Latest / Fertility Untamed / Adenomyosis & Fertility: Can You Still Get Pregnant?
Transcript
- speaker-0: Hello and welcome back to Fertility Untamed, where we discuss all things fertility related. We are Dr. Rebecca Mackenzie Proctor, Dr. Sylvia Ross, and myself Dr. Devanie Amratunga, three reproductive endocrinologists who love having a chat about everything related to fertility. Today we're going to discuss adenomyiosis, the evil sister of endometriosis. So, I took on this topic because I know what it's like to ⁓ get an ultrasound report that ⁓ says adenomyiosis ⁓ on the ⁓ report and then to have all those feelings of great now what? Now what does that mean? So I thought we'd just discuss a little bit about ⁓ what it means for natural fertility and also for assisted reproductive ⁓ treatments and whether we do need to do anything about it and what ⁓ possible management options are. So just to start with, Sylvie, do you want to tell us what adeno is? speaker-1: Yeah, perfect. And it's funny how it's often called the evil sister of Endo because it's not like Endo's a good sister, right? We're like the two evil sisters. ⁓ so adenomiosis, I always explain to patients, it's essentially I'll show them a picture of the uterus and the uterine lining, which is called the endometrium, and that's what builds up, you know, in your body prior to ovulation and sheds as your period ⁓ if you don't conceive in that cycle. And adenomyiosis occurs when that same tissue type actually infiltrates inside the muscle layer of the uterus. So the uterus has three layers, it's got the cirrhosa on the outside, the myometrium, which is the muscle. And the endometrium, which is that inner layer that sheds. So it's essentially a tissue somewhere that it doesn't belong. It's hormonally and biologically active and it can cause inflammation, pain, ⁓ heavy periods and potentially subfertility. speaker-0: Yeah, so that's like the triad that I don't know, ⁓ often presents with. speaker-2: And often I see people coming in with the typical very heavy gush of blood at the beginning of this of their period. So they'll have very heavy it's kinda like turning a tap on and turning a tap off with pain. So someone that gives me a really high suspicion that they've got adenomyosis if they've got ⁓ significant pelvic pain, ⁓ significant p period pain and that tap on, tap off with a heavy bleeding. speaker-0: What do you think about the prevalence? 'Cause I don't know about you, but pretty much every second person that walks through my door has adenomiosis. ⁓ so talk to me about who has adenomiosis and why are we ⁓ diagnosing it more, I suppose. speaker-2: Well, it's ⁓ more associated with people in their older age and it's more associated with Paris women, women who already had babies before. And so, ⁓ that that is an important point. Obviously, a lot of women who we're seeing with infertility haven't had babies before, but it's the exposure of the estrogen over time, we think, that's making this this condition worse. We're also seeing women a lot later for fertility, so I think that's why we're seeing more of them. And maybe going back to our endocrine disruptive conversation we've already had is that our exposure to estrogen like ⁓ ⁓ properties or chemicals or estrogen itself has increased. speaker-0: And I think that's a good factor that, you know, the traditionally we used to say older women who have had babies. We didn't exactly put a a cutoff of age. Actually quite a significant proportion, about twenty percent of women actually are under forty because those are the people who we see, right? At closer to forty who have got infertility and things like that. You don't have to be older, ⁓ like we traditionally used to say. speaker-1: And I and I think the reason we're seeing more of it is we're also better at diagnosing it now. Even when we started our training we used to say to people, ⁓ well, it's really common. We don't don't think it really matters that much. Well, that's not really the case anymore. And that's changed actually in quite recent times. But our scanning capabilities are better now and ultrasound is your best method of diagnosis and we have certain signs that we look for to tell us whether we think there's adenomyiosis there and we're just much better at seeing those now as well. speaker-2: And there's different types of adenomyosis. So you've got your diffuse adenomiosis, which is when the whole muscle layer, the front and the back, where you get focal, it might just be small parts. And so you can sometimes see these ⁓ these cysts within the muscle layer as well. ⁓ and that that's an endometrial cyst, and we think that that's an endometriosis within the muscle itself. So that's a real key sign that you've got speaker-0: Absolutely. And I think yeah. speaker-1: Okay. And also we see it a lot because a lot of our population also has endometriosis and there's a massive crossover there. And it's hard to say exactly how many, you know, people have both, but it's thought that fifty to even eighty percent of people with adenomiosis also have concurrent endometriosis, which makes sense because it's a similar pathology in many ways. speaker-2: What often we'll see, and I think it's it really helps with my diagnosis and my decision making around surgical approaches, is that if I see a patient who's had a scan that says no evidence of endometriosis but has adenomyosis and is coming in with pelvic pain, I'm more likely to go, well, there's probably stage one, stage two endo there and a laparoscopy is going to be a good option for you for if you want into natural conception, ⁓ to give you a bit more of a chance if you want to, because the treatment options for adenomyiosis aren't as good, but we know with an endometriosis there is some benefit in those early stages. speaker-0: So just going back to ⁓ just summarize ⁓ the diagnosis of adenomyosis, theoretically the best diagnosis, well in terms of the cheapest and least invasive is an ultrasound because we're very good at ⁓ ultrasonography now. ⁓ almost as sensitive and speci specific as an MRI, which we traditionally used to use. And there are specific signs on there like you both mentioned, ⁓ you know, the junctional zone being disrupted, ⁓ cis ⁓ there are fanning signs, there's all kinds of signs and ultrasound and they're called the Musa criteria that we now require sonographers to tell us ⁓ to make that diagnosis and it is very operator dependent. So if you do get a scan result that says features consistent with may be, you know, n may not actually be a diagnosis, but you know, may err on the side of you thinking this person has adenomiosis. speaker-2: If I'm scanning someone myself, I'll have a really good look. And typically for me who's not a trained sonographer, but who does a lot of scanning, you'll see a difference in the thickness of the anterior muscle layer or the posterior muscle layer. And I'll be like, ⁓ that's an obvious sign. It's quite easy for us to see. We may not see the nuances of the fanning and fanning or the ⁓ little polypy things you can have at that disrupted junctional zone. speaker-0: The globular the globular to whatever it is. But what about ⁓ also the adenomyoma, which we haven't really talked about? So that's more of a discrete like you were talking about Beck and ⁓ you know, almost like a fib ⁓ fibroid, but not ⁓ not fibroid tissue, but more adenomiotic tissue. So the endometrial lining rather than a muscle ⁓ pathology there. speaker-2: You can imagine why it's so painful, right? I mean if you think bleeding anywhere is bad. If you bleed into a muscle for any other reason, if you have a bruise from a sporting injury, you're gonna be pretty sore afterwards. If we're bleeding into our uterus every month, no wonder we're in pain. speaker-0: Dave toss about that. I'm fine now. speaker-1: It's really worthwhile. Thank you, Madam. speaker-2: Which great the ⁓ segue onto sort of treatment options. Obviously marina is not a good treatment option if you're trying a baby. But it is one of the thought to be one of the best options for people who aren't wanting more ⁓ stronger hormonal suppression, ⁓ that a marina is really good 'cause not only does it offer the hormonal effects but also their local pro prostaglandin ⁓ effects at the uterus. speaker-0: I also have an ablation, so kill two birds with one stone, which I got in Melbourne when I was down one time for forty eight hours and my colleague just quickly did. But anyway, we digress. So talk about let's talk about ⁓ Sylvie adenomiosis and infertility. What is ⁓ you know, when you have a patient come in, 'cause lots of our patients come in with adenomyosis on the ultrasound, what do you think and what do you talk to them about? speaker-1: Always explain what it is. I talk about the potential concurrence with endometriosis. We know that it's inflammatory and that it can have an effect. We don't have great data on what to do about it. You know, we know that surgery is very limited and that and essentially we we don't really do surgery for adenomyosis. I know in places like America with those adenomiomas some people do, but you know, not not speaker-0: And in Italy. I've just been to a conference in Italy actually and they are very ⁓ f for coming with speaker-1: And I think we're more we're more conservative here because once you have a scar in the uterus, that puts you at risk for pregnancy. And let's not do that for something we don't know is going to help. ⁓ we also, you know, so when you're trying to conceive you can't do your medical options. Essentially we think there's an inflammatory change, there's changes to contractility of the uterus, which may affect implantation and and and pregnancy being able to be accommodated there. ⁓ if you have pain and you don't want to have intercourse, that's another way that it can affect fertility. So I think it's difficult because we have to recognise it as a factor, but I don't have a magic wand for it. speaker-0: Absolutely. And I when I see patients, I say, look, I think severity matters actually. Studies do show that if you've got diffuse, you know, significant adenomiosis, that could be a problem versus some mild adenomosis that we're picking up just because we're scanning better. I say I keep that in the back of my mind, but we really need to look at all these other things because like you said, ⁓ treatment options are limited when you're trying to conceive. speaker-1: And it doesn't mean that you can't conceive a factor that we need to consider with everything else. Yeah. speaker-2: If we go back to who has adenomyosis, traditionally it was always the women who've had pregnancies before. So maybe there is something in that that it's not just about stopping you getting pregnant. And I think that's where the theory was behind it not causing such a problem. But now we're seeing women at an older age, it's compounded with everything else that's going on. And there's probably another immunological effect as well from it. We talked about the infl inflammatory effects. So there's probably a lot more to it. And I think it's as it's only just coming out that it's a problem. we're still having a lot more research. I'm hoping in the next five years. speaker-0: Yeah, we've got a ⁓ quite a good Australian study actually that when I was looking into this ⁓ podcast ⁓ that our colleagues have done from ⁓ Victoria and it's quite a large prospective cohort study of more than four thousand IVF pregnancies, so not natural pregnancies. ⁓ and they were screened for ⁓ adenomiosis with their ultrasound and they found that adenomiosis did not significantly affect ⁓ IVF outcomes ⁓ once they're adjusted for those compounding factors that you were talking about, Bex. So maternal age and smoking actually. So, you know, you can very well go on to have a perfectly ⁓ n normal pregnancy, although the caveat is there are some higher risks associated with adenomiosis in pregnancy as well. ⁓ but it doesn't mean that you can't conceive. speaker-2: it's it's another warning sign for us as fertility specialists, as I said before, to say, Hey, is there something else going on? Is it the endometriosis and the issues around that that's causing your fertility? Is there scarring in the tube or something else we haven't looked at, that a laparoscopy ⁓ laparoscopy might be beneficial for you? speaker-1: know, this is not massively evidence based, but if it's inflammatory, I know you and I use a lot of Lapardo, I don't know about you, Dev, but you know, it's a very anti inflammatory oil that we use and we see good success f with minor endo. ⁓ and it may it may be something that's helpful. speaker-0: I think I do I use that a lot and I I mean actually talk about anti inflammatory lifestyle changes as well. Because a lot of the ⁓ studies on the pyrodol didn't ⁓ exclude adeniosis. So y you know, the trials that we know, we think probably had confounders between those two anyway. So it's hard to say which one was actually the one that benefited from it. speaker-2: fertility perspective, the things you can do in a IVF cycle is ⁓ is a lot of debate as well. So there's theories and ⁓ certain population groups will use things like ⁓ a long down regulation cycle for eight weeks using So treatment options in the fertility space ⁓ would be a G agonist. So in the fertility space treatment options include a G agonist ⁓ and some people will add s ⁓ add back electrazole and some people even add a tiny bit of ⁓ estrogen as well. speaker-0: Let's talk about ⁓ treatment. Correct? speaker-2: The thing is these need to be done for, you know, at least two to three months, which is the time taken out of your fertility journey. And in a paper was just published in FNS last year showing that actually it made no difference. speaker-0: Yeah, I think the studies are mixed actually, 'cause we do have quite a few studies that show difference, but quite a few that don't. So it's really hard. And again, it comes to individualization. And I think the the key is adenomosis, like endometriosis, is estrogen dependent. So whether you use an agonist, which is what we've been traditionally using. So just ⁓ you know, for example, ⁓ an injection once a month, ⁓ that we've been using and now there's a more oral ⁓ antagonist that we potentially could be using again in the research kind of phase. Some of us may or may not be using that. But ⁓ these are all things to stop that estrogen ⁓ making that inflammation ⁓ worse. And it is not something we usually do first line. But speaker-1: And that's what I was gonna say. Patients often come and ask me about it first line. And usually if we're doing IVF and we're doing transfers, we have to accept that most of them individually won't work and that I would usually start with the, you know, the basic, shorter protocols, because at the end of the day, time is actually really encouraging for most people. And we don't have the evidence to say, let's take weeks and weeks to try and calm this down first. We'll see if it works first. If it doesn't and we get really stuck, maybe we'll revisit. speaker-0: Yeah, it totally depends on the situation, right? If we can afford to take three months off and you know, do that and we've got lots of embryos, great. But if we don't, so we will individualise that. And what about and we've already kind of talked about excisional surgery and ⁓ yeah, I th I must say I was quite surprised when I recently went to this conference and ⁓ you know, was confronted with this ⁓ surgery with ⁓ removing and not just adenomyomas, like adenomyosis. Histoscopic. speaker-2: It's becoming more and more common. I think people are getting more and more skilled and I've seen lots of video abstracts explaining how to do it and I'm sure there'll be more and more surgeons that will be able to. speaker-0: Yeah, and I think it is important that if you are considering that that the surgical skill is the most important factor in this, like I would not be doing that. I don't ⁓ excise and I don't know, my own. And I am an ages ⁓ trained ⁓ surgeon, but you know, if you're doing this weekly on ⁓ you know, maybe and you're desperate Because unfortunately things like surrogacy and things, you know, are are not easily accessed in in ⁓ countries. But we're it's certainly not saying that you need to spine a surrogate if you've got adenomosis, but we can ask we speaker-1: So it doesn't mean I can't carry a pregnancy. And I guess, you know, for me, I I try to be really reassuring that actually so many people have this and we're just diagnosing it more now and you know, we're gonna keep it in the back of our mind. We're not gonna panic. speaker-2: We don't scan everyone that has a normal pregnancy either, to see if they've had a no beforehand. So we don't actually know what the general population is like out there that are not infertile. So I think you know, there's definitely a skewed view for ourselves as as fertility specialists. speaker-0: What about some other techniques, ⁓ that you may have seen patients ⁓ use or come to you, like ⁓ uterin artery embolization, ⁓ high few, ⁓ like speaker-2: High frequency MRIs and that sort of thing. ⁓ usually they're not recommended so much in the fertility space because the risk is that if you are ⁓ disrupting disrupting the blood supply, you're gonna ⁓ actually disrupt the important part of the blood supply, which is the endometrial receptivity area in the lining of our uterus where we want the embryo to implant. So some of those more invasive techniques have been shown in pregnancies and there is case reports out there about successful pregnancies following these things, but it's not the standard treatment. speaker-0: All kinds of things. ⁓ So I think that speaker-2: The other thing you can sorry, another option you can do for treatment for these patients is remembering that a lot of the time it's the pain and the bleeding that is the problem. So if they're not pregnant, there's other non hormonal ways of managing this. So you can use some of the things like ⁓ tranexamic acid for their heavy bleeding if they're not pregnant ⁓ and your non steroidals in that first part of the phase. So we're careful about non-steroidal anti inflammatory drugs. Around ovulation time, because that can affect there's some studies that show if it can affect ovulation. But once you know you're not pregnant and you're bleeding heavily, then using them is usually safe in that first phase. speaker-0: So another way of diagnosing adenosis, which is usually by the by not something we go to do specifically, is if you d ⁓ at a laparoscopy sometimes we can see uneven surface, ⁓ that terrible word globular, large ⁓ uteruses, which give us ⁓ idea that someone might have adenomiosis. And hysteroscopically you can also see signs, ⁓ blood vessels and certain signs within the endometrium that can show you that this patient has got adenomiosis, but we don't particularly do that for diagnosis, obviously. So from a personal perspective, and to summarise this episode, I think, you know, it can be a bit confronting getting that diagnosis of adenomiosis when you are going through infertility. it gives you an idea potentially that you also might have endometriosis and maybe gives you some extra options in terms of treatment modalities, more in the endometriosis arena probably. However, I think I just want to say that the uncertainty of this disease is is difficult, but also that it's not the end of the world and that, you know, most people will get pregnant with an adenomiosis diagnosis. ⁓ and you know, to make a sensible plan with your ⁓ fertility specialist and that it does need to be individualized and you know, not to catastrophize it. ⁓ speaker-2: put a plug out there for any young researchers or any old researchers out there that are wanting to look at something, I think endometriosis and adenomyosis are two areas that could do with a lot more research. And so please if you're thinking about it, do it. speaker-0: Absolutely. So, ⁓ that is our Fertility Untamed ⁓ episode on adenomiosis. If you found this useful, share it with someone who's just had adenomiosis diagnosed ⁓ and they feel like they're in ⁓ the lurch of not knowing what to do. but otherwise, thank you again, Rebecca and Sylvie, for joining us ⁓ on this episode. Thank you. Thank you.