uterine adenomyosis is a common gynecologic disorder characterized by the presence and growth of heterotopic endometrial or endometrium - like structures in the myometrium , with adjacent smooth muscle hyperplasia and can lead to dysmenorrhea and infertility .
the ectopic endometrial tissue induces hypertrophy and hyperplasia of the surrounding myometrium , resulting in diffuse globular enlargement of the uterus analogous to the concentric enlargement of the pregnant uterus .
the presenting symptoms include a soft and diffusely enlarged uterus with menorrhagia ( 40%50% ) , dysmenorrhea ( 10%30% ) , metrorrhagia ( 10%12% ) , dyspareunia and dyschezia .
the advised treatment for severe adenomyosis is total hysterectomy , but for patients wishing to preserve their uterus , a minimally invasive alternative procedure , uterine artery embolization ( uae ) , can be performed .
uae is a nonsurgical alternative for patients with menorrhagia , symptomatic adenomyosis , or symptomatic uterine fibroids .
although uterine infarction is a relatively common occurrence after uae for the treatment of fibroids or adenomyosis , uterine infarction after ivf - et in a patient with adenomyosis is very rare . to our knowledge
, this is the first report of uterine infarction after ivf - et in a patient with uterine adenomyosis in korea .
she had suffered severe dysmenorrhea , menorrhagia , and pelvic pain due to severe adenomyosis which was diagnosed following a pelvic magnetic resonance imaging ( mri ) and clinical examination three years earlier .
the patient had undergone three unsuccessful cycles of frozen - thawed embryo transfer at an external infertility clinic , due to primary infertility , during the period from 4 - 7 months before hospital admission .
the patient was admitted to hospital for treatment of ovarian hyperstimulation syndrome ( ohss ) arising after controlled ovarian hyperstimulation about four months before the initiation of embryo transfer .
a thyroid function test on january 2013 indicated a euthyroid state : triiodothyronine 166 ng / dl ( range , 80 - 200 ng / dl ) , thyroid stimulating hormone 0.17 iu / ml ( range , 0.4 - 4.1 iu / ml ) , free thyroxine 1.21 ng / dl ( range , 0.80 - 1.90 mg / dl ) .
the patient underwent another cycle of ivf at a local clinic in february 2013 , during which she received follitropin- 150 iu from menstrual cycle day 3 to day 12 and chorionic gonadotropin 250 g at menstrual cycle day 13 .
ovum pick - up was performed about four weeks before she present to the emergency department and embryo transfer three days later .
the patient received intramural progesterone 50 mg and was prescribed a vaginal progesterone gel ( crinone ) for daily use for 11 days after the embryo transfer .
the patient presented to hospital with vaginal bleeding , fever and abdominal pain on eleven days after embryo transfer , and received antibiotic treatment followed by supportive care at a local clinic for three days .
she visited our outpatient clinic due to vaginal bleeding and lower abdominal pain on sixteen days after embryo transfer and was admitted to hospital .
c - reactive protein ( crp ) was elevated to 7.52 mg / dl and intravenous antibiotic treatment was given .
biochemical abortion was diagnosed on nineteen days following embryo transfer after serum -hcg decreased from 161 to 63 mlu / ml in two days .
the patient was discharged after symptom improvement , but presented with vaginal bleeding and lower abdominal pain , at a local clinic two days later , where she received hydration .
the last day of that month , she presented to the emergency department with high fever ( 39 ) and , lower abdominal pain .
peripheral blood cell analysis indicated a : white blood cell count of 17.510/l , an elevated crp of 24.3 mg / dl , a hemoglobin level of 7.6 g / dl and a hematocrit level of 24.5% .
computed tomography at the emergency department revealed a wedge - shaped low attenuation area in the anterior uterine corpus .
focal uterine infarction was suspected , and the pelvic mri revealed a wedge - shaped , irregularly marginated , non - enhancing area in the anterior uterine wall and the presence of preserved myometrium between the endometrial cavity and the inner margin of the necrotic myometrium ( figure 1 ) .
blood markers investigated to establish the cause of infarction , including antiphospholipid immunoglobulin g ( igg ) and igm , protein c activation , protein s , and plasminogen , were all within normal ranges .
five days after hospital admission , pelvic pain improved and crp decreased to 6.08 mg / dl , and the patient was discharged .
two months later , pelvic mri showed interval regression of the previously noted possible focal uterine infarction site with a remarkably improved blood flow ( figure 2 ) .
adenomyosis uteri is a pathological entity characterized by the presence of endometrial glands and stroma embedded within the myometrium , but without apparent contact with the endo - myometrial junction .
uterine adenomyosis is relatively frequent , affecting 1% of females ; its diagnosis is more often made in multiparous patients , in their fourth and fifth decade of life , and for this reason , infertility is not frequently concurrent with adenomyosis .
however , given the trend for first pregnancies to be delayed until women are in their thirties or forties , adenomyosis uteri becoming a more frequently considered diagnosis
. pregnancy resulting from assisted reproductive technology ( art ) is possible in patients with ademoyosis ; however , spontaneous abortion , including biochemical abortion , still occurs in these patients .
uterine infarction after ivf - et in a patient with adenomyosis has not previously been reported .
the objective of uae is to initiate tumor infarction resulting in substantial reduction of the uterine and tumor volumes .
first , when undergoing ivf - et , the risk of thrombosis is increased , as in the cases of pregnancy and hyperthyroidism , with which the patient also presented . the precise mechanisms by which the ohss and exogenous hormonal stimulation used in art induce thromboembolic events are still uncertain . however , vascular endothelial growth factor secreted during ohss , high estradiol concentrations , and blood hyperviscosity play a prominent part in inducing a prothrombotic state .
reported that the overall venous thrombosis incidence rate during ivf pregnancies was three times higher than in reference pregnancies .
an elevated crp can activate the coagulation system , following which microthrombosis formation , in the uterine myometrium , could cause necrosis of the myometrium and lead to focal uterine infarction .
second , the disruption of the endometrial - myometrial interface also disrupts the organization of myometrial muscle fibers and may also disrupt normal contractility of the subendometrium .
uterine adenomyosis with abnormal contractility and the subsequent abortion caused massive vaginal bleeding which may have led to uterine ischemia , and the resulting uterine infarction .
clinical hyperthyroidism is generally accompanied by a hypercoagulable state , which may lead to microthrombosis of the uterine myometrium .
last , fever and the elevated crp suggested that infection could have complicated the ischemic necrosis after uterine infarction .
however , there were no clinical features such as rapid tumor growth , extrauterine extension or metastases , leading to the conclusion that the possibility of uterine sarcoma was very small .
a follow - up mri three months later showed only traces of uterine infarction lesion and adenomyosis . in conclusion , we experienced a rare case of uterine adenomyosis that developed into uterine infarction after ivf - et and biochemical pregnancy .
this case demonstrates that uterine infarction should be considered in the differential diagnosis of acute abdominal pain , vaginal bleeding and infectious signs in women with biochemical abortion after ivf - et , with a history of adenomyosis and hyperthyroidism .
the insertion of a hormonal intrauterine device could be considered another option for treating the symptoms of adenomyosis in cases presenting with focal uterine infarction dysmenorrhea and menorrhagia .
in addition , the surgical management of focal uterine infarction , may be considered in the management of uterine infarction after ivf - et in patients with uterine adenomyosis if future fertility is not desired .
finally , it is important to note that the previous infarction site might be a potential risk site for uterine rupture in a future pregnancy .
 adenomyosis is a common gynecological disorder characterized by the presence of endometrial glands and stroma deep within the myometrium associated with myometrial hypertrophy and hyperplasia . 
 focal uterine infarction after ivf - et in a patient with adenomyosis following biochemical pregnancy has not been previously reported , although it occurs after uterine artery embolization in order to control symptoms caused by fibroids or adenomyosis . 
 we report a case of a nulliparous woman who had uterine adenomyosis presenting with fever , pelvic pain and biochemical abortion after undergoing an ivf - et procedure and the detection of a slightly elevated serum hcg . 
 focal uterine infarction was suspected after a pelvic magnetic resonance imaging demonstrated preserved myometrium between the endometrial cavity and inner margin of the necrotic myometrium . 
 this case demonstrates that focal uterine infarction should be considered in the differential diagnosis of acute abdominal pain , vaginal bleeding and infectious signs in women experiencing biochemical abortion after an ivf - et procedure . 
Introduction
Case report
Discussion