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Study links focal adenomyosis and primary infertility

A new study by French investigators shows that adenomyosis confined to the outer myometrium is associated with primary infertility—but not more diffuse disease.

The findings suggest a new avenue of research on the interrelationship between endometriosis and infertility.

Published in Fertility and Sterility,1 the conclusions are from a cross-sectional analysis of women aged 18 to 42 who underwent surgery for benign gynecological conditions at a single center between May 2005 and May 2018.

Indications for surgery included conditions associated with infertility, pelvic pain, and pelvic mass.

The study population was 496 patients, who were broken into three groups: no infertility (n=361), primary infertility (n=84), and secondary infertility (n=51). Half were diagnosed with adenomyosis on magnetic resonance imaging (MRI) and half had no adenomyosis.

Focal adenomyosis (FAOM) was defined on T2-weighted images as a localized, ill-defined, low-signal-intensity mass, inhomogeneous circumscribed area located in the outer shell of the uterus, with indistinct margins separating it from the maximal junctional zone (JZmax).

Diffuse adenomyosis was defined as a JZmax ≥ 12 mm and a ratio maximum > 40%.

Radiologists performing the MRIs were blinded to results of clinical findings and to the results of the patients’ previous imaging studies.

Significantly more women in the primary infertility group had ≥ 1 FAOM lesion compared with those in the no infertility or secondary infertility groups (42/84 [50%] vs 111/361 [30.7%] and 17/51 [33.3%], respectively; P ≤ .01).

Presence of diffuse adenomyosis was not significantly associated with primary or secondary infertility (101/361 [28.0%] in the primary infertility group, 21/84 [25.0%] in the primary infertility group, and 17/51 [33.3%] in the secondary infertility group; P = .58).

Of the women with adenomyosis, 30.2% overall had infertility. In 19.8% the infertility was primary and in 10.5% it was secondary; some women had both types.

Presence of FAOM remained independently associated with primary infertility (adjusted odds ratio 1.98; 95% confidence interval 1.1 to 3.3) after multivariable analysis and adjustment for age and presence of FAOM or diffuse adenomyosis, endometriosis, and leiomyomas.

“Almost one-third of the adenomyosis population had reported infertility, and most of these patients exhibited FAOM,” concluded the authors. “Using specific imaging tools, therefore, appears to be crucial to properly characterize the adenomyosis phenotype and to offer optimal management to infertile women.”



  1. Bourdon M, Santulli P, Oliveira J, Marcellin L, Maignien C, Melka L, et al. Focal adenomyosis is associated with primary infertility. Fertil Steril. 2020 Aug 28;S0015-0282(20)30590-2. doi: 10.1016/j.fertnstert.2020.06.018