Uterus-Preserving Cold-Knife Adenomyomectomy within a Three-Stage Treatment Strategy for Severe Diffuse Adenomyosis and Its effect on IVF/ICSI and Perinatal Outcomes

Zeng Z, Zhi Zeng, Rui Xiang, Xiang R, Liu Y, Yingying Liu, Peng J, Jintao Peng, Li M, Manchao Li, Panyu Chen, Chen P, Jingjie Li, Li J, Zhao W, Weie Zhao, Xiaolan Li, Li X, Yujie Li, Li Y, Li Q, Qian Li, Zeng H, Haitao Zeng, Liang X, Xiaoyan Liang
Journal of Minimally Invasive Gynecology · 2026 · doi:10.1016/j.jmig.2026.08.024 · PMID:42697509 · W7208729343
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In a retrospective study of severe diffuse adenomyosis, a three-stage cold-knife adenomyomectomy strategy reduced miscarriage risk compared to GnRHa therapy but was associated with uterine rupture in 8.8% of deliveries.

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Abstract

OBJECTIVE: To evaluate the effects of a three-stage treatment strategy featured by cold-knife adenomyomectomy, enhanced endometrial protection and postoperative uterine monitoring for severe diffuse adenomyosis on IVF/ICSI and perinatal outcomes. DESIGN: Retrospective study. SETTING: Tertiary reproductive center. PARTICIPANTS: This study included 221 infertile women with diffuse adenomyosis treated from January 2021 to October 2025, comprising 125 patients with medically refractory disease or recurrent implantation failure who underwent three-stage treatment (surgery group) and 96 patients without these indications who received GnRHa-only therapy (control group). In the surgery group, 32 patients haven't completed uterine monitor, and 12 patients haven't made embryo transfer decision. INTERVENTIONS: A three-stage protocol: (1) extensive energy-free cold-knife debulking; (2) multi-layer tension-balanced uterine reconstruction preserving a 5-mm myometrial-endometrial buffer zone; and (3) postoperative sequential MRI, diagnostic hysteroscopy and/or 3D transvaginal ultrasound screening before embryo transfer. RESULTS: Uterine dimensions were significantly reduced after surgery in 93 patients with postoperative MRI assessments. Among 78 patients who proceeded with embryo transfer and definitive outcome (explicitly excluding two spontaneous conceptions and one ongoing pregnancy), the cumulative clinical pregnancy rate was 62.82% (49/78) and the cumulative live birth rate was 41.03% (32/78). Doubly robust AIPW estimation across 142 first embryo transfer cycles (46 from surgery and 96 from control group) revealed that the three-stage strategy was associated with a markedly reduced miscarriage risk (RR = 0.18; 95% CI, 0.05-0.67; P = 0.011), whereas clinical pregnancy and live-birth rates did not differ significantly between groups. Three third-trimester uterine ruptures occurred, corresponding to 8.8% (3/34) of women who delivered. All 3 patients required emergency cesarean delivery, including 1 woman underwent peripartum hysterectomy. All live-born neonates were discharged in good health. CONCLUSION: This fertility-sparing, non-thermal three-stage cold-knife technique reduces uterine size and appears to optimize reproductive outcomes in severe adenomyosis by reducing miscarriage. Doubly robust analysis reinforces the reliability of these findings, pending confirmation in larger cohorts. Strict single-embryo transfer, serial monitoring of the reconstructed myometrium and amniotic fluid, and planned cesarean delivery are mandatory to minimize uterine rupture risk.

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