Adenomyosis and fertility
What it is
Endometrial tissue within the muscular wall of the uterus, causing the wall to thicken. It commonly coexists with endometriosis, and the two are frequently confused — endometriosis is tissue outside the uterus, adenomyosis is within the uterine wall.
Symptoms
Heavy menstrual bleeding, painful periods, and a feeling of pelvic heaviness or bulk. Many women have no symptoms and it is found incidentally.
As with endometriosis, symptom severity does not reliably predict extent.
Diagnosis
Transvaginal ultrasound, with MRI where the picture is unclear. Diagnosis has improved considerably as imaging criteria have developed — historically it was diagnosed only after hysterectomy, which is why older sources describe it as difficult to identify.
The fertility question, honestly
Adenomyosis has been associated with reduced implantation and increased miscarriage in some studies. The size of that effect, and whether it is independent of coexisting endometriosis, is not well established.
I am not aware of a guideline recommendation specifically on managing adenomyosis for fertility. That absence is worth stating rather than filling — several treatments are offered on the basis of plausible mechanism rather than demonstrated benefit.
What is reasonable
Treating symptoms — heavy bleeding and pain — with hormonal treatment, where you are not currently trying to conceive.
Where you are trying: assessment of the uterine cavity, since adenomyosis can coexist with polyps or fibroids that are separately treatable.
Before IVF: some units use GnRH agonist suppression prior to transfer. Be aware that for endometriosis, ESHRE (2022) strongly recommends against extended GnRH agonist administration before ART, on the grounds that benefit is uncertain — and that recommendation was withdrawn from the previous guideline version. Whether that transfers to adenomyosis is not established, but it is a reason to ask what evidence supports the proposal.
Surgery for adenomyosis is not straightforward, since the disease is within the uterine wall rather than a discrete lesion. It is not routinely recommended for fertility.
The practical position
If you have adenomyosis and are trying to conceive, the most useful steps are assessing everything else properly — ovulation, tubes, a semen analysis — rather than focusing exclusively on the adenomyosis.
Where treatment is proposed specifically to improve fertility, ask what evidence supports it in adenomyosis rather than in endometriosis.
Reviewer note
A specific guideline source on adenomyosis and fertility was not available to this audit. If one exists it should be added, and this page revisited.
Sources
- ESHRE Guideline: Endometriosis (2022)
Frequently Asked Questions
Does adenomyosis prevent pregnancy?▾
Adenomyosis reduces fertility and IVF success rates but does not prevent pregnancy. Women with adenomyosis can and do conceive naturally and with IVF. Adenomyosis reduces IVF live birth rates by approximately 30% compared to women without it, and doubles miscarriage rates. GnRH agonist pre-treatment before IVF may improve outcomes.
How is adenomyosis diagnosed?▾
Transvaginal ultrasound (TVUS) is the first-line investigation — it shows characteristic features including asymmetric myometrial thickening, heterogeneous texture, and fan-shaped shadowing. MRI is the gold standard for non-invasive diagnosis and is more accurate than TVUS for extensive or deep adenomyosis. Definitive diagnosis requires histological examination of myometrial tissue.
Does adenomyosis cause heavy periods?▾
Yes — heavy, painful periods (menorrhagia and dysmenorrhoea) are the hallmark symptoms of adenomyosis. Periods are typically heavier, longer, and more painful than before, often worsening progressively over years. Severe dysmenorrhoea with heavy bleeding that is worsening over time should prompt investigation for adenomyosis (and endometriosis, which frequently coexists).