bone density and increased risk of cardiovascular events, and therefore not feasible for young women. furthermore, all present treatment options are irrelevant options for women trying to conceive. exogenous progestogenic treatments have been found to be ineffective. in ivf-settings long down-regulation prior to ivf might have a positive effect on pregnancy rates. surgery broadly speaking, surgical management of adenomyosis is split into two categories: uterine-sparing and non-uterine-sparing procedures. uterine-sparing procedures are surgical operations that do not include surgical removal of the uterus. some uterine-sparing procedures have the benefit of improving fertility or retaining the ability to carry a pregnancy to term. in contrast, some uterine-sparing procedures worsen fertility or even result in complete sterility. the impact of each procedure on a woman's fertility is of particular concern and typically guides the selection. non-uterine-sparing procedures, by definition, include surgical removal of the uterus and consequently they will all result in complete sterility. uterine-sparing procedures uterine artery embolization (uae): in this minimally-invasive procedure, doctors intentionally block two large arteries that supply the uterus, called the uterine arteries. this is performed in order to dramatically reduce the blood supply to the uterus. by doing so, there is insufficient blood and thus oxygen present for the adenomyosis to develop and spread. 57-75% of women who undergo uae for adenomyosis typically report long-term improvement in their menstrual pain and bleeding. however, there is a recurrence rate of symptoms in 35% of women following a uae. also, uae has the risk of causing major complications in 5% of women who undergo the procedure. major complications include infection, significant bleeding, and needing an additional surgery. uae has also been shown in some cases to reduce ovarian function. finally, 26% of women who undergo uae ultimately end up requiring a hysterectomy. myometrium or adenomyoma resection: in this procedure, surgeons remove a focal consolidation of adenomyosis known as an adenomyoma. to be successful this procedure requires that the adenomyosis is relatively focally isolated and with a minimal diffuse spread. unfortunately, adenomyosis is commonly diffuse and the operation is successful only 50% of the time. the procedure is performed with either a laparoscope or hysteroscope. additionally, it can be a difficult surgery to perform as diffuse adenomyosis physically weakens the myometrium and surgical sutures can tear through the muscle with minimal force. when successful, the procedure significantly improves menstrual pain and bleeding. additionally, it can result in improved fertility with pregnancy rates as high as 78% in women trying to conceive after the operation with successful delivery occurring in as many as 69% of those pregnancies. on the other hand, there is an increased miscarriage rate (as high as 39% of pregnancies), which is higher than the general population. this is likely due to increased uterine scar tissue formation caused by the surgery. myometrial electrocoagulation myometrial reduction mri-guided focused ultrasound surgery endometrial ablation and resection endometrial ablation techniques are only for people who do not want to bear any children after having the surgery. the techniques either include physical resection and removal of the endometrium through a hysteroscope, or focus on ablating or killing the endometrial layer of the uterus without its immediate removal. endometrial ablation and resection techniques are most appropriate for shallow adenomyosis. the efficacy of the procedures is reduced if the adenomyosis is too widespread or deep. furthermore, deep adenomyosis may become trapped behind a scarred region that was ablated, leading to further bleeding and pain. endometrial resection is also limited to relatively shallow adenomyosis as significant bleeding may result from damage to large arteries that are present 5 mm deep within the myometrium. non-hysteroscopic procedures: these techniques do not require a hysteroscope, are relatively fast, and many can be performed as an outpatient procedure. high-energy radiofrequency ablation: using a small expandable mesh placed within the uterus, providers use high-energy radio waves to ablate the endometrium. thermal balloon: using a thin expanding balloon placed within the uterus, providers can introduce heated fluid and ablate the endometrium. this procedure has been shown to result in amenorrhea or complete cessation of menstrual bleeding for 12 months in 23% of patients. 16% of patients eventually experience treatment failure with pain or bleeding requiring additional treatments or a hysterectomy. women older than 45 and those with milder adenomyosis were more likely to experience successful amenorrhea following the procedure. in contrast, women younger than 45, with multiple childbirths, a history of a prior tubal ligation, and/or a history of menstrual pain were more likely to experience treatment failure. cryo-endometrial ablation (cea): a form of cryotherapy whereby using a small probe, providers can directly apply sub-zero temperatures within the uterus to freeze and ablate the endometrium. circulating hot water: heated water directly introduced into the uterus is used to thermally ablate the endometrium. microwave ablation: using a small probe introduced into the uterus, a provider uses microwave energy to ablate the endometrium. hysteroscopic procedures: these techniques all require the use of a hysteroscope to perform. wire-loop resection: under direct visualization through a hysteroscope, a wire loop instrument charged with an electric current permits a provider to carefully remove the endometrium in strips. laser ablation: under direct visualization through a hysteroscope, lasers are used to vaporize and ablate the endometrium. rollerball ablation: under direct visualization through a hysteroscope, a metallic ball on the end of a probe is charged with electricity and rolled across the surface of the endometrium. this has been shown to have a coagulative effect to the depth of 2–3 mm into the myometrium. this destroys the endometrium and the nearby growth of dysfunctional smooth muscle. deeper adenomyosis escapes this coagulative effect. non-uterine-sparing procedures