4. Discussion
ovarian insufficiency, ureter fistula, postoperative ovarian insufficiency, infertility, dysmenorrhea, adenomyosis, Pelvic pain, premature ovarian insufficiency, menorrhagia, hematoma, adenomyotic lesion, comorbid diseases
ENDOMETRIOSIS, PREMATURE OVARIAN INSUFFICIENCY, RECURRENCE, ABNORMAL UTERINE BLEEDING, POSTOPERATIVE COMPLICATIONS, PATHOLOGICAL PROCESS, UTERUS, COMPLICATIONS, DYSMENORRHEA, ADENOMYOSIS, MENORRHAGIA, HEMATOMA, DISEASES, UTERUS
The present study evaluated the clinical efficacy of conservative debulking surgery in infertile patients with severely diffuse adenomyosis. Our novel method of fertility-preserving adenomyomectomy resulted in increased pregnancy rates with successful outcomes, as well as symptom relief of dysmenorrhea and menorrhagia. These results suggested that this method of reductive operation could be effective in preserving fertility in infertile women with adenomyosis. To the best of our knowledge, this is one of the few reports on the clinical pregnancy outcomes of uterus-sparing surgery in diffuse adenomyosis through a prospective clinical trial.Although several studies have been conducted to determine the efficacy of adenomyosis reductive operation, many outcomes have been limited to the relief of menstrual symptoms. The relationship between adenomyosis reductive operation and fertility and pregnancy outcomes in diffuse adenomyosis remains poorly understood.In our cohort, 54.5% (18/33) of patients conceived postoperatively either by natural means, IVF-ET, or thawing ET. After reduction surgery, all patients were recommended to try to conceive through ART. However, some patients refused ART procedures or became pregnant naturally. Our result, which was relatively higher than those of previous studies, is remarkable considering the strict criteria used to select patients with severe adenomyosis. All participants enrolled in this study consisted of infertile patients who failed to conceive via IVF-ET. Although it is difficult to compare the results directly, in a retrospective study included 241 IVF cycles of women with adenomyosis, the pregnancy rate was low at 25.2% to 39.5% without surgery.The proportion of patients who attempted pregnancy was different among studies, accounting for the widely variable pregnancy rates.Although adenomyomectomy primarily aims to increase pregnancy success rates, relieving dysmenorrhea and menorrhagia is also crucial because if symptoms persist, many patients are forced to abandon their active pursuit of pregnancy. Pelvic pain, especially dysmenorrhea, can also be caused by other diseases accompanying adenomyosis, especially endometriosis, which are described as different expressions of the same pathological process.There were 4 cases of postoperative complications in the beginning of the study: subfascial hematoma, ureter fistula, shrinkage of the uterus, and premature ovarian insufficiency (Table To minimize these complications, meticulous and careful procedures are essential. In addition, pre- and postoperative GnRHa treatments may be helpful in improving surgical outcomes by minimizing the endometriosis-induced inflammatory reaction and reversible adenomyotic lesion prior to the operation. These treatment methods also aid in uterine muscular healing postoperatively by blocking menstrual blood from integrating into the intramuscular collection. To avoid postoperative ovarian insufficiency, preoperative cryopreservation of the embryo can be considered in high-risk patients with ovarian insufficiency.Although this study was conducted before the Morphological Uterus Sonographic Assessment consensus was published, the adenomyosis diagnostic criteria used in this were not significantly different from those of Morphological Uterus Sonographic Assessment consensus.CA125 screening, though currently not typically recommended for routine follow-up, is instrumental in fully assessing the efficacy of adenomyosis treatment and evaluating the recurrence of adenomyosis. High CA125 levels commonly present in individuals with adenomyosis, and numerous studies show that CA125 levels positively correlate with development and severity of adenomyosis. Recent research has also established a positive correlation between CA125 levels and the amount of adenomyosis remaining postadenomyomectomy and demonstrated that a reduction in CA125 levels were evident in successful treatments of adenomyosis.The association between adenomyosis and other diseases still requires extensive clinical and molecular investigation. However, in any situation, the presence of adenomyosis does not exclude the possibility of comorbid diseases, so if there are symptoms such as abnormal uterine bleeding, efforts should be made to initially exclude adenomyosis as the primary cause.We found it most difficult to select patients who fit this study criteria due to the controversial nature of conducting clinical research. Finding the right timing for surgery will be an essential research task in the future in order to prevent delayed surgeries that result in infertility and premature surgeries, resulting from hasty decision making, that are ultimately harmful and/or unnecessary.The limitation of this study was the relatively small sample size and not the comparative study without surgery; hence, future studies with more patients will be helpful in evaluating the efficacy of this surgical method. Therefore, we are planning a randomized controlled trial comparing the reproductive and pregnancy outcomes between women who have conducted this novel adenomyomectomy and those who have not in infertile women with diffuse adenomyosis.In conclusion, this study reports successful pregnancy rates and outcomes after reduction surgery. These findings imply that the novel method of adenomyomectomy as a uterus-sparing surgery can alleviate the symptoms of dysmenorrhea and menorrhagia, improve pregnancy rates, and conserve fertility potential in infertile women with severely diffuse adenomyosis.