REVIEW

CURRENT
OPINION New paradigms in the conservative surgical and
interventional management of adenomyosis
Farah A. Alvi, Laura M. Glaser, Angela Chaudhari, Susan Tsai,
and Magdy P. Milad

Purpose of review
Adenomyosis is commonly diagnosed in women of reproductive age. Interest in conservative interventions
has grown as more women desire fertility preservation or avoidance of hysterectomy. This review discusses
surgical and interventional methods for treatment of symptomatic adenomyosis. The technique, evidence,
and utility of each method are described.
Recent findings
Hysteroscopic ablative techniques are associated with lower morbidity than with hysterectomy but may
result in an unacceptable risk of treatment failure. Surgical adenomyomectomy may provide good
symptomatic improvement, especially when combined with preoperative gonadotropin-releasing hormone
agonist treatment. Laparoscopic myometrial coagulation is associated with high rates of future pregnancy
complications. Uterine artery ligation has limited value as an isolated approach but, coupled with other
techniques, provides adequate therapeutic control. Bilateral uterine artery embolization may improve
symptoms, without significantly compromising fertility. Focused ultrasonic surgical methods also show
promise in alleviating symptoms without compromising reproductive outcomes.
Summary
A multitude of surgical and interventional options are available for young women with symptomatic
adenomyosis. These treatment methods have unique associated risks and benefits, and may have varying
impacts on long-term symptom control, fertility, and reproductive outcomes.
Keywords
adenomyosis, fertility, gynecologic surgery, uterine artery embolization

INTRODUCTION become more limited. In addition, adenomyosis

Adenomyosis is a benign gynecologic condition may often coexist with other pelvic pathology, such
characterized by the presence of ectopic endo- as endometriosis and leiomyomata [5]. Thus, careful
metrial glands and stroma in the myometrium, evaluation is necessary prior to offering treatment.
leading to adjacent smooth muscle hyperplasia, The purpose of this review is to examine the evi-
and hypertrophy [1]. Symptoms include abnormal dence for conservative surgical and interventional
uterine bleeding, dysmenorrhea, bulk symptoms, management of adenomyosis and its utility in
and chronic pelvic pain [2]. Diffuse uterine enlarge- women who wish to retain fertility and/or avoid
ment is a common finding, although focal areas of hysterectomy.
nodular smooth muscle aggregates, termed adeno-
&
myomas, may also be seen [3 ]. With remarkable
advances in imaging modalities, namely ultrasound Division of Minimally Invasive Gynecologic Surgery, Department of
Obstetrics and Gynecology, Northwestern University Feinberg School
and MRI technology, diagnosis is no longer con-
of Medicine, Chicago, Illinois, USA
fined to older women at the time of hysterectomy
Correspondence to Farah A. Alvi, MD, MS, Division of Minimally Invasive
but is increasingly found in younger, symptomatic Gynecologic Surgery, Department of Obstetrics and Gynecology, North-
women of reproductive age [4]. Consequently, there western University Feinberg School of Medicine, 250 E Superior Street,
is interest in conservative therapies that may poten- Suite 05-2177, Chicago, IL 60622, USA. Tel: +1 312 472 0505;
tially preserve fertility or preclude major surgery. e-mail: [email protected]
When medical management fails or challenges Curr Opin Obstet Gynecol 2017, 29:240–248
concurrent pregnancy desires, therapeutic options DOI:10.1097/GCO.0000000000000371

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 New paradigms in the surgical management of adenomyosis Alvi et al.

study compared fertility of patients with and with-

KEY POINTS out a histolopathologic diagnosis of adenomyosis at
 Conservative management techniques for symptomatic necropsy or hysterectomy [8]. The authors found
adenomyosis provide important options for patients, as that adenomyosis was associated with lifelong
younger patients often desire fertility preservation or clinical infertility [odds ratio (OR) 20.6]. The pres-
avoidance of hysterectomy. ence of endometriosis was associated with adeno-
myosis, but the association between adenomyosis
 Hysteroscopic ablative techniques are associated with
low morbidity but may be associated with poor and infertility remained even when patients with
symptom improvement in patients with deeply concurrent endometriosis were excluded. Other
penetrating disease. studies have echoed these findings. Puente et al.
&&
[9 ] conducted a cross-sectional study of ultrasound
 Surgical adenomyomectomy appears to be associated
imaging in patients with clinical infertility. Ultra-
with good improvement in symptoms but may be
associated with high rates of future sonographic definitions of adenomyosis are often
pregnancy complications. subjective. In this study, the authors defined
the presence of adenomyosis as sonographic evi-
 Bilateral uterine artery embolization appears to provide dence of at least one of the following: globally
good symptom control without significantly
increased myometrial thickness, uterine asymme-
compromising fertility, but this effect may be temporary.
try, heterogenous myometrial echotexture, pres-
 Newer techniques, such as focused ultrasonic surgical ence of an adenomyoma, irregular myometrium-
methods, show promise in alleviating symptoms without endometrium interphase, anechoic myometrial
compromising reproductive outcomes, but more cysts, or linear striations in the myometrium [9 ].
&&

research is needed.
They found ultrasound-defined adenomyosis was
present in 80% of such patients and was more
prevalent in women with a history of recurrent
pregnancy loss (P ¼ < .005). It has been postulated
FERTILITY AND PREGNANCY that the occurrence of adenomyosis causes func-
IMPLICATIONS tional changes in overlying endometrium – altering
Prior to surgical intervention, a thoughtful discus- decidualization, impairing implantation, and affect-
sion about the impact of adenomyosis on fertility ing normal sperm transport [10].
and reproductive outcomes is necessary. It is unclear The presence of adenomyosis may have an
whether adenomyosis is specifically linked to impact on clinical pregnancy rates in women under-
clinical infertility. The main reason for this contro- going in vitro fertilization (IVF) with intracytoplas-
versy is that endometriosis and other gynecologic mic sperm injection. A recent meta-analysis found
conditions frequently coexist in patients with that the clinical pregnancy rates are significantly
adenomyosis. One review reports the presence lower in women with adenomyosis than in those
of fibroids in 50% and endometriosis in 11% of without [pooled relative risk (RR) 0.72], though
patients with adenomyosis [6]. Another study of heterogeneity among studies was high. In addition,
infertile women compared MRI findings of adeno- first-trimester miscarriage rates were noted to be
myosis in those with and without surgically proven higher in women with adenomyosis than those
endometriosis. The presence of adenomyosis on MRI without this diagnosis (pooled RR 2.12) [11]. Con-
is generally defined as a junctional zone measuring versely, several individual studies reported no differ-
greater than 12 mm, and equivocal findings are ence in IVF response rates in women with and
represented by junctional zones measuring between without adenomyosis [12,13]. In women with
8 and 12 mm. In this study, authors defined the pres- adenomyosis undergoing IVF, specific techniques
ence of adenomyosis as a posterior or focal junctional such as planned frozen–thawed embryo transfer
zone thickness of greater than 10 mm [6]. They noted a following gonadotropin-releasing hormone (GnRH)
significantly thicker posterior junctional zone in agonist pretreatment have been shown to increase
those with endometriosis (P < .001) compared with
&&
pregnancy rates [14 ].
those without (11.5 versus 8.3 mm, respectively). In Few small studies have investigated the inci-
women under age 36 with endometriosis, the pre- dence of pregnancy complications in women with
&&
valence of MRI-diagnosed adenomyosis was 90% adenomyosis. Hashimoto et al. [15 ] examined
[7]. Furthermore, as discussed above, a definitive outcomes in singleton pregnancies both with and
diagnosis of adenomyosis can only be made on patho- without a diagnosis of adenomyosis. Patients with
logic specimens, obscuring its link to infertility. adenomyosis may have increased risks of second-
Several studies have alluded to a correlation trimester loss (OR 11.2), preeclampsia (OR 21.0),
between infertility and adenomyosis. One baboon placental malposition (OR 4.9), and preterm

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 Minimally invasive gynecologic procedures

delivery (OR 3.1). These concerns were reiterated by untreated following hysteroscopic resection, they
Mochimaru et al. [16], who similarly noted increased can result in persistent symptoms as well as worsen-
rates of preterm delivery, preterm premature rupture ing pain [18]. Conversely, resection of deep myo-
of membranes, small-for-gestational age neonates, metrial tissue increases the risk of major bleeding
fetal malpresentation, and cesarean delivery in [23]. If hysteroscopic surgery is unsuccessful,
patients with previous imaging-confirmed adeno- options may include reoperative hysteroscopy or
myosis. Another case–control study of women with hysterectomy. In a retrospective study by Longinotti
term or preterm deliveries noted a significantly et al., 21% of all women undergoing ablation
increased risk of preterm delivery in pregnant required subsequent hysterectomy with younger
women with ultrasound or MRI-confirmed adeno- age being the most predictive factor. The rate of
myosis (OR 1.26); P ¼ .022) [17]. Bias inherent with hysterectomy was highest in women under age 40
all retrospective studies may confound these associ- with rates as high as 40% [24]. Wortman et al. [25]
ations; thus, prospective studies are needed to also evaluated reoperative hysteroscopy after initial
confirm these findings. failure. Areas of endometrial growth and other
disease were identified and excised via ultrasound
guidance. Reoperative hysteroscopy produced excel-
SURGICAL INTERVENTIONS: lent results, avoiding hysterectomy in 44 of 49
HYSTEROSCOPIC RESECTION AND (88.9%) patients. In another retrospective study of
ABLATION 190 adenomyosis patients treated hysteroscopically,
In patients who no longer desire fertility but wish to the need for hysterectomy due to symptom recur-
avoid hysterectomy, hysteroscopic ablative tech- rence was only 1.6% [26].
niques may be a viable option. Endometrial ablation
can be performed using nonresectoscopic global
ablation or resectoscopic (i.e., wire loop, laser, roll- ADENOMYOMECTOMY AND DEBULKING,
&
erball) techniques [3 ,18]. In a retrospective study of CYTOREDUCTIVE SURGERY
816 women undergoing global thermal or radiofre- Since first described in 1952 by Hyams [27], the
quency endometrial ablation, the presence of evolution of excisional surgery for adenomyosis
adenomyosis was associated with a 1.5-fold has been slow. Much of the early struggle involved
increased risk of treatment failure requiring hyster- difficulty in diagnosing and defining the extent of
ectomy or repeat ablation [19]. Coincidentally, pre- the disease prior to hysterectomy. Advancements in
dictors of treatment failure were also risk factors for ultrasound and MRI technology have led to further
adenomyosis and included age over 45, parity of five discussions of uterine-sparing treatment in women
or more, prior tubal ligation, and history of dysme- diagnosed in their reproductive years. Older studies
&
norrhea [3 ,19]. Gemer et al. [20] found that the have reported the efficacy of excision for focal dis-
presence of submucosal myomas also increased the ease to be only 50%, although more recent data
risk of treatment failure with both rollerball and would argue otherwise [23]. In a prospective study
loop resection ablative techniques. Significantly, of 165 women, Wang et al. [28] reported adenomyo-
McCausland and McCausland [21] reported the suc- mectomy with/without GnRH agonist therapy pro-
cess of rollerball ablation to be highly correlated duced significant symptomatic relief of heavy
with the depth of adenomyosis. Patients with over menstrual bleeding and dysmenorrhea. In a recent
2-mm penetration of disease, as determined by systematic review, following complete excision of
intraoperative biopsy, were found to have poor adenomyosis, the dysmenorrhea reduction, menor-
results following treatment, associated with persist- rhagia control, and pregnancy rates were found to
ent pain or bleeding nonresponsive to progesterone. be 82.0, 68.8, and 60.5%, respectively [29]. After
It is, therefore, noteworthy that deeply penetrating partial excision, the dysmenorrhea reduction, men-
adenomyosis is found in approximately 75–87.5% orrhagia control, and pregnancy rates were 81.8,
of the hysterectomy specimens following failed 50.0, and 46.9%, respectively. Furthermore, the
endometrial resection/ablation [21,22]. development of laparoscopic approaches, which
When compared with hysterectomy, hystero- have permitted greater surgical precision and
scopic surgery is associated with decreased pain, reduction in complications, such as blood loss,
better cosmesis, shorter hospitalization, quicker adhesion formation, and uterine trauma, is worth
recovery, reduced cost, and lower overall morbidity. discussing [30]. In one of the first case series pub-
However, perioperative factors that may influence lished, in 2004, Morita et al. [31] described laparo-
the success of hysteroscopic treatment as well as its scopic adenomyomectomy using preoperative
risks should carefully be reviewed with the patient. GnRH and intraoperative vasopressin to minimize
When deep adenomyomatous lesions are left bleeding. All three cases were performed successfully

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 New paradigms in the surgical management of adenomyosis Alvi et al.

without complications. Symptom relief was experi- laparoscopic adenomyomectomy and another at
enced by the first menstrual period. Several sub- 28 weeks following open adenomyomectomy. The
sequent reports have demonstrated the feasibility theoretical risk of rupture proposed by Wang et al.
and efficacy of minimally invasive approaches for [36] was approximately one in eight. In addition,
adenomyomectomy and cytoreductive surgery other complication rates (i.e., spontaneous abor-
&
using various techniques [32,33,34 ,35,36]. tion, preterm labor, and placenta accreta) are
Excisional surgery is undoubtedly more chal- thought to be higher for these patients than for
lenging for diffuse disease. Care must be taken to the general population. Possible reasons include
balance the objective of meticulous excision of dis- formation of weakened scar tissue in place of
ease against unnecessary removal of myometrial healthy myometrium and small perforations in
tissue, which could result in excessive blood loss the endometrium that may result in invasion by
& &
and weakening of the uterine wall. Some investi- the placenta [3 ,36,45 ,46]. For these reasons,
gators have sought to mitigate these challenges. In a patients should be counseled extensively about
study of 26 patients who underwent adenomyomec- the risks of excisional surgery for uterine-sparing,
tomy with the addition of transient occlusion of fertility-preserving benefits and a high index of
uterine arteries, complete remission of dysmenor- suspicion for complications is necessary should
rhea and menorrhagia was observed in 94.4 and pregnancy occur. Caution should be exercised when
100% of patients, respectively [36]. Mean blood offering resection of diffuse disease to patients desir-
loss was 191 ml (range, 80–400 ml, SD 110.9.1) ing pregnancy given the lack of standardization of
and there were no major complications. Although this procedure and lack of long-term outcomes.
most authors have insisted that open techniques Patients with subsequent pregnancy should be con-
remain the mainstay of diffuse disease, some have sidered high-risk for uterine rupture and placental
argued that advancements in minimally invasive site abnormalities based on the limited available
surgery may have made laparoscopic and robotic data.
approaches to extensive adenomyosis excision as
feasible [33,37,38]. More studies on the excision
of diffuse adenomyosis are needed prior to making MYOMETRIAL ELECTROCOAGULATION
any recommendation for their practical use. Laparoscopic myometrial electrocoagulation is
Recent studies have addressed the reproductive thought to cause a reduction in adenomyosis
implications following excision surgery with mixed secondary to tissue necrosis and may be an option
&
results. In a 2-year study period following adeno- for women wishing to preserve their uterus [3 ].
myomectomy, Wang et al. [28] reported that 49 of However, limited studies on myometrial electro-
71 (69%) sexually active women not using contra- coagulation for the treatment of localized and/or
ception went on to have successful deliveries. Of diffuse adenomyosis are available. In a study of 10
these, seven women (14.3%) were diagnosed with patients, Phillips et al. [47] reported a 27.7%
preterm labor. Similarly, Osada et al. [39] reported reduction in uterine volume from baseline when
on fertility and pregnancy outcomes after cytore- women were pretreated with 3 months of GnRH
ductive surgery for diffuse adenomyosis in 104 analogs, and volume reduction increased to 73.9%
women. Of the 26 women wishing to conceive, 16 from baseline following laparoscopic bipolar
became pregnant (61%). Twelve of these women electrosurgery. A more recent study of 39 patients
conceived after IVF, and four were spontaneous demonstrated a uterine volume reduction of 43%
pregnancies. A total of 14 had elective cesarean and significant improvement in quality of life at
sections and two had miscarriages. A study of 103 12 months when unipolar electrocoagulation was
Iranian women treated for diffuse disease demon- used alone [48]. Wood et al. [49] described four
strated a clinical pregnancy rate of 30% in the 70 patients who underwent the electrocoagulation
women attempting pregnancy naturally (n ¼ 21) or with marked improvement in three patients (75%)
using artificial reproductive technology (n ¼ 49) after a follow-up of up 2 years. However, two of these
[40]. Otsubo et al. [41] reported two successful spon- three patients also underwent hysteroscopic endo-
taneous pregnancies in a patient treated for diffuse metrial resection, and it remained unclear which
disease. Although many reports are encouraging, procedure produced the improvement. In a prospec-
there are also several reports of uterine rupture tive, randomized trial of 20 patients, there was no
and other perinatal complications. Wada et al. significant difference in the reduction of menorrha-
[42] reported a uterine rupture at 30 weeks in a twin gia and dysmenorrhea when compared with laparo-
pregnancy following laparoscopic excision. Nagao scopic resection [50].
&
et al. [43 ] and Ukita [44] also reported two uterine Based on limited available data, myometrial
ruptures: one at 35-week gestation following electrocoagulation may best be reserved for women

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 Minimally invasive gynecologic procedures

who have completed child-bearing. The risk of ute- postoperatively, 97% of patients reported
rine rupture secondary to the diminished strength improvement in chronic pain. There was significant
of the myometrium is significant. Wood [51] improvement in postoperative dysmenorrhea, men-
reported a case of uterine rupture at 12-week orrhagia, and quality of life 3, 12, and 36 months
gestation in a woman who had underwent two postoperatively. Significantly, uterine size was
laparoscopic procedures for myometrial electrocoa- reduced by 58% at 36 months after surgery. Only
gulation of symptomatic adenomyosis. Hadisaputra 1.7% of patients had undergone hysterectomy at
and Anggraeni [50] described a uterine rupture at 36 months after surgery. Based on these findings,
8-month gestation in a patient with a history of this surgical uterine artery ligation combined with
procedure. Other disadvantages of electrocoagula- partial disease resection appears to be a promising
tion include the difficulty with precise application technique with better long-term outcomes that
and the inability to confirm adequate destruction, warrants further study.
necessitating further treatment. The possibility of
emergency hysterectomy for uncontrolled bleeding
and adhesion formation has also been discussed ALTERNATIVE INTERVENTIONAL
[52]. Further studies with larger number of patients PROCEDURES: UTERINE ARTERY
are needed prior to adequately determining the EMBOLIZATION
effectiveness and risks of the procedure. Bilateral uterine artery embolization (UAE) has been
extensively studied for symptomatic management
in patients with adenomyosis, producing favorable
UTERINE ARTERY LIGATION results in more recent research. Wang et al. [58 ]
&&

The effects of surgical uterine artery ligation have described 117 patients with pure adenomyosis
been studied extensively in conjunction with myo- undergoing bilateral UAE. After 12 months, a
mectomy, but only in a limited manner as treatment median 51% reduction in uterine size was noted.
for adenomyosis. Bae et al. [53] randomized patients Marked improvement in dysmenorrhea was noted
undergoing laparoscopic myomectomy to concur- in 55% of patients. Another midterm study of 29
rent uterine artery ligation or myomectomy alone. women with pure adenomyosis reported significant
They noted similar estimated blood loss in both improvement in global symptom severity, improved
groups, and significantly lower myoma recurrence from 67 at baseline to a mean of 15 at 29–64 months
&&
rate at 11 months in the uterine artery ligation of follow-up [59 ]. Three patients underwent a
group. Other studies have reported decreased blood second UAE and only one underwent hysterectomy.
loss after uterine artery ligation at the time of myo- Several older studies had shown less vigorous results.
mectomy and similarly reported decreased myoma Froeling et al. [60] reviewed symptoms 40 months
&
recurrence rates [54,55 ]. after UAE in adenomyosis patients with and without
Only one study has examined the effect of sur- uterine fibroids. Clinical failure was 31% in those
gical uterine artery ligation alone on symptoms of with predominant adenomyosis, but 0% in those
adenomyosis [56]. This small prospective study with predominant fibroid disease. Smeets et al. [61]
of 20 women with symptomatic adenomyosis reported an 18% hysterectomy rate at a mean of
undergoing uterine artery ligation with hemoclips 65 months after UAE in women with adenomyosis,
yielded inconsistent results. At 6 months post- with or without fibroid disease. Those with treat-
operatively, patients’ mean uterine size decreased ment failure had significantly thicker junctional
by 0.4–74%. Thirteen of 16 patients with abnormal zones, both at baseline and at follow-up. Another
bleeding achieved control of this symptom, whereas study of 26 women with symptomatic adenomyosis
12 of 16 patients achieved control of dysmenorrhea. undergoing UAE revealed initial improvement in
Significantly, treatment was rated as overall satis- menorrhagia in 79% of patients at 12 months, but
factory by only 15% of patients, and 85% would decline in menorrhagia symptoms in 45% of
not undergo the procedure if given the choice patients followed at 2 years [62].
again. MRI hallmarks of adenomyosis may not change
Surgical uterine artery ligation for adenomyosis significantly following UAE, but markers of necrosis
has also been studied in conjunction with other may predict symptomatic improvement. Jha et al.
surgical techniques. Liu et al. [57] reported on 182 [63] examined MRI findings 1 year after UAE in
patients with adenomyosis, treated with surgical patients with adenomyosis and fibroids. Patients’
uterine artery occlusion and partial resection of postprocedure junctional zone–myometrial ratio
adenomyosis. These authors used bipolar desicca- was not found to be statistically different than base-
tion of the uterine arteries and combined occlusion line imaging. Regions of adenomyosis devasculari-
with resection of focal adenomyosis. At 12 months zation were noted in 40% of patients, all of whom

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 New paradigms in the surgical management of adenomyosis Alvi et al.

had a preprocedure junctional zone thickness over [71]. Pregnancies after UAE were also more likely
20 mm. Similar findings were noted by Kitamura to be delivered by cesarean section (66 versus 49%;
et al. [64], who examined MRI findings 4 months OR 2.1; 95% CI 1.4–2.9) and be complicated by a
after UAE for adenomyosis. The authors noted a postpartum hemorrhage (14 versus 3%; OR 0.9; 95%
decrease in junctional zone thickness, but not in CI 0.5–1.5).
the junctional zone–myometrial ratio. Devasculari-
zation changes were noted in 73% of patients;
however, this did not completely correlate with MRI-GUIDED FOCUSED ULTRASOUND
symptom improvement. Conversely, Bae et al. SURGERY AND ULTRASOUND-GUIDED
&
[65 ] found that patients with less than 34% necrosis HIGH-INTENSITY FOCUSED ULTRASOUND
on MRI 18–48 months after UAE had a higher risk of MRI-guided focused ultrasound surgery (MRgFUS)
symptom recurrence. was first introduced in the 1990s for treatment of
The impact of UAE on future fertility is worth bone lesions and later was Food and Drug Admin-
considering for many patients. Several studies, istration-approved for use in gynecology for the
&&
mainly in women with uterine fibroids, have treatment of uterine fibroids [72 ]. Physician scien-
examined the effects of UAE on future fertility, tists began studying MRgFUS for the conservative
oocyte quality/quantity, and time to menopause. management of adenomyosis. MRgFUS allows
One retrospective study followed 66 women under- ablation of deep tissue without any abdominal wall
going bilateral UAE for 21 weeks postprocedure. incisions. The high-intensity ultrasound beam
Menses resumed in 85% of patients over this time causes thermal coagulation necrosis of lesions
period. Of the 15% without return of menses, 90% and associated vascular damage to the pathologic
had biochemical evidence of ovarian failure and disease. In a similar fashion, ultrasound-guided
all were over age 45 [66]. In contrast, a study of high-intensity focus ultrasound (HIFU) was intro-
20 younger women aged 33–39 undergoing UAE duced, proving the same procedure could be per-
revealed no differences in follicle-stimulating formed with ultrasound technology. The overall
hormone (FSH), E2 levels, and antral follicle counts complication rate remains low and includes skin
measured up to 12 months postprocedure when burns, nausea, vomiting, abdominal pain, low-grade
compared with patients’ baseline measures [67]. fever, hematuria, contact dermatitis, and inguinal/
&& &&
Another prospective cohort study compared FSH, leg pain [73 ,74 ]. Over the last 10 years, these
E2 levels, and antral follicles counts between pre- techniques have been improving and gaining
menopausal women undergoing UAE and age- popularity in the treatment of adenomyosis, with
matched controls [68]. No differences were noted the most vigorous studies being published in the last
&&
in any value up to 5 years postprocedure. 5 years. In a systematic review, Cheung [73 ]
The vast majority of data on pregnancy reported a reduction in menorrhagia at 1, 3, 6, 12,
outcomes following UAE is derived from case series 18, and 24-month follow-up of 12.4–33.3, 25.3–
of pregnant women with history of UAE for symp- 80.8, 16.4–52.4, 24.9–66.4, 44.0–44.8%, respec-
tomatic fibroids. One study of 24 conceptions tively. Reduction in dysmenorrhea at 3, 6, 12, 18,
following UAE reported four spontaneous abor- and 24 months was 25.0–83.3, 44.7–100, 64.0–
tions, 18 live births (four of which were preterm), 72.1, 54.2, and 56.0%, respectively. Reduction
and nine cesarean deliveries [69]. Notably, 12.5% in uterine volume over a follow-up period of
of patients experienced postpartum hemorrhages 1–12 months was 12.7–54%.
due to abnormal placentation, all of which occurred Studies on the reproductive outcomes sub-
in the nulliparous patients. In addition, four sequent to treatment with ultrasonic energy for
newborns were small for gestational age. In another adenomyosis are growing. In a 2006 case report,
retrospective review of 56 pregnancies after UAE, Rabinovici et al. [75] first discussed a case of spon-
31% of patients attempting to conceive became taneous conception followed by uncomplicated
pregnant. Of those who achieved pregnancies, vaginal delivery of a term infant in women pre-
59.6% had successful outcomes and 30.4% resulted viously treated with MRgFUS for adenomyosis.
&&
in spontaneous abortion. Of the 34 deliveries in Zhou et al. [76 ] described 68 patients with adeno-
this cohort, 73% were performed by cesarean myosis treated with HIFU and desiring pregnancy.
section and 18% resulted in postpartum hemor- Fifty-four patients became pregnant at a median
rhage [70]. Similarly, a recent meta-analysis of 10 months. Twenty-one of them delivered
revealed that miscarriage rates were higher in healthy infants and 20 had spontaneous abortions.
pregnancies after UAE than in matched fibroid- These groups did not differ in age, duration of dis-
containing pregnancies at 35 and 17% [OR 2.8; ease, lesion size, nonperfused volume ratio. No ute-
95% confidence interval (CI) 2.0–3.8], respectively rine ruptures occurred. Significantly, spontaneous

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 Minimally invasive gynecologic procedures

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 Minimally invasive gynecologic procedures

72. Ferrari F, Arrigoni F, Miccoli A, et al. Effectiveness of magnetic resonance- 74. Feng Y, Hu L, Chen W, et al. Safety of ultrasound-guided high-intensity
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This is a prospective, cohort study of 18 patients who underwent MRI-guided who underwent ultrasound-guided HIFU. All procedures were completed success-
focused ultrasound surgery and were followed for 1 year after the procedure. fully. Overall complication rate remained low, and there was no significant
Pretreament and posttreament uterine volume and symptomatology were difference in complication rates between the two groups.
assessed, demonstrating favorable treatment efficacy. 75. Rabinovici J, Inbar Y, Eylon SC, et al. Pregnancy and live birth after focused
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and 1150 treatments. Authors concluded HIFU to be well tolerated This is a retrospective review of 68 patients with adenomyosis treated with high-
and effective as an alternative uterine-sparing option for women with adeno- intensity focus ultrasound. Symptom improvement, postoperative imaging
myosis. changes, and reproductive outcomes were described.

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