{"paper_id":"d1b6f715-932e-498d-948c-8d1294b2e76b","body_text":"RESEARCH Open Access\nMiddle East Fertility\nSociety Journal\n© The Author(s) 2026. Open Access  This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, \nsharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and \nthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this \narticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included \nin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  v e c  o m m  o n s .  o r  g / l i c e n s e s / b y / 4 . 0 /.\nMadani et al. Middle East Fertility Society Journal           (2026) 31:31 \nhttps://doi.org/10.1186/s43043-026-00313-5\n†Co-first author: Tahereh Madani and Nadia Jahangiri contributed \nequally to this manuscript and share first authorship.\n*Correspondence:\nFiroozeh Ahmadi\ndr.ahmadi1390@gmail.com; f_ahmadi@royaninstitute.org\n1Department of Endocrinology and Female Infertility, Reproductive \nBiomedicine Research Center, Royan Institute for Reproductive \nBiomedicine, ACECR, Tehran, Iran\n2Department of Basic and Population Based Studies in NCD, Reproductive \nEpidemiology Research Center, Royan Institute, ACECR, Tehran, Iran\n3Department of Reproductive Imaging, Reproductive Biomedicine \nResearch Center, Royan Institute for Reproductive Biomedicine, ACECR, \nTehran, Iran\nAbstract\nBackground Adenomyosis is a benign condition of the uterus. There are few studies available on the prevalence \nof adenomyosis among women experiencing infertility. This study was designed to use ultrasound imaging to \ndetermine the frequency of adenomyosis in infertile women.\nMethods This prospective cross-sectional screening study included 963 eligible infertile women referring to \nthe infertility clinic of Royan Institute for the first time between 2017 and 2020. The women were referred for a \ntransvaginal ultrasound before initiating the treatment. Exclusion criteria involved women: aged >45 years, with \nmultiple and large fibroids, who had vaginismus, and those who did not feel inclined to participate in the study. \nParticipants were divided into groups of women with adenomyosis and without adenomyosis.\nResults The overall prevalence of adenomyosis was found to be 17.13%, of which 53.42% were severe \nadenomyosis. The mean age was significantly higher in the adenomyosis group than in the non-adenomyosis \ngroup (32.06 ± 5.31 vs. 29.51 ± 5.27 years, P < 0.001). The prevalence of women with adenomyosis who had \nconcomitant fibroids and ovarian endometrioma was 21.81% and 8.48%, respectively. The results of the \nmultivariate logistic regression analysis showed that age, type of infertility, presence of ovarian endometrioma \nand fibroids, and causes of infertility were significantly associated with adenomyosis.\nConclusion Adenomyosis seems to be a clinical condition with a high prevalence in infertile women, indicating \nthe importance of routine myometrial evaluation during infertility assessment to enhance patient counseling \nand management.\nKeywords Prevalence, Adenomyosis, Infertility, Ultrasound diagnosis\nEstimated prevalence of adenomyosis among \ninfertile women in an Iranian referral center: \na prospective cross-sectional screening study\nTahereh Madani1†, Nadia Jahangiri1†, Azam Santi1, Mohammad Chehrazi2 and Firoozeh Ahmadi3*\n\nPage 2 of 7\nMadani et al. Middle East Fertility Society Journal            (2026) 31:31 \nBackground\nAdenomyosis is a benign condition of the uterus and \nis defined by the presence of endometrial glands and \nstroma in an abnormal location of endometrial tissue \nwithin the uterine myometrium [ 1, 2]. Adenomyosis, \nas a steroid hormone-dependent [ 3] disorder, is often \nassociated with dysmenorrhea, dyspareunia, abnormal \nuterine bleeding, and infertility [ 4]. However, it should \nalso be considered that approximately one-third of \nwomen who have adenomyosis are reported as asymp -\ntomatic [ 5]. Adenomyosis can appear in both focal and \ndiffuse forms. The diffuse form is more common and \noften is distributed in the myometrium throughout the \nuterus, and the focal form is identified by a circum -\nscribed nodular aggregate of ectopic foci [ 6].\nA definitive diagnosis of adenomyosis is usually made by \nhistological examination of the uterus following a hyster -\nectomy. For several decades, studies evaluating the preva-\nlence of adenomyosis assessed populations of women who \nunderwent hysterectomy, which is likely to overestimate \nits prevalence [7]. Over the past twenty years, diagnostic \nimaging methods such as two-dimensional and three-\ndimensional transvaginal sonography (2D, 3D-TVS) and \nmagnetic resonance imaging (MRI) have been demon -\nstrated as reliable non-invasive techniques for detecting \nuterine adenomyosis [8]. Transvaginal sonography (TVS), \nin particular, provides improved resolution and detailed \nassessment of uterine morphology, is cost-effective, widely \navailable, and well-tolerated compared to MRI, making it \na valuable tool for diagnosing various gynecological disor-\nders [9]. Several risk factors can make a woman more sus-\nceptible to developing adenomyosis, such as high parity, \nage over 40 years, previous caesarean and uterine surgery. \nThe link between adenomyosis and infertility has been \nestablished in recent years [10].\nThe extant epidemiological data on adenomyosis are \nvery limited, with reported prevalence ranges widely \nfrom 22% to 89% [ 5]. Few studies are available in the \nliterature regarding the prevalence of adenomyosis \namong women experiencing infertility [ 5]. In a recent \nsystematic review related to the prevalence of adeno -\nmyosis in infertile women, conducted a decade ago, \nthe authors were troubled to draw certain conclusions \nbecause of limited data [ 11]. Further studies have since \nbeen published about the prevalence of adenomyo -\nsis in infertile women, with a prevalence between 8% \nand 24% [ 5]. In view of this, we conducted a prospec -\ntive observational screening study using 2D-TVS in a \npopulation of infertile women attending the infertility \nclinic of Royan Institute to estimate the prevalence of \nadenomyosis.\nMaterials & methods\nParticipants\nIn this prospective cross-sectional screening study, the \nperiod prevalence of adenomyosis was evaluated in \n963 women admitted for the first time between Febru -\nary 2017 and June 2020, at the infertility clinic of Royan \nInstitute in Tehran, Iran, a national referral center for \ninfertility treatment. Participants were selected using \nsystematic random sampling, with a randomly selected \nstarting point and inclusion of every 10th first-time eli -\ngible patient before ultrasonographic examination.\nThe study was approved by the Institutional Review \nBoard of the Royan Institute Research Center and the \nRoyan Ethics Committee and was performed in accor -\ndance with the Helsinki Declaration. Informed consent \nwas obtained from all individuals before they partici -\npated in the study.\nAll women met the criteria of infertility, defined as the \nfailure to conceive after 12 months of unprotected inter -\ncourse [ 12]. Exclusion criteria were women aged > 45 \nyears, women with multiple (more than two fibroids) and \nlarge fibroids (maximum diameter > 3 cm), women who \ndid not allow for vaginal examination (due to vaginis -\nmus), and those who did not feel inclined to participate \nin the study.\nA baseline demographic and clinical history, including \nage, body mass index (BMI), duration of infertility, type \nof infertility, and cause of infertility was obtained from all \nwomen before undergoing an ultrasound scan.\nSonographic procedure\nAll sonographic assessment was performed by a single \nexperienced radiologist, who was blinded to the patients’ \nclinical data. These assessments took place during the \nearly follicular phase of the patient’s cycle (day 3–5) using \na high-quality ultrasound machine (WS80; Samsung \nMedison Co. Ltd., Seoul, South Korea) equipped with a \n6–9 MHz transvaginal probe. The uterus was scanned \nalong its longitudinal and transverse axes to assess the \nendometrium. A diagnosis of diffuse adenomyosis was \nconfirmed when 2 or more of the following sonographic \nfeatures were present: A globular enlarged uterus, asym -\nmetrical thickness of the myometrium, myometrial \ncysts and small hyperechoic myometrial islands, hetero -\ngeneous myometrial echotexture without considering \nfibroids, and hyperechoic sub-endometrial linear stria -\ntions in the myometrium [ 13]. This diagnostic approach \nis consistent with the updated MUSA (Morphological \nUterus Sonographic Assessment) criteria [ 14] and pre -\nvious studies that demonstrate favorable sensitivity and \nspecificity [9]. Image acquisition and interpretation were \ncarried out following a standardized and consistent pro -\ntocol, which helps ensure the intra-observer consistency \nof imaging assessments. Localized adenomyosis was \n\nPage 3 of 7\nMadani et al. Middle East Fertility Society Journal            (2026) 31:31 \ndefined as the presence of a heterogeneous mass without \na defined margin, like a lesion within the myometrium \n[15]. To assess disease severity, we adopted a two-grade \nclassification (mild vs. severe) based on the extent of dis -\nease on ultrasonography. Mild adenomyosis was defined \nas limited myometrial involvement with focal or subtle \nsonographic features, while severe adenomyosis was \ndefined as extensive involvement and/or multiple fea -\ntures indicative of diffuse disease [ 15]. The ultrasound \ndiagnosis of ovarian endometrioma was confirmed by the \nvisualization of a ground-glass echogenicity of the cyst \nfluid within the ovary [16].\nStatistical analysis\nAll cases were separated into women with and without \nadenomyosis. For prevalence estimation, the numera -\ntor comprised women diagnosed with adenomyosis, and \nthe denominator comprised the total number of eligible \nwomen who were screened (i.e., included in the analysis) \nduring the study period.\nData analysis was performed using SPSS version 22.0 \n(SPSS, Inc., Chicago, IL, USA). Data were expressed as \nmean ± SD or frequency (percentage). Continuous and \ncategorical variables were compared using the t-test \nand the Pearson χ2 or Fisher’s exact tests, respectively. \nThe 95% confidence intervals (CI) for proportions \nand means were calculated when necessary. Multiple \nlogistic regression analysis was used to identify inde -\npendent variables that were significant in univariate \nanalyses and associated with the presence of adeno -\nmyosis. The Hosmer-Lemeshow method was used to \ncheck the regression goodness of fit. Multicollinearity \namong all independent variables was assessed using \nvariance inflation factors (VIF). P < 0.05 indicated sta -\ntistical significance.\nResults\nA total of 981 infertile women were approached for eligi -\nbility in the study, of whom 963 (98.16%) were included \nin the study. Of these, 814 women (84.52%) had primary \ninfertility and 149 (15.47%) had secondary infertility. The \nmean age and duration of infertility were 29.95 ± 5.36 and \n4.45 ± 4.02 years, respectively. The age range was 18–45 \nyears. The characteristics of adenomyosis in the 165 cases \nfound by 2D-TVS are listed in Table 1.\nThe prevalence of adenomyosis was reported to be \n17.13% (95% CI: 14.75–19.52) among infertile women \nwho were screened by 2D-TVS. The majority of cases \nwere diagnosed as generalized adenomyosis (97.58%), \nwhile localized adenomyosis was less common (2.42%). \nThe demographic characteristics of the patient popula -\ntion are presented in Table  2. In this study, adenomyotic \nTable 1 2D-TVS characteristics of women with adenomyosis\nAdenomyosis\n Yes 165 \n(17.13)\n No 798 \n(82.87)\nAdenomyosis type\n Generalized 161 \n(97.58)\n Localized 4 (2.42)\nSeverity of generalized adenomyosis\n Mild 75 (46.58)\n Severe 86 (53.42)\nGlobular large uterus 18 (10.90)\nAsymmetric myometrial thickness 3 (1.81)\nSubendometrial and myometrial cysts 162 \n(98.18)\nHyperechoic myometrial islands or linear striations radiating 47 (28.48)\nObscure endometrial-myometrial border 12 (7.27)\nMass with unclear margins 2 (1.21)\n2D-TVS two-dimensional transvaginal ultrasound\nTable 2 Comparison of demographic and clinical characteristics \nof women with and without adenomyosis\nDemographic \nCharacteristics\nAdenomyo-\nsis\n(n = 165)\nNo Adeno-\nmyosis\n(n = 798)\nTotal\n(n = 963)\nP.\nvalue\nAge (years) 32.06 ± 5.31 29.51 ± 5.27 29.95 ± 5.36 < 0.001\nBMI (kg/m2) 27.74 ± 5.25 26.92 ± 5.40 27.06 ± 5.38 0.078\nInfertility duration \n(years)\n4.64 ± 3.87 4.41 ± 4.05 4.45 ± 4.02 0.504\nInfertility type\n Primary 122 (73.93) 692 (86.71) 814 (84.52) < 0.001\n Secondary 43 (26.06) 106 (13.28) 149 (15.47)\nInfertility cause\n Male factor 45 (27.27) 327 (40.97) 372 (38.62) < 0.001\n Ovarian Factor 44 (26.66) 222 (27.81) 266 (27.62)\n Uterine Factor 4 (2.42) 7 (0.87) 11 (1.14)\n Tubo-peritone -\nal factor\n12 (7.27) 29 (3.63) 41 (4.25)\n Recurrent \nabortion\n10 (6.06) 19 (2.38) 29 (3.01)\n Unexplained 50 (30.30) 194 (24.31) 244 (25.33)\nLarge uterine size 19 (11.51) 2 (0.25) 21 (2.18) < 0.001\nUterine \nheterogeneity\n165 (100.00) 8 (1.00) 172 (17.86) < 0.001\nAssociated \nfibroids\n36 (21.81) 10 (1.25) 46 (4.77) < 0.001\nAssociated ovari-\nan endometrioma\n14 (8.48) 11 (1.37) 25 (2.59) < 0.001\nOvarian endometrioma\n Unilateral 10 (71.43) 8 (72.73) 18 (72.00) 0.943\n Bilateral 4 (28.57) 3 (27.27) 7 (28.00)\nData are written as mean ± SD or n (%)\nP-value was obtained by the independent sample t-test and chi-square test, or \nFisher’s exact test\nStatistically significant level was 0.05\nBMI Body mass index\n\nPage 4 of 7\nMadani et al. Middle East Fertility Society Journal            (2026) 31:31 \nwomen had significantly higher mean age in compari -\nson with those without adenomyosis (32.06 ± 5.31 versus \n29.51 ± 5.27 years; P < 0.001). The prevalence of adeno -\nmyosis was significantly higher in women ≥ 40 years com-\npared with women < 40 years [29.54% ( n = 13/44) \nversus 16.53% ( n = 152/919); OR 2.11; 95% CI 1.08–4.13; \nP = 0.028]. The prevalence of adenomyosis was signifi -\ncantly higher in women with secondary infertility [28.85% \n(n = 43/149)] than those with primary infertility [14.98% \n(n = 122/814)] (OR 2.30; 95% CI 1.53–3.44; P < 0.001). \nThe cause of infertility also differed between groups \n(P < 0.001). As it is reported in Table  2, there were sig -\nnificant differences in the observed rates of large uterine \nsize, uterine heterogeneity, associated fibroids, and asso -\nciated endometrioma between groups. Although women \nwith adenomyosis were more likely to have ovarian endo-\nmetriomas [8.48% ( n = 14/165) versus 1.37% ( n = 11/798); \nOR 6.63: 95% CI 2.95–14.89; P < 0.001] (Table  2), the \npresence of unilateral or bilateral ovarian endometrioma \ndidn’t differ between groups (P = 0.943). The coexistence \nof fibroids and adenomyosis was found in 21.81% of \ncases, and more reported in women aged > 35 years than \nin women aged ≤ 35 years [14.19% ( n = 22/155) versus \n1.73% (n = 14/808); P < 0.001].\nAccording to the analysis of multivariate logistic \nregression, after adjusting for covariates, adenomyosis \nwas independently associated with the variables of age \n(OR 1.04; 95% CI 1.00–1.08; P = 0.025), type of infertil -\nity (OR 1.90; 95% CI 1.17–3.09; P = 0.009), associated \nfibroids (OR 19.63; 95% CI 9.12–42.28; P < 0.001), and \novarian endometrioma (OR 5.77; 95% CI 2.39–13.90; \nP < 0.001). Among different causes of infertility, tubo-\nperitoneal (OR 2.99; 95% CI 1.34–6.69; P = 0.007), recur-\nrent abortion (OR 2.80; 95% CI 1.09–7.18; P = 0.031), and \nunexplained (OR 1.72; 95% CI 1.04–2.82; P = 0.032) were \nassociated with adenomyosis (Table 3).\nDiscussion\nThe present study shows the prevalence of adenomyosis \namong infertile women referring to the infertility clinic \nof our center to be 17.13%. According to our knowledge, \nthe present study is the largest adenomyosis screen -\ning among infertile women in IRAN using vaginal 2D \nultrasound. Assessing the prevalence of adenomyosis in \nthe reproductive context is difficult because it is often \nimpossible to correlate the imaging diagnosis with the \npathology report. This may explain part of the large dif -\nference between the prevalence reported in the studies, \nwhich range from 22% to 89% depending on the num -\nber of diagnostic criteria and populations evaluated [ 5]. \nThe majority of previous studies have investigated the \nprevalence of adenomyosis in the population of hys -\nterectomized women. In a large longitudinal study of \n1252 hysterectomy pathology reports from 33 hospitals \nthroughout Maryland, investigators evaluated the vari -\nability in the frequency of histological diagnosis of ade -\nnomyosis. The prevalence of adenomyosis was reported \nto be between 12–58% in regional hospitals and 10–88% \namong pathologists [ 17]. These disparities suggest that \nadenomyosis may be overdiagnosed and that strict and \nwidely accepted criteria for the diagnosis of adenomyosis \nare required [ 18]. The morphologic features we used in \nthis study have been previously identified in studies [ 13] \nand are consistent with the updated MUSA criteria [ 14]. \nTransvaginal ultrasound is highly specific for diagnosing \nuterine adenomyosis based on any of these morphologi -\ncal features [13, 19].\nThe results of the present study showed that the mean \nage was significantly higher in women with adenomyo -\nsis than in those without adenomyosis (32.06 ± 5.31 vs. \n29.51 ± 5.27 years; P < 0.001). This analysis also identified \na higher prevalence of adenomyosis in women older than \n40 years (29.54% vs. 16.53%; OR 2.11; 95% CI 1.08–4.13; \nP = 0.028), as has been previously reported. Puente et al. \n[20] reported the prevalence of adenomyosis as 24.4% in \ntheir large cross-sectional study conducted by 3D ultra -\nsound on 1015 infertile women. Their study showed the \nhigher prevalence of adenomyosis in women aged ≥ 40 \nyears (29.7%) than in women aged < 40 (22%), which is \napproximately similar to our findings. It has also been \nreported that adenomyosis becomes more frequent \nin later reproductive years and declines after meno -\npause, and a higher incidence of adenomyosis has been \nobserved in women aged 40–50 years [ 5]. Some studies \nhave evaluated age as an independent variable, which has \nno association with the disease [21].\nAdenomyosis is usually accompanied by other patho -\nlogical factors such as leiomyoma and endometriosis. \nThese pathologies are probably estrogen dependent, and \nother factors, such as genetic factors, environmental fac -\ntors, and inflammatory processes may play a role in the \nTable 3 The backward logistic regression analysis with OR and \n95% CI on the factors affecting adenomyosis\nOR 95% CI P value\nAge (years) 1.04 (1.00-1.08) 0.025\nType infertility 1.90 (1.17–3.09) 0.009\nAssociated fibroids 19.63 (9.12–42.28) < 0.001\nAssociated ovarian endometrioma 5.77 (2.39–13.90) < 0.001\nCause of infertility\n Male factor 1*\n Ovarian Factor 1.41 (0.85–2.33) 0.174\n Uterine 1.80 (0.41–7.86) 0.431\n Tubo-peritoneal factor 2.99 (1.34–6.69) 0.007\n Recurrent abortion 2.80 (1.09–7.18) 0.031\n Unexplained 1.72 (1.04–2.82) 0.032\nOR odds ratio, CI Confidence Interval\n*: Reference category\n\nPage 5 of 7\nMadani et al. Middle East Fertility Society Journal            (2026) 31:31 \noccurrence of these pathologies [ 22]. It has been sug -\ngested in theories that pelvic endometriosis and uterine \nadenomyosis may be different forms of the same disease \nthat occurs due to displacement of the basal endome -\ntrium and is caused by internal myometrial dysfunction \n[23]. In our research, we did not investigate endometrio -\nsis; we only focused on the presence of endometrioma.\nIn our findings, the prevalence of adenomyosis among \nwomen with fibroids (21.81%) was higher than in the \nentire study population (17.13%), and a markedly ele -\nvated odds ratio was observed for concurrent uterine \nfibroids (OR = 19.63), indicating a strong association \nbetween the two conditions. According to the studies, the \nultrasound features included in this analysis are typically \ndistinct and can be reliably differentiated [ 24]. In a retro-\nspective study by Hanafi et al. [25], the accuracy, sensitiv-\nity, specificity, and positive and negative predictive values \nfor diagnosing adenomyosis, leiomyoma, or a combina -\ntion of adenomyosis and leiomyoma were evaluated using \nvaginal ultrasound compared to the histopathological \nfindings. Trans-vaginal ultrasound was sensitive enough \n(84.5%), but non-specific (43.4%) to detect adenomyosis. \nAccording to their results, TVS is a valuable non-invasive \nmethod in diagnosing myoma and the combination of \nadenomyosis and myoma in terms of sensitivity (96.4 and \n77.8%, respectively), specificity (96.3% and 67.1%, respec -\ntively), and accuracy (96.3 and 73.00, respectively). In \nour study, although multicollinearity analysis showed no \nsignificant collinearity (VIF for fibroids = 1.07; tolerance \n= 0.930), the findings should be interpreted with cau -\ntion, as some degree of overlap between features cannot \nbe entirely excluded, which may partly contribute to the \nstrong association observed.\nIn some studies [26], multiparity has been described as \na risk factor for adenomyosis in the general population. \nIn the present study, although the study population con -\nsisted of infertile women, secondary infertility was sig -\nnificantly higher in the women with adenomyosis than in \nthose without adenomyosis (26.1 vs. 13.3; P < 0.001), and \nthis association was observed in multivariate regression \nanalysis (OR 1.90; 95% CI 1.17–3.09; P = 0.009).\nAtabekoglu et al. [ 27] focused on the association \nbetween adenomyosis and recurrent miscarriage and \nreported that the prevalence of adenomyosis was sig -\nnificantly higher in women with recurrent miscarriage \ncompared to those without a history of miscarriage \n(19.7% vs. 6.1% respectively, p = 0.035). Similarly, infertil-\nity due to recurrent miscarriage was significantly higher \namong women with adenomyosis (6.06% vs. 2.38%; P \n= 0.01), and multivariate logistic regression indicated \nan independent association between adenomyosis and \nrecurrent abortion, with an odds ratio of 2.80 (95% CI \n1.09–7.18; P = 0.031). In the study of Puente et al. [ 20], \nwomen who specifically referred to the imaging unit \ndue to repeated miscarriages had a high prevalence of \nadenomyosis (38.2%). What can be noted in this case is \nthat the observed association with recurrent pregnancy \nloss may also reflect alternative explanations, such as \nshared underlying pathophysiological mechanisms [ 28] \nor prior uterine instrumentation [29], rather than a direct \ncausal relationship. These women may have experienced \nmore interventions, and this probably caused damage \nto the endometrial-myometrial interface and facilitated \nthe migration of endometrial epithelial cells [ 30]. On \nthe contrary, there is also a possibility that women with \nadenomyosis have a higher risk of miscarriage due to the \nuterine factor [31].\nThe possible cause of the conflicting results between \nstudies may be due to the limited sample size in many \nprevious studies with low power and different assisted \nreproductive techniques utilized. In addition, the pre -\nvious results have not been analyzed according to the \nseverity of the disease, which is probably an impor -\ntant factor. The main strengths of this study include its \nprospective design, a large sample size, and the use of \nstandardized ultrasound conducted by an experienced \nsonographer. However, there are several limitations that \nshould be considered. First, the study’s single-center, \nreferral-based design may limit the generalizability of the \nresults. Consequently, the reported prevalence and asso -\nciations may not be directly applicable to primary care \nsettings, non-referral centers, or populations with dif -\nferent demographic characteristics. Additionally, there \nmay be potential selection bias, as not all infertile couples \nwere routinely assessed with imaging; the screening was \nlimited to individuals selected through systematic sam -\npling. Second, the cross-sectional design of the study \nprevents us from drawing causal inferences. Third, ade -\nnomyosis was diagnosed using ultrasonography without \nconfirmation from histopathological verification or MRI, \nwhich is considered the gold standard. This lack of con -\nfirmation could have affected diagnostic accuracy, espe -\ncially in cases where uterine fibroids were also present. \nFinally, deep infiltrating endometriosis beyond ovarian \nendometriomas was not evaluated, which may introduce \nadditional confounding factors.\nConclusion\nThe high prevalence of adenomyosis observed in our \ngroup of infertile women (17.13%) raises an important \nclinical question regarding routine screening. Our data \nsuggest that it may be beneficial to include a systematic \nevaluation of the myometrium during routine transvagi -\nnal ultrasound as part of the infertility work-up. Early \ndetection of adenomyosis would allow for better patient \ncounseling and stratification. Our secondary regression \nanalysis revealed potential associations between adeno -\nmyosis and several gynecological factors, including age, \n\nPage 6 of 7\nMadani et al. Middle East Fertility Society Journal            (2026) 31:31 \ntype of infertility, a history of miscarriage, and the pres -\nence of uterine fibroids or endometriomas. While these \nfindings are exploratory and derived from a secondary \nanalysis—and thus require cautious interpretation—they \npoint to important clinical synergies that deserve further \ninvestigation. The severity assessment criteria may help \nto conduct future valid studies for better counseling of \ninfertile couples.\nAbbreviations\nBMI  Body mass index\nCI  Confidence intervals\n2D-TV  Two-dimensional transvaginal ultrasound\n3D-TV  Three-dimensional transvaginal ultrasound\nMRI  Magnetic resonance imaging\nTVS  Transvaginal sonography\nVIF  Variance inflation factors\nOR  Odds ratio\nSD  Standard deviation\nAcknowledgements\nThe authors wish to express their gratitude to the Royan Institute and their \nstaff. The authors sincerely thank the women who kindly participated in this \nstudy. We would like to acknowledge that during the preparation of the \nrevised article, the authors utilized Grammarly (an AI writing tool) to enhance \nthe language.\nAuthors’ contributions\nT.M: Conceptualization and Supervision; N.J: Investigation, Methodology, \nInterpretation of data and Manuscript writing; A.S.: Data acquisition; M. Ch: \nStatistical analysis; F.A: Performing all sonographies and Data Validation. All \nauthors have critically reviewed and approved the final manuscript.\nFunding\nNo financial support has been granted.\nData availability\nThe datasets used and/or analyzed during the current study are available from \nthe corresponding author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nThe study was approved by the Institutional Review Board of the Royan \nInstitute Research Center and the Royan Ethics Committee (IR.ACECR.ROYAN.\nREC.1395.204) and performed according to the Helsinki Declaration. All \npatients signed the written informed consent form before participation in the \nstudy.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare no competing interests.\nReceived: 22 December 2025 / Accepted: 28 February 2026\nReferences\n1. Vannuccini S, Petraglia F (2019) Recent advances in understanding and \nmanaging adenomyosis. 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