223 Introduction Adenomyosis is a common benign uterine disorder characterised by invasion of the endometrium into the myometrium and is thought to arise from the junctional zone (JZ). Adenomyosis is often found in conjunction with endometriosis and may share aetiological mechanisms, such as metaplasia of mullerian remnants (10) . Historically, adenomyosis was thought of as a disease affecting multiparous women, however with the advent of improved imaging techniques, it is also increasingly being linked to reproductive failure and infertility alongside endometriosis (80,98). Adenomyosis may have a higher prevalence in subfertile populations than expected, with a reported prevalence as high as 32% in infertile women (79,94,274). Several theories exist to explain why women with adenomyosis may have reduced fertility. First, through disruption of the JZ, adenomyosis affects uterine contractions and thereby spermatozoa transport and embryo implantation due to the alterations in the JZ (77,275). The junctional zone is believed to be vital for uterine contraction initiation and modulation in the menstrual cycle (46,47). Alterations in the function and receptivity of the endometrium have also been reported in adenomyosis patients (84,160,276). Abnormal inflammatory responses have additionally been described, leading to embryo toxicity (277). Finally, anatomical changes of the uterine cavity are also thought to have an influence on embryo implantation (84). Many women with adenomyosis also have (other forms of) endometriosis, which makes it difficult to assess whether the influence on infertility is due primarily to adenomyosis, endometriosis or a combination of both (278). It can be hypothesised, that when the two conditions occur together, the whole reproductive process is affected, with endometriosis affecting oocytes and fertilisation, and adenomyosis embryo implantation and the ongoing pregnancy (81). Few studies exist which have simultaneously investigated the separate and combined effect of endometriosis and adenomyosis on fertility outcomes. Moreover, despite magnetic resonance imaging (MRI) reported to be the most accurate and reproducible non-invasive diagnostic method for adenomyosis and endometriosis with a sensitivity of up to 88% and specificity of up to 91% (29,34), few studies have included patients diagnosed by this
RkJQdWJsaXNoZXIy MTk4NDMw