculated. All tests\nwere two-sided, and a p-value < 0.05 was considered statis-\ntically significant. Given the non-randomized assignment\nand baseline imbalance in adenomyosis type, we adjusted\nfor these factors in the regression model. However, resid-\nual confounding due to unmeasured variables (e.g., lesion\nseverity, surgical difficulty) cannot be entirely excluded\nand is acknowledged as a limitation.\n3. Results\nThe patient selection process is detailed in Fig. 1,\nwhich shows that 215 patients were initially screened, 53\nwere excluded, and 162 met the eligibility criteria. After\napplying strict inclusion and exclusion criteria, a total of\n162 patients were ultimately included in the analysis, com-\nprising 98 in the laparoscopic surgery group and 64 in the\nopen abdominal surgery group.\nComparison of baseline characteristics between the\ntwo groups (Table 1) showed no statistically significant\ndifferences in age, body mass index (BMI), distribution\nof infertility type, basal FSH level, or preoperative AMH\nlevel (p > 0.05), indicating comparability between the two\ngroups in terms of basic fertility characteristics. Addi-\ntional baseline variables, including duration of infertility\nand number of prior ART attempts, were also compara-\nble between groups. However, the proportion of diffuse\nadenomyosis was significantly higher in the open abdomi-\nnal surgery group compared with the laparoscopic surgery\ngroup (65.6% vs. 28.6%, p < 0.001), indicating greater dis-\nease severity in the open surgery group.\nAnalysis of surgical outcomes (Table 2) showed that\nthe open abdominal surgery group presented significantly\ngreater operative time, intraoperative blood loss, and re-\nsected lesion volume compared with the laparoscopic\nsurgery group ( p < 0.001). Specifically, the median (IQR)\noperative time was 146 (115–178) minutes for the open ab-\ndominal surgery group, compared with 125 (100–150) min-\nutes in the laparoscopic surgery group. Median (IQR) blood\nloss was 103 (55–140) mL in the open abdominal surgery\ngroup versus 61 (30–80) mL in the laparoscopic surgery\ngroup. The median (IQR) resected lesion volume was 40\n(22–58) cm 3 in the open abdominal surgery group and 23\n(12–32) cm3 in the laparoscopic surgery group.\nComparison of postoperative IVF treatment parame-\nters (Table 3) revealed no significant differences between\nthe two groups in the duration of gonadotropin (Gn) use,\ntotal Gn dosage, number of oocytes retrieved, fertilization\nrate, or high-quality embryo rate ( p > 0.05). Endometrial\nthickness at the time of embryo transfer was also compara-\nble (median (IQR): 10.1 (8.5–11.7) mm vs. 9.9 (8.0–11.8)\nmm, p = 0.593). The median interval from surgery to the\nfirst postoperative IVF cycle was 6.0 months (IQR: 4.0–8.0\nmonths) in the laparoscopic group and 6.0 months (IQR:\n4.0–9.0 months) in the open abdominal surgery group ( p\n= 0.612). Postoperative cancer antigen 125 (CA-125) lev-\nels at 6 months were compared using the Mann-Whitney U\ntest. The median (IQR) values were 58 (32–80) U/mL in\nthe laparoscopic surgery group and 96 (60–130) U/mL in\nthe open abdominal surgery group, with a p-value of 0.105.\nAlthough the numerical values differed, the difference did\nnot reach statistical significance, likely due to high inter-\npatient variability and limited sample size.\nAnalysis of pregnancy outcomes (Table 4) showed no\nsignificant differences between the two groups regarding\nclinical pregnancy rate, miscarriage rate, or live birth rate.\nThe clinical pregnancy rate was 48.0% (47/98) in the la-\nparoscopic surgery group and 50.0% (32/64) in the open\nabdominal surgery group ( p = 0.795). Regarding live birth\nrate, it was 36.7% (36/98) in the laparoscopic surgery group\nand 37.5% (24/64) in the open abdominal surgery group\n(p = 0.917). The denominator for these rates was the to-\ntal number of patients in each group. All pregnancy out-\ncomes were calculated per patient who underwent at least\none embryo transfer cycle after surgery. In this cohort, all\n162 included patients underwent at least one embryo trans-\nfer; therefore, the denominator for each group is the full\ngroup size. Biochemical pregnancy rates and ectopic preg-\nnancy rates were also similar between the groups.\nMultivariate logistic regression analysis, adjusted for\npotential confounding factors, showed that the surgical ap-\nproach was not an independent factor affecting live birth\nrate (OR = 1.05, 95% CI: 0.54–2.04, p = 0.882) (Table 5).\nAge was a significant factor influencing live birth rate (OR\n= 0.91, 95% CI: 0.84–0.99, p = 0.032), whereas preopera-\n4\n\n\nTable 1. Baseline characteristics of study patients .\nParameter Laparoscopic surgery (n = 98) Open abdominal surgery (n = 64) p-value\nAge (years), median (IQR) 34 (31–37) 35 (32–38) 0.423\nBMI (kg/m2), median (IQR) 22.0 (20.0–24.5) 22.0 (19.5–24.5) 0.521\nDuration of infertility (months), median (IQR) 24 (12–36) 24 (12–36) 0.682\nPrior ART attempts, median (IQR) 1 (0–2) 1 (0–2) 0.754\nInfertility type 0.690\nPrimary infertility, n (%) 52 (53.1) 36 (56.3)\nSecondary infertility, n (%) 46 (46.9) 28 (43.8)\nBasal FSH (IU/L), median (IQR) 7.6 (6.1–9.5) 8.0 (6.3–9.8) 0.445\nPreoperative AMH (ng/mL), median (IQR) 2.6 (1.2–4.1) 2.5 (1.1–4.3) 0.872\nAdenomyosis type, n (%) <0.001\nDiffuse 28 (28.6) 42 (65.6)\nFocal 70 (71.4) 22 (34.4)\nCoexisting endometriosis, n (%) 53 (54.1) 38 (59.4) 0.507\nNote: Continuous variables were tested for normality; non-normally distributed variables are presented as median (IQR). The\np-values for infertility type and coexisting endometriosis were calculated using the chi-square test. BMI, body mass index;\nIQR, interquartile range; FSH, follicle-stimulating hormone; AMH, anti-Müllerian hormone; ART, assisted reproductive tech-\nnology.\nTable 2. Comparison of intraoperative parameters between surgical groups .\nSurgical parameter Laparoscopic surgery (n = 98) Open abdominal surgery (n = 64) p-value\nOperative time (min), median (IQR) 125 (100–150) 146 (115–178) <0.001\nBlood loss (mL), median (IQR) 61 (30–80) 103 (55–140) <0.001\nResected lesion volume (cm 3), median (IQR) 23 (12–32) 40 (22–58) <0.001\nPostoperative hospital stay (days), median (IQR) 3 (2–4) 5 (4–6) <0.001\nNote: All continuous variables were non-normally distributed and are therefore presented as median (IQR). Group comparisons\nwere performed using the Mann-Whitney U test.\nTable 3. Postoperative IVF treatment parameters .\nIVF parameter Laparoscopic surgery (n = 98) Open abdominal surgery (n = 64) p-value\nGn duration (days), median (IQR) 10 (9–12) 10 (9–12) 0.387\nTotal Gn dose (IU), median (IQR) 2250 (1600–2900) 2380 (1700–3100) 0.356\nOocytes retrieved (n), median (IQR) 8 (4–12) 8 (3–12) 0.645\nFertilization rate (%), median (IQR) 75 (62–88) 74 (60–88) 0.598\nHigh-quality embryo rate (%), median (IQR) 53 (35–70) 51 (33–68) 0.658\nEndometrial thickness on transfer day (mm), median (IQR) 10.1 (8.5–11.7) 9.9 (8.0–11.8) 0.593\nPostoperative CA-125 (U/mL), median (IQR) 58 (32–80) 96 (60–130) 0.105\nSurgery-to-IVF interval (months), median (IQR) 6.0 (4.0–8.0) 6.0 (4.0–9.0) 0.612\nNote: p-values were calculated using the Mann-Whitney U test for continuous variables. IVF, in vitro fertilization; Gn, gonadotropin.\nTable 4. Comparison of pregnancy outcomes .\nPregnancy outcome Laparoscopic surgery (n = 98) Open abdominal surgery (n = 64) p-value\nClinical pregnancy, n (%) 47 (48.0) 32 (50.0) 0.795\nBiochemical pregnancy, n (%) 9 (9.2) 6 (9.4) 0.964\nMiscarriage, n (%) 11 (11.2) 8 (12.5) 0.799\nEctopic pregnancy, n (%) 2 (2.0) 1 (1.6) 1.000\nLive birth, n (%) 36 (36.7) 24 (37.5) 0.917\nNote: Denominator is the number of patients who underwent at least one embryo transfer cycle after surgery\n(laparoscopic surgery group, n = 98; open abdominal surgery group, n = 64). All outcomes are reported per\npatient.\n5\n\nTable 5. Multivariate logistic regression analysis of factors affecting live birth rate .\nV ariable Adjusted OR 95% CI p-value\nSurgical approach (open vs. laparoscopic) 1.05 0.54–2.04 0.882\nAge (years) 0.91 0.84–0.99 0.032\nPreoperative AMH (ng/mL) 1.14 0.99–1.32 0.072\nIntraoperative blood loss (mL) 1.00 0.99–1.01 0.665\nResected lesion volume (cm 3) 1.01 0.99–1.02 0.423\nAdenomyosis type (diffuse vs. focal) 0.87 0.45–1.68 0.674\nDuration of infertility (months) 1.01 0.98–1.04 0.520\nPrior ART attempts (n) 0.92 0.70–1.21 0.550\nNote: V ariables were selected using forward stepwise (likelihood ratio) method.\nThe model was adjusted for age, AMH, adenomyosis type, duration of infertil-\nity, and prior ART attempts. OR, odds ratio; CI, confidence interval; AMH, anti-\nMüllerian hormone; ART, assisted reproductive technology.\nTable 6. Comparison of postoperative and pregnancy complications .\nComplication Laparoscopic surgery (n = 98) Open abdominal surgery (n = 64) p-value\nPostoperative complications\nPostoperative fever, n (%) 2 (2.0) 6 (9.4) 0.038\nWound infection, n (%) 1 (1.0) 2 (3.1) 0.560\nPregnancy complications\nHypertensive disorders, n (%) 4 (4.1) 3 (4.7) 1.000\nGestational diabetes mellitus, n (%) 8 (8.2) 7 (10.9) 0.581\nPlacenta previa, n (%) 3 (3.1) 2 (3.1) 1.000\nPreterm birth, n (%) 5 (5.1) 4 (6.3) 1.000\nUterine rupture, n (%) 0 (0) 0 (0) -\nNote: Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. The denom-\ninator for all pregnancy-related complications was the total number of patients in each surgical group (laparoscopic\nsurgery group, n = 98; open abdominal surgery group, n = 64).\ntive AMH levels showed marginal significance (OR = 1.14,\n95% CI: 0.99–1.32, p = 0.072). Intraoperative blood loss\n(OR = 1.00, 95% CI: 0.99–1.01, p = 0.665) and resected\nlesion volume (OR = 1.01, 95% CI: 0.99–1.02, p = 0.423)\nwere not significantly correlated with live birth rate. The\nregression model also included duration of infertility and\nprior ART attempts, neither of which reached statistical sig-\nnificance.\nRegarding postoperative complications, the incidence\nof postoperative fever was significantly higher in the open\nabdominal surgery group compared with the laparoscopic\nsurgery group (9.4% vs. 2.0%, p = 0.038) (Table 6). For\npregnancy complications, there were no significant differ-\nences in the rates of hypertensive disorders of pregnancy,\ngestational diabetes mellitus, placenta previa, or preterm\nbirth between the two groups. Furthermore, no uterine rup-\nture occurred in any of the live birth cases in this study.\nWe further performed a subgroup analysis based on\nadenomyosis type. Among patients with diffuse adeno-\nmyosis, there was no statistically significant difference in\nlive birth rate between the laparoscopic and open abdom-\ninal surgery groups (35.7% vs. 38.1%, p = 0.832). Simi-\nlarly, among patients with focal adenomyosis, the live birth\nrates were comparable between the two groups (37.1% vs.\n36.4%, p = 0.954).\n4. Discussion\nThis retrospective study analyzed the clinical data\nfrom 162 patients with infertility and adenomyosis who un-\nderwent conservative surgery, either laparoscopic or open\nabdominal surgery. Although the open abdominal surgery\ngroup presented with a higher proportion of diffuse lesions,\nresulting in greater intraoperative blood loss, larger resected\nlesion volume, and longer operative time (all p < 0.001), re-\nflecting the greater surgical complexity in this group, mul-\ntivariate analysis showed that the surgical approach itself\nwas not an independent predictor of live birth rate follow-\ning postoperative IVF. Furthermore, intraoperative blood\nloss and the extent of resection were not significantly corre-\nlated with live birth outcomes. Within the limitations of the\nretrospective design and the substantial baseline imbalance\nin disease severity between groups (diffuse adenomyosis:\n65.6% in the open group vs. 28.6% in the laparoscopic\ngroup), these findings suggest that the choice of surgical\n6\n\n\napproach may not be a key determinant of subsequent IVF\nsuccess in this cohort. These results provide preliminary ev-\nidence supporting individualized surgical planning in clin-\nical practice; however, causal inference remains limited by\nthe non-randomized design.\nPrevious studies on the impact of adenomyosis\nsurgery on fertility have largely focused on comparisons\nbetween surgical versus non-surgical treatment, or on the\ngeneral evaluation of surgical efficacy [ 17,18]. However,\nfor infertile patients and clinicians, clear evidence regarding\nwhich of the two most common approaches, laparoscopic\nor open abdominal surgery, better optimizes IVF outcomes\nhas been lacking [11]. This study directly compared the two\nsurgical approaches and systematically evaluated surgery-\nrelated variables, such as blood loss and lesion resection\nvolume, finding that none of these factors independently af-\nfected live birth rate. This aligns with earlier studies [ 6,19],\nwhich reported that various surgical techniques could im-\nprove fertility outcomes; however, our study further clar-\nifies, through multivariate analysis, that the surgical ap-\nproach itself is not the key determinant of outcome.\nThese findings should not be interpreted as evidence\nof equivalence between laparoscopic and open abdominal\nsurgery. Rather, they indicate that, in this cohort and af-\nter adjustment for measured confounders, no statistically\nsignificant difference in live birth rates was observed. The\nabsence of a significant difference may reflect the limited\nsample size, the marked imbalance in disease severity be-\ntween groups, and potential residual confounding. There-\nfore, caution is warranted when generalizing these results to\nall patients with adenomyosis, and the choice of surgical ap-\nproach should continue to be guided by lesion characteris-\ntics and surgical expertise rather than assumed equivalence.\nOur findings may address concerns raised in the litera-\nture regarding the potential impact of laparoscopic suturing\nquality on uterine healing and subsequent pregnancy out-\ncomes [ 19]. Although open surgery may theoretically of-\nfer more robust suturing conditions, the laparoscopic group\nin this study demonstrated comparable live birth rates and\npregnancy safety, with no cases of uterine rupture [ 20].\nThis suggests that, in the hands of experienced surgeons, la-\nparoscopic multilayer closure using delayed absorbable su-\ntures can achieve adequate uterine wall reconstruction, and\npostoperative healing appears sufficient to withstand the\nphysiological demands of pregnancy [ 21]. Therefore, for\npatients with focal lesions or with diffuse lesions suitable\nfor laparoscopic surgery, opting for the minimally invasive\napproach does not compromise fertility outcomes based on\nthe current data.\nPostoperative CA-125 levels at 6 months, analyzed by\nthe Mann-Whitney U test, showed no statistically signifi-\ncant difference between groups (median [IQR]: 58 [32–80]\nvs. 96 [60–130] U/mL, p = 0.105). The higher CA-125 lev-\nels in the open group may reflect more extensive or diffuse\ndisease, consistent with the baseline characteristics; how-\never, the lack of statistical significance, likely due to high\ninter-individual variability and limited sample size, under-\nscores the difficulty in isolating the effect of surgical ap-\nproach from underlying disease severity.\nThe principal clinical implication of this study is that,\nfor infertile patients with adenomyosis requiring surgery,\nthe choice of surgical approach should be guided primar-\nily by lesion-specific characteristics, such as extent, loca-\ntion, relationship to surrounding tissues [ 22], surgeon pro-\nficiency with each technique [ 17], and individual patient\ncircumstances [23], rather than by potential concerns about\nadverse effects of a particular approach on IVF outcomes.\nWhen the surgeon possesses the requisite technical exper-\ntise, the balance of clinical decision-making scale may fa-\nvor laparoscopic surgery given its minimally invasive na-\nture and associated faster recovery [ 24].\nLimitations\nThis study has several limitations. First, the retrospec-\ntive, non-randomized design carries an inherent risk of se-\nlection bias. The choice of surgical approach was deter-\nmined by lesion characteristics and physician judgement\nrather than random assignment, resulting in a significantly\nhigher proportion of diffuse adenomyosis in the open ab-\ndominal surgery group (65.6% vs. 28.6%). Although con-\nfounding was addressed through strict inclusion and exclu-\nsion criteria and multivariate analysis, residual confounding\nby unmeasured factors cannot be entirely excluded. This\nlimits any causal interpretation of the observed absence of\nsignificant differences in IVF outcomes between the two\ngroups. Second, the statistical reporting of continuous vari-\nables in the original manuscript did not consistently reflect\nthe normality assumptions. Some variables that deviated\nfrom normality were initially reported as mean ± SD rather\nthan median (IQR). After re-analysis using appropriate non-\nparametric methods (e.g., Mann-Whitney U test for CA-\n125), the conclusions remained unchanged; nonetheless,\nthis inconsistency is acknowledged as a limitation. Specif-\nically, postoperative CA-125 levels had median (IQR) val-\nues of 58 (32–80) U/mL in the laparoscopic group and\n96 (60–130) U/mL in the open abdominal surgery group,\nand the Mann-Whitney U test yielded a p-value of 0.105.\nAlthough the median was higher in the open abdominal\nsurgery group, the difference did not reach statistical sig-\nnificance, likely attributable to large inter-individual vari-\nability, as reflected by the wide IQRs, and limited sample\nsize. The possibility of a type II error cannot be ruled out.\nThird, although the sample size exceeds that of some pre-\nvious studies, it remains insufficient for detecting rare out-\ncomes such as uterine rupture or for performing more re-\nfined subgroup analyses, for example, stratified by lesion\nlocation or extent of resection. Fourth, surgical decision-\nmaking and operative techniques reflect the experience of\na single center, and these conclusions should therefore be\ngeneralized with caution. The strengths of this study in-\nclude a relatively large sample size, systematic data col-\n7\n\nlection, and multivariable adjustment for multiple potential\nconfounding factors.\n5. Conclusions\nIn summary, within the limitations of this retrospec-\ntive cohort study and the substantial baseline imbalance in\ndisease severity between the two surgical groups, no sta-\ntistically significant difference in subsequent IVF live birth\noutcomes was observed between laparoscopic and open ab-\ndominal surgery in infertile patients with adenomyosis. In-\ntraoperative blood loss and extent of lesion resection were\nlikewise not significantly associated with the live birth rate.\nBased on these findings, and acknowledging that residual\nconfounding by indication cannot be excluded despite mul-\ntivariable adjustment, the surgical approach in clinical prac-\ntice may be selected according to lesion characteristics and\nsurgeon expertise, as the available evidence does not sup-\nport an independent effect of the specific approach on IVF\nlive birth outcomes. However, the present findings should\nnot be interpreted as evidence of equivalence between the\ntwo surgical approaches. Larger prospective studies with\nimproved control for disease severity and case selection are\nneeded to confirm these observations and to establish more\ndefinitive comparative conclusions.\nAvailability of Data and Materials\nAll data reported in this paper will also be shared by\nthe corresponding author upon request.\nAuthor Contributions\nXLi, JC, LX and DH designed the research study.\nXLi, JC, LX, YH, JY and YC performed the experiments\nand acquired the data. XLi and DH analyzed and interpreted\nthe data. WY , XLiu and AZ contributed to data curation\nand validation, and provided critical input for the interpreta-\ntion of results. All authors contributed to editorial changes\nin the manuscript. All authors read and approved the fi-\nnal manuscript. All authors have participated sufficiently\nin the work and agreed to be accountable for all aspects of\nthe work.\nEthics Approval and Consent to Participate\nThis study was approved by Sir Run Run Shaw Hos-\npital IRB on February 21, 2025. (Approval number: 2025\nNo.1055). Informed consent was obtained from all partic-\nipants. The study was conducted in accordance with the\nprinciples of the Declaration of Helsinki.\nAcknowledgment\nWe appreciate the whole staff at Sir Run Run Shaw\nHospital for their clinical work and data recording for the\npatients we reported in this article.\nFunding\nThis study was funded by the “Pioneer” and “Lead-\ning Goose” R&D Program of Zhejiang (2024C03200)\nand the Major Social Public Plan of Zhejiang Province\n(2023C03167).\nConflicts of Interest\nThe authors declare no conflicts of interest.\nSupplementary Material\nSupplementary material associated with this article\ncan be found, in the online version, at https://doi.org/10.\n31083/CEOG51376.\nReferences\n[1] V ercellini P , Bandini V , Viganò P , Ambruoso D, Cetera GE,\nSomigliana E. Proposal for targeted, neo-evolutionary-oriented\nsecondary prevention of early-onset endometriosis and adeno-\nmyosis. Part II: medical interventions. 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