The location of adenomyosis, and recurrent abortion

Repeated pregnancy loss in women with adenomyosis might be due to its localization.

Key Points

Importance:

• The new ESHRE recommendation is to rule out adenomyosis by ultrasonography if the woman has repeated pregnancy loss.

Highlights:

• Patients with recurrent pregnancy loss should be investigated for adenomyosis along with its type and localization.

What's done here:

• An Italian research team set up a retrospective observational case-control study to evaluate the association between adenomyosis and repeated pregnancy loss (RPL).
• Three research groups, each containing 40 women matched by age and BMI.
• Women with adenomyosis and RPL (Group 1), women with adenomyosis and without RPL (Group 2), and women with adenomyosis without RPL (Group 3).
• The reproductive and clinical data were collected, and each had an ultrasonographic report, including a diagnosis of adenomyosis and endometriosis if it's present.
• All factors, including genetic, anatomical, thrombophilia, and autoimmune diseases that could impact the type and location of adenomyosis evaluated statistically.

Key Results:

• Women with adenomyosis and RPL, forming Group 1, had a significantly higher number of pregnancy losses when compared to Groups 2 and 3.
• Adenomyosis localized in the inner myometrium was more frequently found in Group 1 than in Group 3, which conversely had more adenomyosis localized in the outer myometrium.
• The findings for endometriosis were statistically significant in Group 3, which contained women with adenomyosis without RPL. 

Lay Summary

ESHRE defines repeated pregnancy loss (RPL) as the loss of pregnancies with two or more weeks of gestation. Adenomyosis is the presence of ectopic endometrium, in the myometrium. High-resolution transvaginal ultrasound and sonographic criteria can help to diagnose the disease clinically. However, no consensus has been reached on the classification of adenomyosis. The most likely reason why adenomyosis causes pregnancy complications is its location in the sub-endometrial layer of the myometrium. This affects the uterine functions, especially uterine peristalsis, which aids in transporting the spermatozoa and implanting the blastocyst. 

The present study aimed to investigate the potential or possible impact of adenomyosis on repeated pregnancy loss and its correlation to the type and location of the adenomyosis. Exacoustos et al. from the Department of Obstetrics and Gynecology of the University of Rome, Italy, set up a case-control study involving 120 patients divided into three groups.

The University Hospital's RPL service used a standardized workup to investigate whether the patients had uterine anatomical anomalies, thrombophilias, endocrine or autoimmune diseases, parenteral karyotype anomalies, smoking habits, and the number of pregnancy losses. Following every live birth pregnancy, questions such as maternal age at conception, use of ART, mode of delivery, preterm birth, placental abnormalities, hypertensive disorders of pregnancy, gestational diabetes, and small for gestational age were asked to the mothers.

During the TVS investigation of the uterus, at least one direct sign of adenomyosis, according to MUSA criteria, was deemed sufficient for the diagnosis. All patients were also evaluated for the presence of pelvic endometriosis using the US mapping system. 

This study indicated adenomyosis, especially located in the inner myometrium, is a risk factor for RPL after evaluating and comparing the three groups. Uterine fibroids accompanying adenomyosis were the only factor potentially involved in RPL among all other endocrine, genetic, and anatomic factors. Surprisingly, in the presence of deep endometriosis and outer adenomyosis together, women had more live births than repeated pregnancy loss. The authors underlined the strength of ultrasonographic examination and detailed classification of adenomyosis in patients with repeated pregnancy loss. 

This interesting paper was recently published in Reproductive Sciences.

Research Source: https://pubmed.ncbi.nlm.nih.gov/38619796/