Adenomyosis and Fertility: The Overlooked Disease We Can No Longer Ignore
For years, adenomyosis has lived in the shadow of endometriosis and fibroids. It has often been underdiagnosed, underestimated, and too frequently dismissed as a condition that matters only when a woman is done having children and ready for a hysterectomy.
That view is outdated.
At this year’s Endometriosis Summit, one message came through clearly: adenomyosis is emerging as one of the most important yet under-recognized conditions affecting pelvic pain, abnormal bleeding, infertility, miscarriage risk, and pregnancy outcomes. It is not a side note. It is often a major part of the problem.
At Endometriosis Surgical Specialists International (ESSI), we believe adenomyosis deserves the exact same level of seriousness, precision, and innovation that the endometriosis field has begun to develop.
What Is Adenomyosis?
Adenomyosis is a condition in which endometrial-type tissue and associated inflammatory changes are found within the muscular wall of the uterus, known as the myometrium. Over time, this can lead to hypertrophy, fibrosis, edema, uterine enlargement, distortion of the uterine architecture, and a highly inflamed uterine environment.
Patients may experience:
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Painful periods and chronic pelvic pain
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Painful intercourse (dyspareunia)
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Heavy or abnormal bleeding
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Infertility and recurrent implantation failure
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Miscarriage
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Severe inflammatory symptoms around menstruation
Historically, adenomyosis was thought of as a disease of older reproductive-age women. That is no longer enough. We are increasingly recognizing it in younger patients, including adolescents and women in their 20s and 30s. That matters immensely—especially for fertility.
Why Adenomyosis Is So Often Missed
One of the most important themes from the summit was that adenomyosis is still being missed far too often, even in patients who have had multiple ultrasounds, infertility workups, or surgery consultations. Why? Because adenomyosis is not always obvious. It can appear in different forms, such as focal adenomyosis, adenomyoma, diffuse adenomyosis, or junctional zone disease.
There is also significant symptom overlap with endometriosis, fibroids, pelvic floor dysfunction, bowel and bladder symptoms, and venous congestion. In other words, many patients do not have “just one thing.” They have a complex pelvic pain and fertility picture, and adenomyosis is often one of the central, overlooked contributors.
Imaging Is Changing the Game
The good news is that adenomyosis can often be identified with modern imaging. Both expert ultrasound and MRI can be highly useful. Increasingly, skilled gynecologic ultrasound is becoming a frontline diagnostic tool, especially when performed dynamically and interpreted by clinicians who truly understand the disease.
This is a major shift: adenomyosis can no longer be left solely to static radiology reports or incidental findings. It must be actively looked for.
Why Adenomyosis Matters So Much in Fertility
Adenomyosis can interfere with fertility on multiple levels. It may disrupt:
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Uterine anatomy and the junctional zone
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Sperm and embryo transport
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Implantation and endometrial receptivity
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Uterine contractility
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The inflammatory balance inside the uterus
This is why many patients with adenomyosis face lower clinical pregnancy rates, higher miscarriage rates, poorer IVF outcomes, and increased obstetric risks once pregnant. The closer the disease is to the endometrial cavity or the junctional zone, the more clinically significant it often becomes.
Medical Treatment: Useful, but Not the Full Answer
Medical therapy has an important role, especially for symptom control and fertility optimization. Common approaches include oral contraceptives, progestins, the levonorgestrel IUD, and GnRH agonists.
In fertility patients, one of the most discussed approaches remains ultra-long GnRH agonist suppression (often for about three months) before an embryo transfer. While far from perfect, this is one of the better-studied strategies for improving outcomes in selected IVF patients with adenomyosis.
A practical principle emphasized at the summit was this: Make Embryos First. Optimize the Uterus Second. Transfer Later. For many patients, especially those with significant adenomyosis, separating egg retrieval from embryo transfer may be the smartest path. Embryos can be created and preserved first, while time is taken to treat inflammation, optimize the uterine environment, and plan the safest next step.
Surgery for Adenomyosis: Powerful, but Highly Selective
Conservative uterine surgery for adenomyosis is far more difficult than a myomectomy (fibroid removal). Unlike fibroids, adenomyosis usually does not have clean planes. The tissue is infiltrative, inflamed, fibrotic, and often poorly defined.
In carefully selected cases, especially with focal adenomyosis or an adenomyoma, surgery can be very valuable. Pregnancy and delivery are possible, and outcomes can be meaningful in expert hands.
But diffuse adenomyosis is a different story. Many surgeons now believe that diffuse adenomyosis is often not a good surgical disease, especially in women pursuing fertility, due to the trauma to the uterus and concerns about uterine rupture in pregnancy. That is why precise patient selection is everything.
New Technology Is Changing the Landscape
Treatment is no longer limited to a binary choice between “do nothing” and hysterectomy. Newer uterus-sparing options include:
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Radiofrequency ablation
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Microwave ablation
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High-intensity focused ultrasound (HIFU)
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Hybrid hysteroscopic/laparoscopic approaches
Used appropriately, these technologies may offer meaningful symptom relief, a reduction in bleeding, and—in selected cases—even the preservation of reproductive potential.
Pregnancy Risks Are Real
Adenomyosis is not just about getting pregnant; it also affects what happens after pregnancy begins. The summit emphasized higher risks of miscarriage, pregnancy-induced hypertension, preterm delivery, small-for-gestational-age infants, and postpartum hemorrhage. Adenomyosis is not merely an imaging finding. It is a disease with real reproductive and obstetric consequences.
Dr. Vidali’s Analysis
Adenomyosis is one of the most underdiagnosed and underestimated diseases in modern gynecology. In my view, there are three populations where the under-recognition is especially dangerous:
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The younger patient, who is often told they “probably have endometriosis” while diffuse adenomyosis is never properly considered.
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The fertility patient, especially those with implantation failure or miscarriage who have had countless evaluations where nobody identified the uterine disease in front of them.
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The pregnant patient (or the patient trying to conceive), where ignoring adenomyosis means ignoring a major source of miscarriage risk and pregnancy complications.
Adenomyosis is not just a structural disorder. It is also an inflammatory and likely immunologic disease. This may explain why some patients have severe systemic symptoms and IVF failure even when their disease does not look dramatic on casual imaging.
The ESSI Philosophy: Dual Treatment When Dual Disease Exists
One of the most important mistakes in pelvic pain and fertility care is treating endometriosis and adenomyosis as if they were separate, unrelated diseases. At ESSI, we do not see them that way.
We very often see these conditions coexisting, interacting, and amplifying one another. A patient may undergo surgery for endometriosis, have implants removed beautifully, and still continue to suffer because the uterus itself remains diseased.
Endometriosis affects structures outside the uterus. Adenomyosis affects the uterine muscle itself. But from the patient’s perspective, they arrive together as part of the exact same clinical syndrome.
If a surgeon addresses only the visible endometriosis and ignores the diseased uterus, the patient may still be left with major pain, abnormal bleeding, or reproductive failure. At ESSI, our philosophy is straightforward: when both endometriosis and adenomyosis are present, both must be considered in the treatment plan.
Why Microwave Thermal Destruction Matters
One of the most promising advances we utilize at ESSI is microwave thermal destruction as a uterus-sparing treatment for adenomyosis.
This technology allows for targeted thermal coagulation of diseased uterine tissue. In carefully selected patients, it can reduce inflammatory burden, decrease pain, improve bleeding, and debulk adenomyotic tissue—all without requiring a hysterectomy.
At ESSI, this is not viewed as a replacement for the expert excision of endometriosis. It is viewed as a complementary, uterine-preserving approach. We can excise endometriosis thoroughly while simultaneously addressing the adenomyosis component. That is the essence of true dual treatment.
Beyond Hysterectomy
At ESSI, we believe adenomyosis has been ignored for too long because many clinicians assumed nothing meaningful could be done short of a hysterectomy.
That is no longer true. With modern imaging, advanced laparoscopic skill, and technologies such as microwave thermal destruction, we now have real opportunities to treat uterine disease intelligently.
Adenomyosis should no longer be treated as an afterthought. It is central to pain, central to fertility, and in many patients, it is the disease that was missed while everyone was looking somewhere else.
The future is not about choosing between treating endometriosis or adenomyosis. The future is about recognizing when the patient has both, and treating them with the level of multidisciplinary nuance they deserve.
