prof aboubakr elnashar

1. Adenomyosis
associated
infertility
Case
scenario
Prof.
Aboubakr
Elnashar
Aboubakr
ELNASHAR
❑An
32-year-old
presented
with
primary
infertility
of
1.5
years
▪
Cycle:
Regular
4-5
/
27-29
▪No
history
of
infection,
pelvic
operation
or
pain
apart
from
mild
primary
dysmenorrhea
▪
Weight:
70
Kg.
Height:
163
cm.
BMI:
26.4Kg/
m
2
▪Sexual
relation
2-3
times
/
W.
Aboubakr
ELNASHAR

2. Fertile
Semen
•Count(M/ml):
18.7
Million/ml
•Total
motility
44%
N:42%
•Progressive
motility:
33.6%
•Normal
forms:
23.2%
Aboubakr
ELNASHAR
HSG
:
Both
tubes
are
patent
Aboubakr
ELNASHAR

3. HSG
:
Both
tubes
are
patent
Aboubakr
ELNASHAR
Adenomyosis
Aboubakr
ELNASHAR
TVS

4. ❑What
is
ultrasonographic
diagnosis?
A.
Fibroid
B.
Adenomyosis
Aboubakr
ELNASHAR
❑What
is
ultrasonographic
diagnosis?
A.
Fibroid
B.
Adenomyosis
Aboubakr
ELNASHAR

5. TVS:
3
or
more
of
the
followings:
1.
Globular
uterus:
95%
of
cases.
2.
Asymmetrical
thickening:
Anterior
or
posterior
myometrial
wall
appearing
thicker
than
its
counterpart
3.
Mottled
heterogeneous
myometrial
texture:
All
cases.
4.
Small
myometrial
hypoechoic
cysts:
cystic
glands
within
ectopic
endometrial
foci:
82%.
5.
“Shaggy”
indistinct
endometrial
strips:
82%.
6.
Striated
projections
extending
from
the
endometrium
into
the
myometrium
(Mehasseb
,
Habiba,
2009)
Aboubakr
ELNASHAR
❑If
there
is
still
doubt
how
to
differentiate
between
adnomyosis
and
fibroid?
A.
HSG
B.
3
DUS
C.
Color
Doppler
US
D.
MRI
Aboubakr
ELNASHAR

6. ❑If
there
is
still
doubt
how
to
differentiate
between
adnomyosis
and
fibroid?
A.
HSG
B.
3
DUS
C.
Color
Doppler
US
D.
MRI
Aboubakr
ELNASHAR
Color
or
power
Doppler
Aboubakr
ELNASHAR
Adenomyosis
Fibroid
Diffuse
vascularity
Peripheral
vascularity

7. 3D
US
or
MRI
Aboubakr
ELNASHAR
▪Thickness
of
the
junctional
zone
>
12
mm
▪Internal
punctate
foci
of
increased
signal
T2
MRI
confirm
the
diagnosis
Aboubakr
ELNASHAR

8. ❑MRI
▪More
accurate
in
distinguishing
adenomyosis
from
fibroids
in
larger
uteri.
1.
Junctional
zone:
Diffuse
or
focal
widening
2.
Areas
of
low
signal
intensity
{corresponding
to
smooth
muscle
hyperplasia}.
3.
High
signal
intensity
foci
or
4.
Linear
striations
Aboubakr
ELNASHAR
❑Patient
asked
is
adenomyosis
the
cause
of
delay
of
pregnancy?
A.
Yes
B.
No
.
Aboubakr
ELNASHAR

9. ●Patient
asked
is
adenomyosis
the
cause
of
delay
of
pregnancy?
A.
Yes
B.
No
.
Aboubakr
ELNASHAR
❑
Adenomyosis
and
infertility
▪Strong
association
between
adenomyosis
and
fertility.
▪Infertile
women
should
be
evaluated
for
the
possibility
of
adenomyosis
[Vercellini
et
al,
2014
].
▪Decreased
CPR
▪Increased
abortion
rate
Aboubakr
ELNASHAR

10. ●
She
received
▪
2
cycles
clomiphene
citrate
▪
One
cycle
letrozole
▪
One
cycle
HMG
&hCG
▪What
is
the
next
step?
She
asked
?
Aboubakr
ELNASHAR
❑What
is
the
best
advice
for
this
Patient?
A.
Further
2
cycle
COS
with
HMG
&
hCG
B.
IUI
+
COS
using
HMG
C.
IUI
+
COS
using
HMG
preceded
by
Gn
RH
agonist
Aboubakr
ELNASHAR

11. ❑What
is
the
best
advice
for
this
Patient?
A.
Further
2
cycle
COS
with
HMG
&hCG
B.
IUI
+
COS
using
HMG
C.
IUI
+
COS
using
HMG
preceded
by
Gn
RH
agonist
Aboubakr
ELNASHAR
❑The
patient
underwent
one
failed
IUI
and
she
asked
for
IVF
Trial
What
is
the
advised
protocol?
A.
Long
agonist
protocol
B.
Short
agonist
protocol
C.
Antagonist
protocol

12. ❑The
patient
underwent
one
failed
IUI
and
was
disappointed
.She
insist
to
underwent
IVF
Trial
What
is
the
advised
protocol?
A.
Long
agonist
protocol
B.
Short
agonist
protocol
C.
Antagonist
protocol
Aboubakr
ELNASHAR
❑Patient
underwent
one
failed
IVF
trial
&
was
disappointed.
Is
there
any
surgical
solution?
A.
No
benefit
of
conservative
surgery
B.
Yes
after
one
IVF
failure
C.
Yes
after
repeated
IVF
failure
Aboubakr
ELNASHAR

13. ❑Patient
underwent
one
failed
IVF
trial
and
was
disappointed.
Is
there
any
surgical
solution?
A.
No
benefit
of
conservative
surgery
B.
Yes
after
one
IVF
failure
C.
Yes
after
repeated
IVF
failure
Aboubakr
ELNASHAR
❑Indications
of
uterine
sparing
surgery
▪Desire
for
pregnancy.
▪IVF
failures
▪Age
≤39
years.
{No
benefit
on
fertility
≥40
y
(Kishi
et
al,
2014)
CPR:
41.3%
in
those
aged
≤
39
y
3.7%
in
those
aged
40
y}
[odds
ratio
(OR)
0.77,
95%
CI
0.67e0.88,
p
¼
0.002]
Aboubakr
ELNASHAR

14. ❑Decision
should
be
taken
carefully
after
1.
Extensive
counseling
2.
Consideration
of
alternatives
3.
Low
index
of
suspicion
with
uterine
rupture
in
women
who
conceive
after
uterine
sparing
surgery
[Pepas
et
al,
2012
].
Aboubakr
ELNASHAR
❑Management
of
women
with
adenomyosis-
associated
infertility
(Tsui
et
al,
2015).
1.
Routine
infertility
investigation
plus
ORT
▪
Normal:
long
agonist
protocol
and
natural
conception
▪
Abnormal:
IVF
2.
Failed
natural
conception
or
IVF:
repeat
IVF
3.
Failed
IVF:
▪
conservative
surgery
▪
IVF
after
3
m
Aboubakr
ELNASHAR

15. ❑
Types
(Horng
et
al,
2014)
Aboubakr
ELNASHAR
Thanks
Aboubakr
ELNASHAR