Fertility and Sterility On Air - Live from the American Association of Gynecologic Laparoscopists 2025 Global Congress

Fertility & Sterility on Air is at the American Association of Gynecologic Laparoscopists 2025 Global Congress! In this episode, our host Pietro Bortoletto conducts a roundtable with expert reproductive surgeons Rebecca Flyckt, Zaraq Khan, and Michael Neblett on the surgical and medical management of adenomyosis with emphasis on diagnosis, innovative medical therapies, and uterus-sparing surgical techniques designed to optimize fertility outcomes.

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Welcome to Fertility and Sterility On Air, the podcast where you can stay current on the latest global research in the field of reproductive medicine. This podcast brings you an overview of this month's journal, in-depth discussions with authors, and other special features. FNS On Air is brought to you by the Fertility and Sterility family of journals, in conjunction with the American Society for Reproductive Medicine, and is hosted by Dr. Kurt Barnhart, Editor-in-Chief, Dr. Eve Feinberg, Editorial Editor, Dr. Micah Hill, Media Editor, Dr. Pietro Bortoletto, Interactive Associate-in-Chief, and Associate Editor, Dr. Kate Devine.

I'm here with a esteemed panel of friends and master surgeons to talk to you guys a little bit about how the reproductive endocrinologist thinks about adenomyosis, particularly medical and surgical management options that exist, and how they fit into the patient's wishes for future pregnancy. From left to right, I have with me Dr. Michael Neblett, who's at the Mayo Clinic. I have Dr. Zaraq Khan, Division Director at the Mayo Clinic, and Dr. Rebecca Flyckt, Division Director at University Hospitals in Cleveland.

Guys, welcome. Good morning, Pietro. Always a pleasure.

Good morning. Morning. Thanks.

We have a tough task. It's the last day of the AAGL meeting. We're coming to you early, 8.30 in the morning, in the expo hall.

I want to give the audience a master class for how the reproductive endocrinologist thinks, diagnoses, and treats adenomyosis. I want to make it hyper practical. I want to teach them what you tell patients, what your counseling points are, and hopefully I'll leave with a little bit more knowledge about the next adenomyosis patient in front of us.

I want to start really basic. When should we suspect, based on someone's history, that they might have adenomyosis? Presenting to you also for an infertility consultation. I'm happy to take that, Pietro.

Typically, patients with suspected adenomyosis will present with classic pain and bleeding. When I see patients presenting with both pain and bleeding, adenomyosis is really at the top of my differential diagnosis. Outside of that, in the fertility clinic, patients may present with recurrent implantation failure, failed IVF cycles.

When we dig further, we're seeing these signs and symptoms on imaging, which we'll talk about a little later, I think. Just to add to that, I think adenomyosis is so much like endometriosis in the sense that if you actually listen to your patients, they will tell you. I think the problem is that oftentimes, especially when it comes to fertility, we're not thinking about it, so we're not asking the questions.

But the signs of adenomyosis are not always subtle. Usually, if you really take a good history, you don't need any fancy imaging. You can have that suspicion from the get-go just by talking to patients.

I agree. Anecdotally, it's interesting because when we start reviewing the negative IVF cycles, it's interesting how much more adenomyosis we find when we start reviewing those negative IVF cycles when we actually don't look at them very closely before. One last point about that is just that there's good data to show that our patients are very disappointed when you find it out after the fact, after they've done two, three unsuccessful embryo transfers.

Also, their outcomes are better for endometriosis and adenomyosis if you find it prior to initiating your therapies. Rebecca, you mentioned it. I call adenomyosis the evil sister of endometriosis, where if endometriosis is the drama queen, adenomyosis is the evil person lurking in the background that's hiding.

That's what I call it. That's good. Speaking to how patients present, one of those words that often elicits a really big nod from patients like, oh yeah, that's me, is I ask them, are your periods drenching? Are your periods so heavy that you're talking about super pads? You're talking about changing tampons out frequently during those first two, three days.

It's surprising how much agreement you get with a patient like, yes, that's exactly what I'm feeling. I think you nailed it on the head. The combination of bleeding and pain should raise your suspicion of something going on in the uterus.

It could certainly be fibroids. It could certainly be endo, but adeno has to be in the mix. If not, you'll miss it.

I'm going to make a plug here for a pretty simple concept, but I think that we often think of urine bleeding as a pretty subjective marker. Even going back down to basics, I try to objectivize that amount of bleeding. We use pictorial blood loss assessment charts or scores, because women that have been having heavy bleeding most of their reproductive age don't know that they're having- They've normalized it.

They've normalized it, and they've learned to live with those symptoms and live with that. Really an in-depth questionnaire of menstrual accidents, how many times do you wake up to change menstrual products? Have you ever soaked through menstrual products? Then really objectivizing the amount of bleeding is really helpful. The patient's in front of you.

They've screened positive on your history. Talk to me about what's the next diagnostic step that you guys take, be it exam, imaging, surgical diagnosis. How do you approach that patient in front of you? I'm pretty old school where I still believe in some exams, not for all patients, but I do think heavy bleeding and then also deep dyspareunia is one that we miss quite often on adenomyosis.

I think exams still can give us some telltale signs, but honestly, if you have advanced imaging, you sometimes can even get away without an exam, especially if the patient doesn't have dyspareunia. Now, you're looking for pelvic floor tension and other things in those scenarios, but a good history examination and then either a detailed ultrasound that you're either doing yourself or with a very trusted sonographer that's looking at different dynamic maneuvers or, of course, advanced imaging in form of MR. Spell it out for the listeners. What are you looking for on an exam that makes you suspicious of adenomyosis? Personally, I look at sometimes you'll be surprised how many times you can actually feel a uterus that you can palpate in the abdomen with two adenomyosis.

A uterine fundus that's elevated with some tenderness, deep palpation tenderness, and then also in bimanual examinations, cervical motion tenderness is fairly common as the adenomyotic uterus is fairly like a bruised muscle, and it's fairly common to see pelvic floor tension with these patients as well because they've been compensating from that pain by tightening their pelvic floor and have significant pelvic floor tension myalgia. About the literature will show about 40% will have endometriosis as well, so you can find a lot of nodularities in the cul-de-sac. Yeah, I absolutely agree with that, and I think many of us are fortunate to have access to ultrasounds in our clinic, whether we're performing them ourselves or we have a dedicated sonographer, but one of the things that I see often in REI practice, I'm curious if this happens in the MIGS community as well, is that the minute we stick the ultrasound probe in and see endometriomas, it's like, oh, endometriosis, and, you know, we know based on the the concomitance rate of endometriosis and adenomyosis that if we're just focused on that, we're going to miss a different pathology, and then the problem is that actually those are distinct entities.

Maybe they're sisters, but they're not the same, and so the treatment that you're going to do for that may vary considerably, so I guess I just put in a plug for when we see endometriosis not to just think about it in isolation. And that's true for a lot of literature too, right? When we look at the endometriosis literature, the hard thing is they don't rule out adenomyosis in a lot of that data, and so historically, even in the literature, they've been thought of as one and the same thing, when we know they're very, very different things, and they have very different impact on fertility. Yeah, if you look at the the TLH literature for patients undergoing TLH for endo, I think it's as high as 40 to 60 percent, depending which series you're reading, where endometriosis and adenomyosis coexist.

So when our endo-excision fails, I think adenomyosis has to be up there when we're thinking about why are they still symptomatic, and why are they not reaping the benefits of a thorough excision surgery ahead of the next embryo transfer. You brought up a great point about imaging. So I think fewer and fewer of us are doing a thorough physical exam, the rise of telemedicine, the rise of really outstanding imaging.

If you had to pick one modality to help you diagnose an adeno, are you going ultrasound, are you going MRI? You're on a deserted island, you can only bring one. If I can only bring one, I'm taking an MR everywhere with me. No, but I'm sure my colleagues would agree that I think the MUSA criteria is fairly outlined and well outlined, and I think it has very good sensitivity and specificity for adenomyosis.

Spell it out for the listener. What are some of the markers that you're looking for in an MRI or an ultrasound that raise your suspicion of adenomyosis? Yeah, there's some necessary ones and some sort of additional ones, but they're a globular uterus, a heterogeneous myometrium, indistinct endomyometrial junction or myometrial cysts, some striations from shadowing. I think much like any other thing with ultrasound, it's more dependent on the person that's doing the scan, but it's definitely a wonderful modality as a screening tool.

I'm not sure what your guys' experience is. No, I completely agree with you as usual. I mean, MRI is definitely the gold standard.

However, I think the vast majority of patients I'm not getting an MRI because there are now ultrasonographic features that can lead you in that direction if you are thinking about it. But the other thing I would say, and I just have to give a plug to Dr. Luciano. We did a postgrad course and her talk on adenomyosis was like a tour de force.

I always say like, oh, there's more we don't know about adenomyosis than we do know, but wow, she really knew a lot and it was very educational. So I think all of us, including our patients, have a lot to learn. So I think that the fact that there's a lack of any national or society guidelines around how we detect adenomyosis has really left a huge black hole for us.

So yes, MUSA is very good, but I would love to see us get to some consensus either through the ASRM or otherwise of like really clear criteria that we can agree on nationally. I think the majority of patients, let's face it, are getting just an ultrasound. It's a very small minority that progressed to getting an MRI or get an MRI as primary imaging.

I think when they're, you're in your hands for surgical consult, more likely, but the average OBGYN, the average infertility doctor's not ordering an MRI. My favorite sonographic sign, I'm going to ask everyone what their favorite sonographic sign for adeno. Mine is the treble clef, the S-shaped appearance to the endometrium that you see when the posterior wall starts to get nice and thick and displaces the endometrium up.

I love that one. That's my personal favorite. I'm going to have to start using treble clef.

I use question mark sign, which I think is the whole thing of adenomyosis. I have more questions than answers. Okay, I like it.

Pietro's classier than you. I'm sorry. I like the Venetian blinds.

Ah, yes. The Venetian blind. But yeah, for me, it's a lot about the posterior wall.

Like, I think if you really look carefully, and then, I mean, if you, if you find as an RE that you're seeing those sub endometriosis, like that's such a giveaway. Yeah. My, my new favorite modality for patients who I'm seeing who have a suspicion of adenomyosis is actually hysteroscopy.

Hysteroscopy, I think historically people have looked for, are there adhesions, are there polyps, are there fibroids, and let's call it a day. But I think if you are, know what you're doing with hysteroscopy, and you can also understand chronic endometritis, retain products. And I think there's a growing body of literature that we can pretty, do a pretty good job detecting adenomyosis during the time of hysteroscopy.

Can you share with us a little bit about what that looks like inside the uterus? Yeah. And I mean, just a quick plug for office hysteroscopy. I mean, I think, especially as REs and also as, as MIG specialists, it's, it's such a different look than what you get with a saline ultrasound.

So, you know, I used to really do a lot more in terms of my fertility evaluation with saline ultrasound, because obviously you get the adenaxa and the uterine pathology. However, when you're really focused on the endometrium and endometrial health, like you just can't replace being able to actually look with your eyes, assess inflammatory changes, assess crypts and things that might be a giveaway for adenomyosis. So those true beculations at the fundus, those little pockets of sub endometrial blood, you're like, Oh, I know what we're dealing with here.

And I can have a very thoughtful conversation with you in real time about how we're going to manage it now that we've made a diagnosis. The strawberry sign. Don't forget that.

That's my favorite. Hysteroscopic. Fine.

I love a good strawberry sign. So we we've talked through how we can screen patients for adenomyosis based on their history. We've talked through exam.

We've talked through imaging. Let's talk about more invasive imaging. So you haven't, you haven't thought that adenomyosis exists, but you've taken them to the OR for something else.

What are the incidental findings that you see in the pelvis at the time of a laparoscopy that raise your suspicion for adenomyosis? You know, typically like once you put the camera in, you may see that glandular endometriotic sort of disease overlying the uterus. But typically that's when you start seeing that enlarged. It just looks larger than you would anticipate.

Boggy. You know, if you're doing a robotic surgery for advanced endometriosis, you know, and we're seeing the, the uterus at the same time and just squishing it and pushing it just, it's just squishy. And, you know, instead of like that nice, firm, muscular, you know, anatomy of the uterus, it's just often different.

Yeah. I use the word like dough, like it's fairly soft. The uterus it's enlarged, it's globular.

It likes to bleed a lot. And then you can say, well, that's when Michael pokes it. And then you can sometimes see the disease sort of go through the wall and almost see that bluish hue and color of the uterine wall.

That's what I was going to say. I mean, so for posterior compartment dissection and everyone loves to hate, but I mean, sometimes it can be hard to know where, you know, like where your deep endometriosis ends and where your adenomyosis externa begins. And I think that's a good point, right? Like we're going back to the sort of imaging and the lack of a consensus of how to classify this disease, which makes it that much more difficult.

I think as, as, as physicians and surgeons, we like to sort of like take an organized approach and put things in boxes. And when that doesn't exist, there's a free for all, but adenomyosis is a spectrum. It can be starting from an, just an enlarged junctional zone on MRI to a completely diffuse adenomatic uterus.

That's 28 weeks in size. And so there's everything in between there as well. And then this whole debate of, is it true adenomyosis or is it endometriosis in the posterior cul-de-sac that is now invading into the bowel and the torus uterinus and the posterior retroservical area and the uterus.

That's also a very big controversial question of, do we treat it any different from adenomyosis? What I always try to do during a laparoscopy with trainees is I have them look at the uterus when we're looking at it fundally. And I draw a line with a pointer from one round ligament to the other. Look at how much is above that round ligament, how much is below.

And if there's a discrepancy there, it should raise your suspicion. If you're having a hard time manipulating and getting that uterus out of the pelvis, because so much of the posterior wall occupies that cul-de-sac, it should raise your suspicion about adenomyosis. But again, I mean, I think that yes, sometimes we diagnose it incidentally at the time of surgery, but it should be in our minds.

And then I think the tricky thing is once you put it in your operative note, you know, that that uterus appeared adenomyotic, like then the patient is going to carry that with them. And I think the problem is we don't know which of those cases are significant. How often is adenomyosis contributing to the overall picture? So it's hard once you get that word in the chart.

Which brings me to the next kind of great transition point. And I appreciate the opportunity to talk now about you've put that in their chart. You've made a diagnosis.

The patient's going to wake up and is going to ask you, what do we do about it? And this is a surgical conference, but we're going to start talking about medical options first. Oftentimes because patients ask about it, a lot of times because insurances demand it. But let's talk through what medical options exist for us, specifically for the patient who has desire for pregnancy in the near term.

And just one quick point, which is, I mean, if you go online, the number of endometriosis communities, endometriosis support, social media groups, huge. It's everywhere. Lots of advocacy.

Adenomyosis, our patients go online to Google it. First of all, hard to spell. And then second of all, like there's not a community that they can hook up with.

They don't know who to go see. And so I think, you know, one of the areas where we can improve is kind of getting the word out to patients of what we know and what we don't know. So the patient's in front of you, and is asking, like, I'm not ready for surgery.

I don't think I want surgery for this. You don't think surgeries are a great option for her. How do you lay out the options for her that are suppressive options that may facilitate your next step in fertility treatment? Yeah, absolutely.

So for fertility treatment, it's, I'll be honest with you, it's a little bit hard because like I said, adenomyosis is, it can present in various ways. It's a spectrum. Most in the fertility world, honestly, we would say we diagnose it.

And if it's not a surgical case, and if this is a young patient, there's no sperm issues, tubes are open, robust ovarian reserve, we'll give them some time to try on their own because they could get pregnant. They might be a higher increased risk of miscarriage in the first trimester, but we can give some time for a spontaneous pregnancy. And if not, then we really talk about fertility treatments that can either be in form of ovulation induction and IUI, or sometimes being aggressive with in vitro fertilization and IVF.

And in those scenarios, I do talk to patients about genetic testing. As we know, uterine factor infertility is a diagnosis of exclusion. So you have to remove all the variables in the equation.

And embryo chromosomal ploidy is a very, very important one. And once that's excluded, of course, there's data on suppressing these patients. There's various protocols of suppression.

And I'm not sure that there's good data to show that one is superior to the other. But they are, ESHRA, for example, would recommend eight weeks of gyn-RH analog suppression prior to embryo transfer. As colleagues, we have colleagues doing different things, gyn-RH analog with latrazole, gyn-RH analog on its own, the oral medications that are now available.

So there's a whole plethora of sort of menu items of things that we can do. I'm just not sure we have a good body of evidence that tells us what the ideal protocol is. Well, and sorry, but I mean, we don't even know if we need to be treating it, right? I think you have to take the whole picture of like, is this patient symptomatic? Where is she on her fertility journey? I mean, classically, adenomyosis is a disease of Paris women.

That means women with adenomyosis are getting pregnant. And so I think it's really important to know where you are on that continuum. But symptomatic, are they having intermenstrual bleeding? Are they having to double protect? And then lastly, are they doing embryo transfers? Is it recurrent implantation failure? Because I don't know that many of us are going to do a suppression protocol or treat just because we see adenomyosis.

The context is important. We'll brought them there. For the listeners who may not be so familiar with why latrazole makes sense as an additional adjunct, I think Lupron is kind of intuitive, suppression therapy makes sense.

But why the addition of latrazole in these patients? What are we trying to tackle there? Yeah, I think the theory at least is the aromatase activity and the sort of revving up of like the buffet line of estrogen that adenomyosis and endometriosis likes to create for ourselves. And so at least in theory, it is to suppress that aromatase activity to further reduce and suppress the disease. And you've talked about a bunch of potential GnRH analogs as suppressive therapies.

I think traditionally we've always done Q30 day Lupron for two months, plus or minus latrazole. In this hall, there's a couple of oral options. How do those factor into your practice and when do you use one versus the other? Yeah, I'd love to see what my colleagues do.

Honestly, it's mostly patient's choice. Right now I tell them that there's literature for the classic GnRH analogs, but the others should be used synonymously or could be used synonymously. And so I do have patients that would prefer to do the oral and we have done that and they have been getting pregnant.

I think one of the biggest limitations is cost with that. I mean, a lot of my patients want to do that. Certainly I'd want to take a pill then take an injection, intramuscular on top of that, but it's just limitation of just getting access.

I feel like this is so hopefully with more access, maybe I'll do more. Yeah. And I, I just, cause this is an interactive, I mean, I'm curious.

So when you guys are treating specifically adenomyosis, show of hands, how many people are using a GnRH either agonist or antagonist? Yeah. I think that has made the rounds. How many do combination therapy? So like agonist plus either adbacnorthendrone or an aromatase inhibitor.

Okay. Yeah. And I mean, I think that it has become more known the aromatase activity of adenomyosis and I'm just going to bring it into the conversation and I'm sorry, but you know, BCL-6 testing has become very common in REI.

Ubiquitous. Yes. Ubiquitous in REI practice.

And so you know, I think it is still remain to be seen what the relationship is of positive BCL-6 testing and adenomyosis. Does that help us highlight disease that needs to be treated more with a higher score? I think, again, we don't know, but I'm curious what you guys all do. Yeah.

So the patient desires pregnancy. You have talked to them about suppressive options. You may have tried some suppressive options ahead of an embryo transfer cycle.

They continuously fail their suppressive options. You're not moving the needle for them and they're now back in front of you and saying, I'm open to surgery again. Is this something that you think surgery could fix? Michael, could you walk us through who is the patient that you think adenomyosis surgery may benefit and who would you actively counsel against? Absolutely.

I think the first part is just identifying the type of disease that they have. Are we talking about diffuse disease or is there a more focal disease like an adenomyoma? I think for more focal disease and adenomyoma, what I look at is a couple of things besides recurrent losses, recurrent failed IVF cycles is when I do my SIS, how much of an impact does that focal adenomyoma push and distort into the cavity? Are they insignificant pain? I think pain and distortion are things that may point me more into surgery. And for those cases, doing an adenomyomectomy could be a benefit.

Maybe. I'll push it like question mark, maybe. There's different sort of techniques.

In my practice, I like to use a four pedal technique, which has been published and talked about at this conference. First heard about it at this conference actually a few years ago. And it's because we talked about adenomyosis and endo, but thinking about adenomyomas and fibroids, they could not be more different.

Where that fibroid nicely shells out, adenomyosis is like roots of a tree and it grows and invades and it's impossible to remove that disease. So I still am thinking, am I helping these patients? I've done these adenomyomectomies and am I committing this person to a C-section? Maybe I'm breaching that cavity. Despite me doing a concomitant hysteroscopy at time of adenomyomectomy or what I've started doing more and more is ICG in the cavity to delineate with Firefly alone in the robot.

I just don't know. And I think that's where hopefully we get more and more data about that. Certainly I've had improvement of pain in patients for fertility, not sure.

What does your anecdata tell you of the patients that you have operated on? Have you seen that you've moved the needle with a four pedal technique? I'm still not convinced. And I think that, you know, I'm taking the patients that are poor prognosis to the OR are in significant pain in general. And, you know, one of the questions that you mentioned and Zahra kind of brought it up is truly, are we talking about the chicken or the egg in this case in fertility, right? Is it uterine factor in fertility or is there more, you know, we can't forget chromosomes.

Those are important for fertility, right? Is there any issues with embryo quality? So, you know, what is the role of PGTA for doing this? And if they're having negative transfers, despite beautiful euploid embryos, I think we have to start bringing in that discussion of gestational care in the mix. So just really quickly, I think this is so interesting when you get to go to other society meetings. So we're just, you know, coming off of ASRM where suppression is all the rage.

But coming here, what I find so interesting talking to my MIGS colleagues is, you know, for you REIs that are out there, our patients are finding their way to MIGS and they are expressing that they are not being listened to, that all we're thinking about is their fertility and yet they're in pain and they're bleeding and we're losing those patients, you know, and it really opened my eyes being here and talking to some of my MIGS friends because we don't know the patients we don't see that drop out of treatment, but they are going to find what they need with other gynecologists. So quick point there. And then the second thing is like when we think about suppression, just like for endometriosis, for adenomyosis, they're not all the same.

Like sometimes I look at a patient that's had suppression after suppression with her RE, then I do her scope and it's like stage a million endometriosis. Like you're not going to suppress away a 10 centimeter endometrioma. Like, so I think again, like it's looking at that whole picture to figure out like, is there focal disease, is there diffuse disease? So I just had a recurrent implantation failure patient.

She had like only a two to three centimeter adenomyoma right at the top of the cavity. And like they sent her to me actually for septoplasty because the cavity looked like there was a septum there, but it was actually an adenomyoma. And I mean, that's what she needed.

And after years of IVF. Yeah, I would agree with that completely. I think that we tend to ignore people's pain.

And I think patients, we always say if you want fertility or pain, but patients want both. Oh, yes. Right.

I mean, that's not a choice. It's like Sophie's choice. We do.

We're not going to make that choice. They want both. And so with adenomyoma, honestly, I am yet to see a pretty big anecdote, pretty big change in moving the needle.

But I do think these people get pregnant after years of infertility. Now, the thing that I'm still not convinced about very well is are we doing them justice for like obstetrical care and making sure that we're reducing that obstetrical hemorrhage risk or placentation risk. My anecdote is a lot of my patients that we do adenomyomectomy on do end up having some placental issues.

Now, uterine rupture, fortunately, has not been an issue, at least in my series of sub 80 or whatever, 50 people. But placentation can still be an issue that one needs to think about. But we know that adenomyosis and or endo are also risk factors for abnormal placentation.

So is it now you're facilitating a pregnancy where an abnormal placentation has an opportunity to arise and it's independent of your procedure? Really tough to tell. Yeah. And you read my mind, which is one of our hot topics in endometriosis is whether adverse pregnancy outcomes are associated with endo.

I think it may get back to that same issue of like, is what we're thinking of as endo potentially also adeno? Because to me, the adeno has a much more direct relationship with the placentation. In those studies, it's just so hard to parse out. So I think two other things is, one, I always tell people, and this audience knows this, but I always say adenomyomectomy is a completely different surgery than a myomectomy.

And I say this because I oftentimes see patients that have gone into surgery for a myomectomy, an incision on the uterus has been made, and then it's sort of very difficult to close that. And then patients get referred for a second surgery. So that's really, I think, an important point for us.

Then for diffuse disease, as far as surgery, going back to like, when do you operate or not? I think that is what I have even more questions than answers. I mean, right. I mean, I just took my boards this year.

I can tell you all about Dr. Osada's triple plaque technique in an open standard. And now we're pushing the envelope different, doing things more minimally invasive. And in fertility and sterility, just a few months ago, a nice video article that came out with Gabby, Dr. Mouad in Miami showed a nice, beautiful robotic approach.

So we'll see how those things go. So, so my wife's an MFM and you can imagine our pillow talk is pretty, pretty boring. But we talk about these big procedures, a triple flap, a four pedal technique.

What do you tell your patients after you've performed this procedure and how much time they should wait before trying to conceive? We're talking about anecdata here. So I want to know what your anecdata is. I was going to say, you're asking some very difficult questions.

Yes. I'd love to pull the audience. Okay.

Show of hands for three months. I think that's probably the shortest duration. Three months after an adenomyomectomy.

What about six months? And nine months? Okay. Let me pose this question to you because this is very, very common. And for the listeners, most hands were up for three and six months, very few hands up at the 12 month mark.

Would these hands change if your patient is 42 years old, which is my average patient. What did you get pregnant yesterday? Right. And so just for the podcast, everybody's shaking their heads.

Yes. Right. And it depends too.

Is she going to go and try to get pregnant on her own? That may take a while or does she have a Euclid blast ready to go? And that's why sometimes we like to, for advanced age patients or patients with low ovarian reserve, I think that's where the beauty of a reproductive surgeon comes in, where we wear our IVF hat as well as our surgical hat and can really have that conversation with the patient to say, we're not going to surgery. If you don't have adnexal disease, even if you have bowel endometriosis, we're going to surgery only when we have a good cohort of embryos in the bank so that when we do surgery, we can go to fertility treatment one after the other and not are wasting another two years to get embryos. Okay.

I know Pietro's the host, but I'm going to ask you guys a question. So this came up in our, in our postgraduate course. And honestly, opinions were all over the place, which is, you know, you know, that you have several months built in now after your adenomyosis surgery, are they going on suppression? You know, can you do that? Can you do suppression going into your adenomyosis surgery? Like what are you guys doing? I try not to suppress going into adenomyosis surgery.

To me, I've always regretted when I'm in there operating, it's always messy and it's particularly just extra messy, but maybe a little less bloody. But if I have embryos made and I'm thinking about biding some time here after surgery to get into an embryo transfer, I will suppress them. I know for sure that there's microscopic disease that we were not able to successfully remove.

And how are you suppressing? I use Lupron and Letrozole. Okay. I use triple therapy.

I give a little bit of ad back because these patients do suffer when you put them on either a GnRH agonist, antagonist plus Letrozole. I mean, it's not pleasant. I don't go into suppression at the time of surgery, but when we say that two months of Lupron and three months of healing time, I usually say we can take the last two months of your three months of healing time and put you on Lupron and then start with the embryo transfer right away.

So I think most of us agree that at the very minimum, three months without trying to conceive after a procedure. Okay. So we've done your procedure.

Patients waited three months. Now the patient is in front of you and is asking, I have embryos made. I'm ready to use them.

What is the optimal way to utilize that embryo in the patient who you've now operated on? You may or may not have suppressed. What is the protocol you consider and does suppression factor into that leading up to the embryo transfer? I think I can speak for everybody unanimously here that I think we all agree that suppression, at least from the ESHRA guidelines, help. Now how we're suppressing the patients is up for debate because I think the more people we ask, the more answers we're going to get.

The interesting thing is at least the literature would not support one versus the other, but I think the standard Lupron suppression for two months or Lupron plus letrozole could be reasonable as well. And then there's some ad back as well that people do. Yeah.

And I'm sure you guys were up this morning reading your journal articles, but Dr. Khan and I were just talking about like hot off the presses in reproductive biomedicine online. There is a meta-analysis looking at GnRH pretreatment before a frozen embryo transfer for women with adenomyosis. And sadly, despite everything that we're saying right now, it actually did not show improved outcomes.

It didn't seem to make things worse, but it's not a strong vote in favor of suppression. So, you know, I do think we have to bring, even though this is a good discussion among people who do this a lot, like we have to at some point, you know, acknowledge that the data right now are not strong. Patients had surgery, they've gotten pregnant, they're coming back to see you and they want to know what's the likelihood that I'm going to have a recurrence.

You've done this big old gnarly procedure and you've had me wait for a couple of months, but you got me pregnant. How often do you see recurrence of your adenomyoma or your diffuse adenomyosis post a triple flap, post an OSADA procedure? Yeah. I think it just depends on what you're dealing with at first, right? I think I always say we're never doing an adenomyomectomy, we're doing a debulking procedure because we're not removing all the disease.

And so there is no good data. There is no data to even guide us how we image these patients or how often we see these patients afterwards. And so in the absence of any data available, I usually use symptoms as a guide and I use religious suppression as a strategy.

And so if they are pregnant, that's great. Postpartum, I'd like to recommend an IUD placement because I think an IUD works really nicely for adenomyosis or some form of suppression that induces amenorrhea. I think we'll do imaging if patients are symptomatic despite of being amenorrheic, whether that's oral medication-induced amenorrhea or IUD-induced amenorrhea.

I really like the IUD as a strategy to prevent recurrence, particularly in the postpartum patient. I agree. I'm a huge fan.

And I agree with Zorak. It's sort of like an onc procedure. You're going for optimal debulking, hopefully less than a centimeter of disease.

But when I see my patients post-op, I tell them, you have adenomyosis right now. Like we're two weeks from surgery. You have adenomyosis.

Because the last thing I want is for them to have the impression that I've removed every microscopic bit of disease. Because we haven't. We know that we haven't.

It's almost like I'm joking at their graduation, the fertility clinic saying, you know, we're giving them wishes for delivery. And then I'll say, I'll see you back for your hysterectomy because it's like such a high chance of recurrence. I'm sure they love that.

I love that. No, no, no. A good patient report.

Well, actually, we just presented... It shows up on your prescannies, I'm sure. That's right. Well, it's interesting because as a reproductive surgeon, we just presented a case where I saw a patient as an adolescent and as a 19-year-old when she was going off to college for heavy bleeding and adenomyosis.

And we started with medical treatment. Then I said, I mean, I'm going to disclose my age right now, but I started when I was two. And then I saw her when she was done with college for her babies and her IVF cycle, we did an adenomyectomy.

She had a postpartum hemorrhage and wanted baby number two, had ashram. And so all the GYN pathologies existed in this patient. And then ended up with actually for baby number two, ended up with a gestational carrier and we did a hysterectomy on this patient.

So it's like a full reproductive cycle circle of adenomyosis and fertility that was interwoven in one patient. And if you're doing the math, it's C62, just really good skincare, really good skincare. I think that shows the power of like true reproductive surgery, right? That evolves over the patient's lifetime based on what her individual needs are.

Like, I think that's the best of what we can do. The other plug that I had, it was for the fertility provider who's seeing patients for egg freezing. Maybe this patient's 32, 34, and we're doing ultrasounds.

We do for all of our patients. And we see adenomyosis. That may be a great time to talk about an IUD because we had, we kind of jumped in the medical about gerontology analogs, but you're right, there are progesterone-only, continuous OCPs.

And I'm a big fan. I agree with you, Petro, IUDs are great. I would have one if I had a uterus is what I told patients all the time.

I'm sure we can figure it out. We'll figure it out, uterine transplantation. When there's a will, there's a way.

But the PSA of egg freezing as well, right? Like even if you diagnose adenomyosis at 22 and this patient's going off to college or is in college, you're talking IUD, there could be a potential threat to her fertility and really talking about, you know, deferred reproduction and egg freezing. We talk about it with endometriomas and endometriosis. We often tend to forget it with adenomyosis.

And to me, adenomyosis is a bigger curse for fertility than endometriosis, to be honest. And when we think about eggs and embryos, I think one of the hottest of hot topics in our field right now obviously is like who and when and whether to offer PGT. So I'm curious, and I know RAF is like a favorite topic of Petro's, but how many of you are recommending PGT, not because of our classic reasons, but when you see a patient with adenomyosis, show of hands, are you more likely to offer PGT to reduce those of you that are doing embryo transfers, which I know.

I think I'm more likely to offer PGT. Like I want to isolate every variable that I can. I'm not a PGT for everyone person, but I think that is one of those scenarios where we know there's a risk for recurrent implantation failure.

We have a lot of minimally invasive surgeons in the audience. For us who manage these patients during their IVF cycles, what can their patients expect from a symptom perspective during stimulation and immediately post-retrieval, particularly for adeno, but because we know it coexists with endo so often, how do you tell patients that and what should they be counseling their patients about IVF? Michael. Well, typically, just like we've seen endo, adeno, things get worse.

And I feel like that first period after a retrieval, patients will say, that's the worst period I've had in years because they've been on suppression. We've got their estradiol levels at 2, 4, 6,000. And when they have that first cycle, it's significant.

And then they will because many times, at least in my practice, patients are doing a freeze-all strategy for PGTA and then quickly going back on that suppression. So just sort of giving them that understanding going in to what to expect is really important. Sometimes, there's a thought about giving aromatase inhibitors during the simulation to sort of lower estradiol levels.

And I think for some endo patients that may have some permanent pain, I don't have a lot of, at least, adeno patients I can think of in my head right now to sort of quantify the percent reduction in pain, but could be another strategy potentially. And the other thing is a lot of these patients that Michael and I see are usually not going to a transfer right away. So we place an IUD at the time of surgery, and we stim them through the IUD so then they're not having that bleeding after.

And I know really, you know, oftentimes we are dealing with adenomyosis afterwards, but we don't talk a lot about primary prevention and just some food for thought. You know, I just had a patient, she went through her fifth IVF stimulation to get more embryos after her embryos didn't implant. And then all of a sudden, you're seeing adenomyosis pop up.

And you wonder, I mean, I didn't have her on letrozole during her stims. Like, are we giving people adenomyosis in the course of their multiple IVF cycles? And is there something we could do to prevent, like, you know, we all use letrozole for our cancer patients, hormone sensitive diseases. I mean, giving someone an estrogen level of 5 to 10,000, you know, even if they didn't have adenomyosis when they started, are they going to have it when we're done with them? In my practice, when I have a patient with adeno or endo, I'm pretty routinely using Provera for ovulatory suppression, which outside of stimulation is beneficial for symptom control for them.

And I also use a continuous aromatase inhibitor, 2.5 milligrams through retrieval. And I continue it post retrieval for 7 to 10 days. Obviously, with a Lupron trigger to minimize any OHSS symptoms and a quick reduction back to baseline.

Patients seem to do pretty well with it. But you definitely have to counsel them ahead of time that this may be a little bit more rockier of a journey for you than the average non-adeno patient. But there are tools that we can use to help improve symptoms.

And they stay amenorrheic? Yeah. That's perfect. With the Provera, that really works.

Works really well. All right. I want to use our last few minutes to talk about the future.

There are some things in this exhibit hall, some things that we saw at ASRM that are getting us excited about what potentially could be coming in adenomyosis. First, from a diagnostic perspective, I have seen papers, and I have seen mostly from Europe, unfortunately. We haven't really seen much of it in the US.

The use of elastography to be able to detect preclinical, very early pre-symptomatic adenomyosis. How do you feel that that may factor into our practice for early detection and early intervention? Yeah, I personally think it holds a lot of promise. MR elastography is something I had a little bit of experience with in fellowship as well.

And it's interesting how the architecture of the uterus completely changes with adenomyosis. For those of us that have done adenomyomectomies, we know what that uterus feels like. It's really hard to close that uterus as well.

So I do think it has a lot of role. And it probably has a role for that early stage adenomyosis, where I call it brewing adenomyosis. Something is brewing.

You just have a spidey sense that the junctional zone is not quite thick, but it's on its way there. And they have symptoms of adenomyosis. Then you stim them once or twice, like Rebecca was saying, and now they have full blown.

Yes. And so I'm hoping for a world in the future where we have classification of these patients where, yeah, it's like preclinical adenomyosis or something like that. And I think that imaging is going to be our segue into identifying those patients.

You know, this whole conference has been built on AI. It's a big theme for this conference this year. So I think having AI and imaging, I think that's part of the future.

And I think it's looking at prognosis. Maybe my MRI machine will tell you, your junctional zone is this thick. You have this many glands and stroma.

Patient's this young or old of age. And this is their chance of pregnancy. So maybe for counseling, that could be helpful.

In my perfect world, if I can draw it up, that's what I'd want. Yeah. And I think it does have promise.

I don't know that it's necessarily needed. I mean, I think there are so many subtle signs of adeno that are easily picked up on a bedside office ultrasound. So those would be maybe for the most challenging cases.

Are we going to talk about hysteroscopic resection? Oh, yeah. So let's talk about hysteroscopic resection. I still have one more technique that we want to talk about.

Ablative therapy. So we have, in our armamentarium for fibroids, the ability to do the assessa, the sonata, coagulative necrosis of fibroids. At our recent ASRM meeting, there was a company that was demonstrating a device that did microwave thermal ablation for diffuse adenomyosis, particularly posterior wall fundal disease, not so much lower segment or bladder for obvious reasons.

How do you think that might factor into our practice? Because I imagine it will be a lot less morbid to ablate adeno with microwaves than performing a triple flap or nosata. I agree. I mean, I think there's lots of Korean data that's been looking at Haifu for adenomyosis for a while.

I, in my practice, have used even uterine artery embolization for the really bad diffuse adenomyosis patients. And so there are these innovative therapies that I do think hold a lot of space in the future. Like you said, the microwave ablation is really interesting because the theory behind it, at least for microparticle ablation, I might be misquoting that, but there's a newer kind of ablation, apparently, and I talked to my radiologist, that actually will, the tissue is necrosed, but it doesn't cause liquefied necrosis, liquefication.

And so really you necrose the tissue and immediately collagen sets in. So it forms a scar right away rather than that liquefied mess that then doesn't heal very well. I do think that would have a big role in the future if we can advance those technologies.

Because like I said, the surgeries are really fun, but they're morbid, and we're not doing the job that we need to, which is a complete excision of the disease process. And I'm excited about radiofrequency ablation. I think that has a role.

I think we'll, we need to use some of the myomectomy data for that. I mean, as a fertility surgeon and team that we are up here, I think that the fertility outcomes would be of crucial importance in that case. And so maybe sort of using some of that data from fibroids, which is still ongoing, before safety, we'll have to see.

But if so, I definitely think it's certainly less morbid than, you know, filleting a uterus open, so. Yeah, I mean, I would just push forward, whether it's for uterine artery embolization or HIFU or any of these emerging technologies. Like, again, it's not just reduction of disease.

It's healthy live birth outcomes. And, you know, even on the ultrasound, I can't remember which of the companies, but it still says it's not intended for women with reproductive goals. And so I think overall the data is reassuring.

And I think we can't ignore that, that, you know, I think that women get pregnant even when we tell them not to. And so I think those data are overall reassuring. But still, I mean, we don't know.

So that's ultra new. What about using existing technology that we have been using for a long time? And Rebecca, I want to lean to you on hysteroscopy now. We've all, we use the resectoscope or the tissue morselator all the time.

How might it be beneficial for the patient with adenomyosis? Yeah, so this is an area I'm really excited about. And I think we've talked about it a bit at this meeting, as well as at ASRM. Just in the way that when we think about isthmoceles, you know, initially I used to do those laparoscopically, then evolved to robotically.

And now a lot of those I can treat hysteroscopically. It's a very similar technique to isthmocele resection using the resectoscope. Most of us have access to bipolar machines now.

But I've just started to do this. I'll admit I'm just dipping a toe in. But I had a... Anecdota.

Yes, anecdota. I had an opportunity to review some very good videos as part of our role with fertility and sterility. And it kind of got me interested.

And I will tell you, if you guys venture into this, it's best for just one of those sub-endometrial pockets. You can see it right on ultrasound. There's not a ton of concomitant disease.

Maybe they have recurrent implantation failure. And so then I use an ultrasound while I'm doing it. And I just have to tell you, like, where you're depends the first time that you go and resect into that space.

Because it's terrifying. It releases all this brownish stuff. You're sure that you perfed.

And then you can actually like get almost into like the capsule and get the entire thing out. And at first I was very nervous. Like the last thing you ever want to do is ruin someone's reproductive chances.

But you think back to when we used to use resectoscopes all the time for myomectomies. I mean, the uterus is quite robust and it heals really nicely. So again, to be able to spare a big, maximally invasive, minimally invasive procedure, you know, I'm really kind of interested in hysteroscopy as the next frontier.

But you have to keep your bipolar resectoscope skills. You cannot morselate those out. Amen.

We've covered so much ground. We've covered diagnosis. We've covered medical management, surgical management, and had a look towards the future.

We have time for a few questions from the audience. If you have a patient in their 30s with uterine size of 700, 800, diffuse adenomyosis, and she's not ready for babies at the time with heavy bleeding, how you preserve her uterus, her fertility for the next few years and controlling her bleeding? The other thing is, if you do uterine artery embolization on this patient, what's the fertility outcome? I think with diffuse adenomyosis in the 30s, and if it's not immediate fertility, but just pain and heavy bleeding issues, I'd really resort to medical management, looking at either an IUD or oral suppression strategy that causes, induces amenorrhea. I think it'd be a really good option and strategy to talk to this patient about egg freezing or embryo freezing if they have a partner for the future.

I think those would be some important things. As far as the uterine artery embolization data is concerned, I think that if you truly look at the data, I think REIs are more scared of UAE than they should be. I'm a little bit more liberal in the use of UAE in our practice.

When you look at the true data of UAE, under 40, the delta in FSH was not statistically significant. So there was a slight drop in AMH that recovered, and the FSH drop or increase was not significant at all. Also, with the type of pellets you use, if you use the absorbable foam pellets now, that's fairly reversible for ovarian reserve to even in the above 40 age group.

And so for those very resistant patients with diffuse adenomyosis that we cannot induce amenorrhea, do not want a hysterectomy, sure, I think use of a UAE at this point is fairly reasonable with the lack of any other strategy. I would try to get some eggs on ice before the UAE, just in case. And how long you will consider IVF after you try an artery embolization? So we would try to do it before, but if they have done urinary artery embolization, I don't think there's any data to show that you need to pause for a certain amount of time before you go in for IVF.

I'd probably just consider delaying until they have good symptom control from the UAE before stimulation. But just to clarify, I mean, would you use an IUD before you go to UAE? 100%. I would do medical management strategies as my first line.

IUD. Sometimes I do double suppression because I think double suppression works really nicely too, especially with patients that can tolerate that. So an IUD with oral suppression works really nicely.

And I would jump to oral GNH analogs before UAE too. It's my preference. I mean, UAE would be the last one, but you could certainly, what I'm trying to say is that we are at least a little bit more scared of it than we technically should looking at the data.

Yeah. And just to kind of underscore the double, I mean, again, there's so much endometriosis that goes along with adenoma that the IUD is great, but the IUD does not keep people from ovulating. So I would typically do an IUD and then something like maybe norethindrone, you know, for any concomitant endometriosis.

And to answer your question, like very few people will just have isolated adenomyosis, right? So if this is a patient that has no fertility desire, but has pain and heavy bleeding, of course we would try to address the endometriosis if there's advanced endo as well and surgically excise and suppress these people. We have another question from the audience. Thanks.

I just have a question. I have a question from the obstetrical standpoint, which is now the patient's pregnant. She's trying to carry the pregnancy.

What are the decision makings that need to be done by the obstetrician in terms of giving progesterone? Are you liberal for vaginal progesterone? I just want to hear. We would be asking Dr. Bordoletto's wife on that. I think that's the most common question we get asked is you're doing these for the surgical, right? You're filling, you're like, I keep saying filling, because literally you are cutting into the uterus.

What's that chance of rupture? So, you know, we talked about our antelope evidence. What does the evidence show? I think the largest study that I know of is about 2000 patients from 13 centers in Japan. And they found that for more of an open adenomyomectomy, it was around 4% chance of rupture, which they put into perspective, you know, the chance of rupture with myomectomy is less than 1%.

So this is four times, some data to suggest maybe laparoscopic approach, maybe higher at 6% chance of rupture. But it's not zero. And it's certainly more.

So I think that thinking about alternative strategies, we have to, we have to consider. So, but you're right, the high risk will be, so follow up with MFM and high risk will be these people are not going to labor. So elective primary delivery with a cesarean delivery, usually they're doing it at 37 weeks, just depends on obstetrical indications as well.

And then of course, to look at their placentas. So at least in our group, especially if there's a posterior placenta and we've done an adenomyomectomy, our group will actually consider looking at that placenta closely. And if need be, even get an MR to rule out accreta and increta, just to be more prepared at the time of delivery for obstetrical hemorrhages.

And just thinking about early pregnancy, I'm curious to, again, to pull the audience. I know reproductive immunology is like a dirty word in our field. But I, as a medical director, I get a lot of referrals of patients that have been on prednisone and other immunosuppressants.

We know that endometriosis and adenomyosis are more common in women with immunologic diseases. So I'm very curious for those of you that do IVF, are any of you using steroids or other immuno? Yeah, it's happening a lot. I mean, I'm certainly seeing it a lot in my practice.

Now on the flip side, you know, when we were doing the uterus transplants, I mean, that woman who was on immunosuppression had the worst accreta I've ever seen. So I don't know whether it's good or bad, but. Prednisone is a sledgehammer to the immune system in the uterus.

But use it carefully. I just had a question, too, about the use of progesterone during the time of the pregnancy. Any thoughts on that? I mean, just my own one experience is that the patient delivered earlier.

She had stimulation or uterine activity earlier. I wonder how much of that was the surgery or how much was the fact that she had adenomyosis and she might be reactive. Yeah.

Any thoughts on just prophylactically giving that? I've had that conversation with our MFM. We've actually taken a deep dive at the literature, too. Of course, there's nothing present in the literature.

At least my MFM group is still reserving progesterone supplementation for shortened cervix or obstetrical reasons, not purely because they had adenomyosis or adenomyectomy. But the jury's still out on that, I feel. Or if they had a surgery.

Or if they've had a surgery, correct. I mean, for that purpose, I would challenge to say that could be applied to myomectomy patients, yet we don't do that. Thank you, everyone, for being here in person for our fourth annual live ASRM and AAGL joint podcast.

And this episode will be available on the FNS OnAir podcast if you've listened to it live and want to listen to it again or share it with your trainees. Thank you all for being here. This concludes our episode of Fertility and Sterility OnAir, brought to you by Fertility and Sterility in conjunction with the American Society for Reproductive Medicine.

This podcast is produced by Dr. Molly Kornfield, Dr. Adriana Wong, Dr. Elena HogenEsch, Dr. Selina Park, Dr. Carissa Pekny, and Dr. Nicholas Raja. This podcast was developed by Fertility and Sterility and the American Society for Reproductive Medicine as an educational resource in service to its members and other practicing clinicians. While the podcast reflects the views of the authors and the host, it is not intended to be the only approved standard of practice or to direct an exclusive course of treatment.

The opinions expressed are those of the discussants and do not reflect Fertility and Sterility or the American Society for Reproductive Medicine.