Estimated prevalence of adenomyosis among infertile women in an Iranian referral center: a prospective cross-sectional screening study

Background Adenomyosis is a benign condition of the uterus. There are few studies available on the prevalence of adenomyosis among women experiencing infertility. This study was designed to use ultrasound imaging to determine the frequency of adenomyosis in infertile women.

This prospective cross-sectional screening study included 963 eligible infertile women referring to the infertility clinic of Royan Institute for the first time between 2017 and 2020. The women were referred for a transvaginal ultrasound before initiating the treatment. Exclusion criteria involved women: aged >45 years, with multiple and large fibroids, who had vaginismus, and those who did not feel inclined to participate in the study. Participants were divided into groups of women with adenomyosis and without adenomyosis.

The overall prevalence of adenomyosis was found to be 17.13%, of which 53.42% were severe adenomyosis. The mean age was significantly higher in the adenomyosis group than in the non-adenomyosis group (32.06 ± 5.31 vs. 29.51 ± 5.27 years, P < 0.001). The prevalence of women with adenomyosis who had concomitant fibroids and ovarian endometrioma was 21.81% and 8.48%, respectively. The results of the multivariate logistic regression analysis showed that age, type of infertility, presence of ovarian endometrioma and fibroids, and causes of infertility were significantly associated with adenomyosis.

Adenomyosis seems to be a clinical condition with a high prevalence in infertile women, indicating the importance of routine myometrial evaluation during infertility assessment to enhance patient counseling and management.

Prevalence, Adenomyosis, Infertility, Ultrasound diagnosis Estimated prevalence of adenomyosis among infertile women in an Iranian referral center: a prospective cross-sectional screening study Tahereh Madani1†, Nadia Jahangiri1†, Azam Santi1, Mohammad Chehrazi2 and Firoozeh Ahmadi3* Page 2 of 7 Madani et al. Middle East Fertility Society Journal (2026) 31:31

Adenomyosis is a benign condition of the uterus and is defined by the presence of endometrial glands and stroma in an abnormal location of endometrial tissue within the uterine myometrium [ 1, 2]. Adenomyosis, as a steroid hormone-dependent [ 3] disorder, is often associated with dysmenorrhea, dyspareunia, abnormal uterine bleeding, and infertility [ 4]. However, it should also be considered that approximately one-third of women who have adenomyosis are reported as asymp - tomatic [ 5]. Adenomyosis can appear in both focal and diffuse forms. The diffuse form is more common and often is distributed in the myometrium throughout the uterus, and the focal form is identified by a circum - scribed nodular aggregate of ectopic foci [ 6]. A definitive diagnosis of adenomyosis is usually made by histological examination of the uterus following a hyster - ectomy. For several decades, studies evaluating the preva- lence of adenomyosis assessed populations of women who underwent hysterectomy, which is likely to overestimate its prevalence [7]. Over the past twenty years, diagnostic imaging methods such as two-dimensional and three- dimensional transvaginal sonography (2D, 3D-TVS) and magnetic resonance imaging (MRI) have been demon - strated as reliable non-invasive techniques for detecting uterine adenomyosis [8]. Transvaginal sonography (TVS), in particular, provides improved resolution and detailed assessment of uterine morphology, is cost-effective, widely available, and well-tolerated compared to MRI, making it a valuable tool for diagnosing various gynecological disor- ders [9]. Several risk factors can make a woman more sus- ceptible to developing adenomyosis, such as high parity, age over 40 years, previous caesarean and uterine surgery. The link between adenomyosis and infertility has been established in recent years [10]. The extant epidemiological data on adenomyosis are very limited, with reported prevalence ranges widely from 22% to 89% [ 5]. Few studies are available in the literature regarding the prevalence of adenomyosis among women experiencing infertility [ 5]. In a recent systematic review related to the prevalence of adeno - myosis in infertile women, conducted a decade ago, the authors were troubled to draw certain conclusions because of limited data [ 11]. Further studies have since been published about the prevalence of adenomyo - sis in infertile women, with a prevalence between 8% and 24% [ 5]. In view of this, we conducted a prospec - tive observational screening study using 2D-TVS in a population of infertile women attending the infertility clinic of Royan Institute to estimate the prevalence of adenomyosis.

& methods Participants In this prospective cross-sectional screening study, the period prevalence of adenomyosis was evaluated in 963 women admitted for the first time between Febru - ary 2017 and June 2020, at the infertility clinic of Royan Institute in Tehran, Iran, a national referral center for infertility treatment. Participants were selected using systematic random sampling, with a randomly selected starting point and inclusion of every 10th first-time eli - gible patient before ultrasonographic examination. The study was approved by the Institutional Review Board of the Royan Institute Research Center and the Royan Ethics Committee and was performed in accor - dance with the Helsinki Declaration. Informed consent was obtained from all individuals before they partici - pated in the study. All women met the criteria of infertility, defined as the failure to conceive after 12 months of unprotected inter - course [ 12]. Exclusion criteria were women aged > 45 years, women with multiple (more than two fibroids) and large fibroids (maximum diameter > 3 cm), women who did not allow for vaginal examination (due to vaginis - mus), and those who did not feel inclined to participate in the study. A baseline demographic and clinical history, including age, body mass index (BMI), duration of infertility, type of infertility, and cause of infertility was obtained from all women before undergoing an ultrasound scan. Sonographic procedure All sonographic assessment was performed by a single experienced radiologist, who was blinded to the patients’ clinical data. These assessments took place during the early follicular phase of the patient’s cycle (day 3–5) using a high-quality ultrasound machine (WS80; Samsung Medison Co. Ltd., Seoul, South Korea) equipped with a 6–9 MHz transvaginal probe. The uterus was scanned along its longitudinal and transverse axes to assess the endometrium. A diagnosis of diffuse adenomyosis was confirmed when 2 or more of the following sonographic features were present: A globular enlarged uterus, asym - metrical thickness of the myometrium, myometrial cysts and small hyperechoic myometrial islands, hetero - geneous myometrial echotexture without considering fibroids, and hyperechoic sub-endometrial linear stria - tions in the myometrium [ 13]. This diagnostic approach is consistent with the updated MUSA (Morphological Uterus Sonographic Assessment) criteria [ 14] and pre - vious studies that demonstrate favorable sensitivity and specificity [9]. Image acquisition and interpretation were carried out following a standardized and consistent pro - tocol, which helps ensure the intra-observer consistency of imaging assessments. Localized adenomyosis was Page 3 of 7 Madani et al. Middle East Fertility Society Journal (2026) 31:31 defined as the presence of a heterogeneous mass without a defined margin, like a lesion within the myometrium [15]. To assess disease severity, we adopted a two-grade classification (mild vs. severe) based on the extent of dis - ease on ultrasonography. Mild adenomyosis was defined as limited myometrial involvement with focal or subtle sonographic features, while severe adenomyosis was defined as extensive involvement and/or multiple fea - tures indicative of diffuse disease [ 15]. The ultrasound diagnosis of ovarian endometrioma was confirmed by the visualization of a ground-glass echogenicity of the cyst fluid within the ovary [16]. Statistical analysis All cases were separated into women with and without adenomyosis. For prevalence estimation, the numera - tor comprised women diagnosed with adenomyosis, and the denominator comprised the total number of eligible women who were screened (i.e., included in the analysis) during the study period. Data analysis was performed using SPSS version 22.0 (SPSS, Inc., Chicago, IL, USA). Data were expressed as mean ± SD or frequency (percentage). Continuous and categorical variables were compared using the t-test and the Pearson χ2 or Fisher’s exact tests, respectively. The 95% confidence intervals (CI) for proportions and means were calculated when necessary. Multiple logistic regression analysis was used to identify inde - pendent variables that were significant in univariate analyses and associated with the presence of adeno - myosis. The Hosmer-Lemeshow method was used to check the regression goodness of fit. Multicollinearity among all independent variables was assessed using variance inflation factors (VIF). P < 0.05 indicated sta - tistical significance.

A total of 981 infertile women were approached for eligi - bility in the study, of whom 963 (98.16%) were included in the study. Of these, 814 women (84.52%) had primary infertility and 149 (15.47%) had secondary infertility. The mean age and duration of infertility were 29.95 ± 5.36 and 4.45 ± 4.02 years, respectively. The age range was 18–45 years. The characteristics of adenomyosis in the 165 cases found by 2D-TVS are listed in Table 1. The prevalence of adenomyosis was reported to be 17.13% (95% CI: 14.75–19.52) among infertile women who were screened by 2D-TVS. The majority of cases were diagnosed as generalized adenomyosis (97.58%), while localized adenomyosis was less common (2.42%). The demographic characteristics of the patient popula - tion are presented in Table  2. In this study, adenomyotic Table 1 2D-TVS characteristics of women with adenomyosis Adenomyosis Yes 165 (17.13) No 798 (82.87) Adenomyosis type Generalized 161 (97.58) Localized 4 (2.42) Severity of generalized adenomyosis Mild 75 (46.58) Severe 86 (53.42) Globular large uterus 18 (10.90) Asymmetric myometrial thickness 3 (1.81) Subendometrial and myometrial cysts 162 (98.18) Hyperechoic myometrial islands or linear striations radiating 47 (28.48) Obscure endometrial-myometrial border 12 (7.27) Mass with unclear margins 2 (1.21) 2D-TVS two-dimensional transvaginal ultrasound Table 2 Comparison of demographic and clinical characteristics of women with and without adenomyosis Demographic Characteristics Adenomyo- sis (n = 165) No Adeno- myosis (n = 798) Total (n = 963) P. value Age (years) 32.06 ± 5.31 29.51 ± 5.27 29.95 ± 5.36 < 0.001 BMI (kg/m2) 27.74 ± 5.25 26.92 ± 5.40 27.06 ± 5.38 0.078 Infertility duration (years) 4.64 ± 3.87 4.41 ± 4.05 4.45 ± 4.02 0.504 Infertility type Primary 122 (73.93) 692 (86.71) 814 (84.52) < 0.001 Secondary 43 (26.06) 106 (13.28) 149 (15.47) Infertility cause Male factor 45 (27.27) 327 (40.97) 372 (38.62) < 0.001 Ovarian Factor 44 (26.66) 222 (27.81) 266 (27.62) Uterine Factor 4 (2.42) 7 (0.87) 11 (1.14) Tubo-peritone - al factor 12 (7.27) 29 (3.63) 41 (4.25) Recurrent abortion 10 (6.06) 19 (2.38) 29 (3.01) Unexplained 50 (30.30) 194 (24.31) 244 (25.33) Large uterine size 19 (11.51) 2 (0.25) 21 (2.18) < 0.001 Uterine heterogeneity 165 (100.00) 8 (1.00) 172 (17.86) < 0.001 Associated fibroids 36 (21.81) 10 (1.25) 46 (4.77) < 0.001 Associated ovari- an endometrioma 14 (8.48) 11 (1.37) 25 (2.59) < 0.001 Ovarian endometrioma Unilateral 10 (71.43) 8 (72.73) 18 (72.00) 0.943 Bilateral 4 (28.57) 3 (27.27) 7 (28.00) Data are written as mean ± SD or n (%) P-value was obtained by the independent sample t-test and chi-square test, or Fisher’s exact test Statistically significant level was 0.05 BMI Body mass index Page 4 of 7 Madani et al. Middle East Fertility Society Journal (2026) 31:31 women had significantly higher mean age in compari - son with those without adenomyosis (32.06 ± 5.31 versus 29.51 ± 5.27 years; P < 0.001). The prevalence of adeno - myosis was significantly higher in women ≥ 40 years com- pared with women < 40 years [29.54% ( n = 13/44) versus 16.53% ( n = 152/919); OR 2.11; 95% CI 1.08–4.13; P = 0.028]. The prevalence of adenomyosis was signifi - cantly higher in women with secondary infertility [28.85% (n = 43/149)] than those with primary infertility [14.98% (n = 122/814)] (OR 2.30; 95% CI 1.53–3.44; P < 0.001). The cause of infertility also differed between groups (P < 0.001). As it is reported in Table  2, there were sig - nificant differences in the observed rates of large uterine size, uterine heterogeneity, associated fibroids, and asso - ciated endometrioma between groups. Although women with adenomyosis were more likely to have ovarian endo- metriomas [8.48% ( n = 14/165) versus 1.37% ( n = 11/798); OR 6.63: 95% CI 2.95–14.89; P < 0.001] (Table  2), the presence of unilateral or bilateral ovarian endometrioma didn’t differ between groups (P = 0.943). The coexistence of fibroids and adenomyosis was found in 21.81% of cases, and more reported in women aged > 35 years than in women aged ≤ 35 years [14.19% ( n = 22/155) versus 1.73% (n = 14/808); P < 0.001]. According to the analysis of multivariate logistic regression, after adjusting for covariates, adenomyosis was independently associated with the variables of age (OR 1.04; 95% CI 1.00–1.08; P = 0.025), type of infertil - ity (OR 1.90; 95% CI 1.17–3.09; P = 0.009), associated fibroids (OR 19.63; 95% CI 9.12–42.28; P < 0.001), and ovarian endometrioma (OR 5.77; 95% CI 2.39–13.90; P < 0.001). Among different causes of infertility, tubo- peritoneal (OR 2.99; 95% CI 1.34–6.69; P = 0.007), recur- rent abortion (OR 2.80; 95% CI 1.09–7.18; P = 0.031), and unexplained (OR 1.72; 95% CI 1.04–2.82; P = 0.032) were associated with adenomyosis (Table 3).

The present study shows the prevalence of adenomyosis among infertile women referring to the infertility clinic of our center to be 17.13%. According to our knowledge, the present study is the largest adenomyosis screen - ing among infertile women in IRAN using vaginal 2D ultrasound. Assessing the prevalence of adenomyosis in the reproductive context is difficult because it is often impossible to correlate the imaging diagnosis with the pathology report. This may explain part of the large dif - ference between the prevalence reported in the studies, which range from 22% to 89% depending on the num - ber of diagnostic criteria and populations evaluated [ 5]. The majority of previous studies have investigated the prevalence of adenomyosis in the population of hys - terectomized women. In a large longitudinal study of 1252 hysterectomy pathology reports from 33 hospitals throughout Maryland, investigators evaluated the vari - ability in the frequency of histological diagnosis of ade - nomyosis. The prevalence of adenomyosis was reported to be between 12–58% in regional hospitals and 10–88% among pathologists [ 17]. These disparities suggest that adenomyosis may be overdiagnosed and that strict and widely accepted criteria for the diagnosis of adenomyosis are required [ 18]. The morphologic features we used in this study have been previously identified in studies [ 13] and are consistent with the updated MUSA criteria [ 14]. Transvaginal ultrasound is highly specific for diagnosing uterine adenomyosis based on any of these morphologi - cal features [13, 19]. The results of the present study showed that the mean age was significantly higher in women with adenomyo - sis than in those without adenomyosis (32.06 ± 5.31 vs. 29.51 ± 5.27 years; P < 0.001). This analysis also identified a higher prevalence of adenomyosis in women older than 40 years (29.54% vs. 16.53%; OR 2.11; 95% CI 1.08–4.13; P = 0.028), as has been previously reported. Puente et al. [20] reported the prevalence of adenomyosis as 24.4% in their large cross-sectional study conducted by 3D ultra - sound on 1015 infertile women. Their study showed the higher prevalence of adenomyosis in women aged ≥ 40 years (29.7%) than in women aged < 40 (22%), which is approximately similar to our findings. It has also been reported that adenomyosis becomes more frequent in later reproductive years and declines after meno - pause, and a higher incidence of adenomyosis has been observed in women aged 40–50 years [ 5]. Some studies have evaluated age as an independent variable, which has no association with the disease [21]. Adenomyosis is usually accompanied by other patho - logical factors such as leiomyoma and endometriosis. These pathologies are probably estrogen dependent, and other factors, such as genetic factors, environmental fac - tors, and inflammatory processes may play a role in the Table 3 The backward logistic regression analysis with OR and 95% CI on the factors affecting adenomyosis OR 95% CI P value Age (years) 1.04 (1.00-1.08) 0.025 Type infertility 1.90 (1.17–3.09) 0.009 Associated fibroids 19.63 (9.12–42.28) < 0.001 Associated ovarian endometrioma 5.77 (2.39–13.90) < 0.001 Cause of infertility Male factor 1* Ovarian Factor 1.41 (0.85–2.33) 0.174 Uterine 1.80 (0.41–7.86) 0.431 Tubo-peritoneal factor 2.99 (1.34–6.69) 0.007 Recurrent abortion 2.80 (1.09–7.18) 0.031 Unexplained 1.72 (1.04–2.82) 0.032 OR odds ratio, CI Confidence Interval *: Reference category Page 5 of 7 Madani et al. Middle East Fertility Society Journal (2026) 31:31 occurrence of these pathologies [ 22]. It has been sug - gested in theories that pelvic endometriosis and uterine adenomyosis may be different forms of the same disease that occurs due to displacement of the basal endome - trium and is caused by internal myometrial dysfunction [23]. In our research, we did not investigate endometrio - sis; we only focused on the presence of endometrioma. In our findings, the prevalence of adenomyosis among women with fibroids (21.81%) was higher than in the entire study population (17.13%), and a markedly ele - vated odds ratio was observed for concurrent uterine fibroids (OR = 19.63), indicating a strong association between the two conditions. According to the studies, the ultrasound features included in this analysis are typically distinct and can be reliably differentiated [ 24]. In a retro- spective study by Hanafi et al. [25], the accuracy, sensitiv- ity, specificity, and positive and negative predictive values for diagnosing adenomyosis, leiomyoma, or a combina - tion of adenomyosis and leiomyoma were evaluated using vaginal ultrasound compared to the histopathological findings. Trans-vaginal ultrasound was sensitive enough (84.5%), but non-specific (43.4%) to detect adenomyosis. According to their results, TVS is a valuable non-invasive

in diagnosing myoma and the combination of adenomyosis and myoma in terms of sensitivity (96.4 and 77.8%, respectively), specificity (96.3% and 67.1%, respec - tively), and accuracy (96.3 and 73.00, respectively). In our study, although multicollinearity analysis showed no significant collinearity (VIF for fibroids = 1.07; tolerance = 0.930), the findings should be interpreted with cau - tion, as some degree of overlap between features cannot be entirely excluded, which may partly contribute to the strong association observed. In some studies [26], multiparity has been described as a risk factor for adenomyosis in the general population. In the present study, although the study population con - sisted of infertile women, secondary infertility was sig - nificantly higher in the women with adenomyosis than in those without adenomyosis (26.1 vs. 13.3; P < 0.001), and this association was observed in multivariate regression analysis (OR 1.90; 95% CI 1.17–3.09; P = 0.009). Atabekoglu et al. [ 27] focused on the association between adenomyosis and recurrent miscarriage and reported that the prevalence of adenomyosis was sig - nificantly higher in women with recurrent miscarriage compared to those without a history of miscarriage (19.7% vs. 6.1% respectively, p = 0.035). Similarly, infertil- ity due to recurrent miscarriage was significantly higher among women with adenomyosis (6.06% vs. 2.38%; P = 0.01), and multivariate logistic regression indicated an independent association between adenomyosis and recurrent abortion, with an odds ratio of 2.80 (95% CI 1.09–7.18; P = 0.031). In the study of Puente et al. [ 20], women who specifically referred to the imaging unit due to repeated miscarriages had a high prevalence of adenomyosis (38.2%). What can be noted in this case is that the observed association with recurrent pregnancy loss may also reflect alternative explanations, such as shared underlying pathophysiological mechanisms [ 28] or prior uterine instrumentation [29], rather than a direct causal relationship. These women may have experienced more interventions, and this probably caused damage to the endometrial-myometrial interface and facilitated the migration of endometrial epithelial cells [ 30]. On the contrary, there is also a possibility that women with adenomyosis have a higher risk of miscarriage due to the uterine factor [31]. The possible cause of the conflicting results between studies may be due to the limited sample size in many previous studies with low power and different assisted reproductive techniques utilized. In addition, the pre - vious results have not been analyzed according to the severity of the disease, which is probably an impor - tant factor. The main strengths of this study include its prospective design, a large sample size, and the use of standardized ultrasound conducted by an experienced sonographer. However, there are several limitations that should be considered. First, the study’s single-center, referral-based design may limit the generalizability of the results. Consequently, the reported prevalence and asso - ciations may not be directly applicable to primary care settings, non-referral centers, or populations with dif - ferent demographic characteristics. Additionally, there may be potential selection bias, as not all infertile couples were routinely assessed with imaging; the screening was limited to individuals selected through systematic sam - pling. Second, the cross-sectional design of the study prevents us from drawing causal inferences. Third, ade - nomyosis was diagnosed using ultrasonography without confirmation from histopathological verification or MRI, which is considered the gold standard. This lack of con - firmation could have affected diagnostic accuracy, espe - cially in cases where uterine fibroids were also present. Finally, deep infiltrating endometriosis beyond ovarian endometriomas was not evaluated, which may introduce additional confounding factors.

The high prevalence of adenomyosis observed in our group of infertile women (17.13%) raises an important clinical question regarding routine screening. Our data suggest that it may be beneficial to include a systematic evaluation of the myometrium during routine transvagi - nal ultrasound as part of the infertility work-up. Early detection of adenomyosis would allow for better patient counseling and stratification. Our secondary regression analysis revealed potential associations between adeno - myosis and several gynecological factors, including age, Page 6 of 7 Madani et al. Middle East Fertility Society Journal (2026) 31:31 type of infertility, a history of miscarriage, and the pres - ence of uterine fibroids or endometriomas. While these findings are exploratory and derived from a secondary analysis—and thus require cautious interpretation—they point to important clinical synergies that deserve further investigation. The severity assessment criteria may help to conduct future valid studies for better counseling of infertile couples. Abbreviations BMI Body mass index CI Confidence intervals 2D-TV Two-dimensional transvaginal ultrasound 3D-TV Three-dimensional transvaginal ultrasound MRI Magnetic resonance imaging TVS Transvaginal sonography VIF Variance inflation factors OR Odds ratio SD Standard deviation

The authors wish to express their gratitude to the Royan Institute and their staff. The authors sincerely thank the women who kindly participated in this study. We would like to acknowledge that during the preparation of the revised article, the authors utilized Grammarly (an AI writing tool) to enhance the language. Authors’ contributions T.M: Conceptualization and Supervision; N.J: Investigation, Methodology, Interpretation of data and Manuscript writing; A.S.: Data acquisition; M. Ch: Statistical analysis; F.A: Performing all sonographies and Data Validation. All authors have critically reviewed and approved the final manuscript. Funding No financial support has been granted. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of the Royan Institute Research Center and the Royan Ethics Committee (IR.ACECR.ROYAN. REC.1395.204) and performed according to the Helsinki Declaration. All patients signed the written informed consent form before participation in the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Received: 22 December 2025 / Accepted: 28 February 2026

1. Vannuccini S, Petraglia F (2019) Recent advances in understanding and managing adenomyosis. F1000Research 13:8:F1000 Faculty Rev-283. h t t p s : / / d o i . o r g / 1 0 . 1 2 6 8 8 / f 1 0 0 0 r e s e a r c h . 1 7 2 4 2 . 1 2. Yu O, Schulze-Rath R, Grafton J, Hansen K, Scholes D, Reed SD et al (2020) Adenomyosis incidence, prevalence and treatment: United States popula- tion-based study 2006–2015. Am J Obstet Gynecol 223(1):94. e1-94 e10. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . a j o g . 2 0 2 0 . 0 1 . 0 1 6 3. Morassutto C, Monasta L (2016) Incidence and Estimated Prevalence of Endometriosis and Adenomyosis in Northeast Italy: A Data Linkage Study. PLoS ONE 11(4):e0154227. h t t p s : / / d o i . o r g / 1 0 . 1 3 7 1 / j o u r n a l . p o n e . 0 1 5 4 2 2 7 4. Gordts S, Grimbizis G, Campo R (2018) Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertil Steril 109(3):380–388e1. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . f e r t n s t e r t . 2 0 1 8 . 0 1 . 0 0 6 5. Upson K, Missmer SA (2020) Epidemiology of adenomyosis. Semin Reprod Med 38(2–03):89–107. h t t p s : / / d o i . o r g / 1 0 . 1 0 5 5 / s - 0 0 4 0 - 1 7 1 8 9 2 0 6. Exacoustos C et al (2020) New sonographic classification of adenomyosis: do type and degree of adenomyosis correlate to severity of symptoms? J Minim Invasive Gynecol 27(6):1308–1315. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . j m i g . 2 0 1 9 . 0 9 . 7 8 8 7. Ferenczy A (1998) Pathophysiology of adenomyosis. Hum Reprod Update 4(4):312–322. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / h u m u p d / 4 . 4 . 3 1 2 8. Tellum T, Nygaard S, Lieng M (2020) Noninvasive diagnosis of adenomyosis: a structured review and meta-analysis of diagnostic accuracy in imaging. J Minim Invasive Gynecol 27(2):408–418e3. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . j m i g . 2 0 1 9 . 1 1 . 0 0 1 9. Shaikh A, Masroor I, Masood A, Saeed SA (2023) Diagnostic Accuracy of Transvaginal Ultrasound in Adenomyosis Taking MRI as a Gold Standard. J Coll Physicians Surg Pak 33(10):1118–1123. h t t p s : / / d o i . o r g / 1 0 . 2 9 2 7 1 / j c p s p . 2 0 2 3 . 1 0 . 1 1 1 8 10. Pados G, Gordts S, Sorrentino F, Nisolle M, Nappi L, Daniilidis A (2023) Adeno- myosis and infertility: a literature review. Medicina 2 59(9):1551. h t t p s : / / d o i . o r g / 1 0 . 3 3 9 0 / m e d i c i n a 5 9 0 9 1 5 5 1 11. Maheshwari A, Gurunath S, Fatima F, Bhattacharya S (2012) Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. Hum Reprod Update 18(4):374–392. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / h u m u p d / d m s 0 0 6 12. Zegers-Hochschild F et al (2017) The international glossary on infertility and fertility care, 2017. Hum Reprod 32(9):1786–1801. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / h u m r e p / d e x 2 3 4 13. Di Donato N et al (2014) Prevalence of adenomyosis in women undergoing surgery for endometriosis. Eur J Obstet Gynecol Reprod Biol 181:289–293. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . e j o g r b . 2 0 1 4 . 0 8 . 0 1 6 14. Matot R et al (2025) Differences in the sonographic features of adenomyosis and concurrent endometriosis compared to isolated adenomyosis: A MUSA criteria analysis. J Ultrasound Med 44(6):1077–1084. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / j u m . 1 6 6 6 7 15. Van den Bosch T et al (2015) Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consen- sus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol 46(3):284–298. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / u o g . 1 4 8 0 6 16. Ștefan R-A et al (2021) Ultrasonography in the differentiation of endometrio- mas from hemorrhagic ovarian cysts: the role of texture analysis. J Pers Med 11(7):611. h t t p s : / / d o i . o r g / 1 0 . 3 3 9 0 / j p m 1 1 0 7 0 6 1 1 17. Seidman JD, Kjerulff KH (1996) Pathologic findings from the Maryland Women’s Health Study: practice patterns in the diagnosis of adenomyosis. Int J Gynecol Pathol 15(3):217–221. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 7 / 0 0 0 0 4 3 4 7 - 1 9 9 6 0 7 0 0 0 - 0 0 0 0 5 18. Habiba M, Benagiano G, health p (2021) Classifying adenomyosis: progress and challenges. Int J Environ Res Public Health 18(23):12386. h t t p s : / / d o i . o r g / 1 0 . 3 3 9 0 / i j e r p h 1 8 2 3 1 2 3 8 6 19. Sam M et al (2020) Accuracy of findings in the diagnosis of uterine adeno- myosis on ultrasound. Abdom Radiol (NY) 45(3):842–850. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / s 0 0 2 6 1 - 0 1 9 - 0 2 2 3 1 - 9 20. Puente JM et al (2016) Adenomyosis in infertile women: prevalence and the role of 3D ultrasound as a marker of severity of the disease. Reprod Biol Endocrinol 14(1):60. h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 5 8 - 0 1 6 - 0 1 8 5 - 6 21. Afzali N, Hafizi L, Abdollahi S (2025) Risk factors for uterine adenomyosis diagnosed by MRI in women of reproductive age. Ann Med Surg (Lond) 87(4):1941–1946. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 7 / M S 9 . 0 0 0 0 0 0 0 0 0 0 0 0 3 1 7 5 22. Bulun SE et al (2023) Endometriosis and adenomyosis: shared pathophysi - ology. Fertil Steril 119(5):746–750. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . f e r t n s t e r t . 2 0 2 3 . 0 3 . 0 0 6 23. Habiba M, Guo S-W, Benagiano G (2023) Are adenomyosis and endometriosis phenotypes of the same disease process? Biomolecules 14(1):32. h t t p s : / / d o i . o r g / 1 0 . 3 3 9 0 / b i o m 1 4 0 1 0 0 3 2 24. Van den Bosch T (2018) Uterine evaluation using a diagnostic protocol based on MUSA. In: Guerriero SCG, Alcázar JL (eds) How to perform ultrasonography in endometriosis. Springer, p 37. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / 9 7 8 - 3 - 3 1 9 - 7 1 1 3 8 - 6 Page 7 of 7 Madani et al. Middle East Fertility Society Journal (2026) 31:31 25. Hanafi M (2013) Ultrasound diagnosis of adenomyosis, leiomyoma, or com- bined with histopathological correlation. J Hum Reprod Sci 6(3):189–193. h t t p s : / / d o i . o r g / 1 0 . 4 1 0 3 / 0 9 7 4 - 1 2 0 8 . 1 2 1 4 2 1 26. Wang M-H, Chen J-H, Qi X-Y, Li Z-X, Huang Y (2025) Global prevalence of adenomyosis and endometriosis: a systematic review and meta-analysis. Reprod Biol Endocrinol 23(1):148. h t t p s : / / d o i . o r g / 1 0 . 1 1 8 6 / s 1 2 9 5 8 - 0 2 5 - 0 1 4 8 3 - z 27. Atabekoğlu CS et al (2020) The association between adenomyosis and recur- rent miscarriage. Eur J Obstet Gynecol Reprod Biol 250:107–111. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . e j o g r b . 2 0 2 0 . 0 5 . 0 0 6 28. Carbonnel M, Pirtea P , de Ziegler D, Ayoubi JM (2021) Uterine factors in recur- rent pregnancy losses. Fertil Steril 115(3):538–545. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . f e r t n s t e r t . 2 0 2 0 . 1 2 . 0 0 3 29. Gilman AR, Dewar KM, Rhone SA, Fluker MR, Canada G (2016) Intrauterine adhesions following miscarriage: look and learn. J Obstet Gynaecol Can 38(5):453–457. h t t p s : / / d o i . o r g / 1 0 . 1 0 1 6 / j . j o g c . 2 0 1 6 . 0 3 . 0 0 3 30. Leyendecker G et al (2015) Adenomyosis and endometriosis. Re-visiting their association and further insights into the mechanisms of auto-traumatisation. An MRI study. Arch Gynecol Obstet 291(4):917–932. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / s 0 0 4 0 4 - 0 1 4 - 3 4 3 7 - 8 31. Horton J, Sterrenburg M, Lane S, Maheshwari A, Li TC, Cheong Y (2019) Repro- ductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. Hum Reprod Update 25(5):592–632. h t t p s : / / d o i . o r g / 1 0 . 1 0 9 3 / h u m u p d / d m z 0 1 2 Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.