31 Effect of adenomyosis on fertility In the previous sections, we have established how adenomyosis behaves, is diagnosed, and how it may disrupt uterine contractile function. One other crucial aspect of uterine function (arguably the uterine function) that adenomyosis has been reported to affect is fertility. With the advent of improving imaging techniques, adenomyosis has also been more frequently diagnosed in younger, nulliparous women, and is being increasingly causally linked to sub- or in-fertility and adverse pregnancy outcomes (78–81). Adverse reproductive outcomes in adenomyosis could occur for several reasons. First, JZ disruption in adenomyosis is thought to cause dysfunction in uterine peristaltic movement, and thereby inhibits both sperm transport and embryo implantation (75,82,83). Further evidence exists showing a different expression of factors involved in embryo implantation such as osteopontin and HoxA10 in adenomyosis, as well as increased endometrial free radicals and inflammatory cytokines (84,85) which may impact embryo development. In the context of infertility, several studies have investigated specifically how adenomyosis affects IVF outcomes. The majority of studies seem to show a negative influence of adenomyosis on IVF, with a recent retrospective study by Sharma et al. (86) showing a significantly reduced pregnancy rate after IVF in women with signs of adenomyosis on TVUS. A study by Ballester et al. (87) with endometriosis patients showed a particularly large contrast, with IVF pregnancy rates of 19% versus 82% respectively for patients with and without adenomyosis. A study examining adenomyosis characteristics on TVUS also reported a direct relationship between severity of adenomyosis and assisted reproductive technologies (ART) outcomes (80). These findings have been corroborated in meta-analyses (88,89), with Vercellini et al., reporting that adenomyosis reduces likelihood of pregnancy in ART by 28%. Conversely, studies have also been published that cannot show an association of adenomyosis with IVF failure (90–93), including in a meta-analysis (94). Thus, there still remains a lack of consensus regarding the extent to which adenomyosis affects fertility and IVF.
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