Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

Reproductive outcomes of high-intensity focused ultrasound ablation and myomectomy for uterine fibroids: a systematic review and meta-analysis

RESEARCH QUESTION

Does high-intensity focused ultrasound (HIFU) ablation have comparable reproductive outcomes to myomectomy for patients with uterine fibroids?

DESIGN

A systematic review and a meta-analysis of data extracted from published studies up to March 2024.

RESULTS

Through a more structured analysis, HIFU treatment yielded a pooled pregnancy rate of 23.3% (95% CI 11.5 to 37.6%) and a pooled live birth rate (LBR) of 17.3% (95% CI 7.8 to 29.3%), significantly lower than those after myomectomy, which had a pooled pregnancy rate of 56.9% (95% CI 45.6 to 67.9%) and a pooled LBR of 44.1% (95% CI 34.9 to 53.4%) (P = 0.0001 and P = 0.0003, respectively). After controlling for patient age, ultrasound-guided HIFU studies reported significantly lower pregnancy rate and LBR compared with myomectomy. Moreover, studies enrolling younger patients and explicitly recruiting those desiring to conceive reported better reproductive outcomes.

CONCLUSIONS

Patients with uterine fibroids undergoing HIFU treatment and desiring to preserve their uteri resulted in poorer reproductive outcomes compared with myomectomy. Although uterine fibroids are now the number one disease that receives HIFU treatment worldwide, the overall quality in design and execution of HIFU studies on reproductive outcomes for women with uterine fibroids leaves much room for improvement. Above all, comparative trials against the standard of care are badly needed.

Different subtypes of ultrasound-diagnosed adenomyosis and in vitro fertilization outcomes: A systematic review and meta-analysis

INTRODUCTION

Adenomyosis prevalence among women with infertility is increasing; their management during in vitro fertilization is usually based on ultrasound diagnosis alone. Herein, we summarize the latest evidence on the impact of ultrasound-diagnosed adenomyosis on in vitro fertilization outcomes.

MATERIAL AND METHODS

The study was registered with The International Prospective Register of Systematic Reviews (CRD42022355584). We searched PubMed, Embase, and Cochrane Library databases from inception to January 31, 2023, for cohort studies on the impact of adenomyosis on in vitro fertilization outcomes. Fertility outcomes were compared according to the presence of adenomyosis as diagnosed by ultrasound, concurrent endometriosis and adenomyosis, and MRI-based or MRI- and ultrasound-based adenomyosis diagnosis. Live birth rate was the primary outcome while clinical pregnancy and miscarriage rates were secondary outcomes.

RESULTS

Women diagnosed with adenomyosis by ultrasound had lower live birth (odds ratio [OR] = 0.66; 95% confidence interval [CI]: 0.53-0.82, grade: very low), lower clinical pregnancy (OR = 0.64; 95% CI: 0.53-0.77, grade: very low), and higher miscarriage (OR = 1.81; 95% CI: 1.35-2.44, grade: very low) rates than those without adenomyosis. Notably, symptomatic and diffuse, but not asymptomatic adenomyosis as diagnosed by ultrasound, adversely affected in vitro fertilization outcomes, with lower live birth (OR = 0.57; 95% CI: 0.34-0.96, grade: very low), clinical pregnancy (OR = 0.69; 95% CI: 0.57-0.85, grade: low), and miscarriage (OR = 2.48, 95% CI: 1.28-4.82, grade: low) rates; and lower live birth (OR = 0.37; 95% CI: 0.23-0.59, grade: low) and clinical pregnancy (OR = 0.50; 95% CI: 0.34-0.75, grade: low), but not miscarriage rate (OR = 2.18; 95% CI: 0.72-6.62, grade: very low), respectively. Concurrent adenomyosis in endometriosis is associated with a significantly lower live birth rate (OR = 0.44; 95% CI: 0.26-0.75, grade: low) than endometriosis alone. Finally, the use of MRI-based or MRI- and ultrasound-based adenomyosis diagnosis showed no significant association with in vitro fertilization outcomes (grade: very low for all outcomes).

CONCLUSIONS

Considering ultrasound findings, symptoms, and different subtypes of adenomyosis may aid in offering personalized counseling, improving treatment decisions, and achieving better outcomes of in vitro fertilization.

Adenomyosis and fertility: does adenomyosis impact fertility and does treatment improve outcomes

PURPOSE OF REVIEW

Adenomyosis has recently been associated with infertility. Relief of bleeding and pain has been demonstrated with medical and surgical therapy. Less is known about reproductive outcomes after treatment.

RECENT FINDINGS

Imaging findings during infertility evaluation can be suggestive of adenomyosis without pathologic evaluation. Among women with infertility undergoing assisted reproductive technologies (ART), adenomyosis is associated with lower live birth rates and clinical pregnancy rates. Treatment with gonadotropin releasing hormone (GnRH) modulators prior to frozen embryo transfer may increase the live birth rate and clinical pregnancy rate among women with adenomyosis. Pregnancy has been documented following image-guided adenomyosis ablation; however, the reproductive impact is not well established. Pregnancy following excisional procedures appears to be well tolerated, although may carry a higher risk of uterine rupture compared with pregnancy following myomectomy. It is not clear if ablative therapy or resection increases pregnancy rates.

SUMMARY

Adenomyosis is associated with lower embryo implantation rates and ongoing pregnancy rates. Adenomyotic changes in the uterus can be seen by ultrasound and MRI. GnRH modulators may be useful for women with adenomyosis undergoing ART. Additional prospective data is warranted to determine the optimal medical or surgical therapy for women with adenomyosis desiring conception.Video abstract Supplementary digital content, http://links.lww.com/COOG/A78.