245 Introduction Adenomyosis is a benign gynaecological condition characterised by the infiltration of endometrial tissue and stroma into the myometrium of the uterus, causing disruption in the so-called junctional zone (JZ) (278). The prevalence of adenomyosis is unclear due to lack of consensus in diagnostic method and criteria, with reported prevalence varying widely from 5 to 70% (194,280). Younger nulliparous women are being more frequently diagnosed with adenomyosis and it is increasingly being linked to poor obstetric outcomes and infertility (80,81,94,107). A recent meta-analysis showed detrimental effects of adenomyosis on in vitro fertilisation (IVF) outcomes, with significantly reduced implantation, clinical pregnancy, ongoing pregnancy and live birth in adenomyosis patients (281). Diagnosis of adenomyosis Conventionally, the diagnosis of adenomyosis was obtained histologically from hysterectomy specimens, and this remains the gold standard (19). With the advent of improved imaging techniques, the diagnosis can also be made via trans-vaginal ultrasound (TVUS, sensitivity 78%, specificity 78%, positive likelihood ratio of 3.5 and a negative likelihood ratio of 0.28) and magnetic resonance imaging (MRI, sensitivity of 78%, specificity of 88%, a positive likelihood ratio of 6.8 (4.5%–10%), and a negative likelihood ratio of 0.25) (29,37). TVUS is arguably less reliable for diagnosing adenomyosis as it is relatively operator dependent (37). Furthermore, distinguishing adenomyosis from other uterine disorders such as leiomyomas or carcinomas can be difficult on TVUS. MRI is therefore often the preferred diagnostic method, specifically in atypical or mild cases of adenomyosis (19,61). Unfortunately, in contrast to TVUS, which has clear diagnostic criteria (the MUSA criteria (183)), there are no accepted diagnostic criteria for adenomyosis for MRI. The most widely reported MRI criteria are based on the appearance of the JZ, by looking at the following three features: (i) a JZ thickness ≥ 12 mm; (ii) a ratio of greater than 40% of JZ to myometrium and (iii) a difference greater than 5 mm between the maximum and minimum JZ diameter. There are further reported indirect and direct criteria for adenomyosis (with presence of myometrial cysts seeming most promising) on MRI but their diagnostic and clinical potential remains unclear (32,181).
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