Adenomyosis and IVF: What It Means for Fertility Treatment
Key Takeaways
Adenomyosis is linked with less favourable fertility results in some people, but pregnancy is still possible. IVF plans depend on symptoms, scans, age, ovarian reserve and earlier transfers. Current evidence does not support routine hormone suppression before a frozen embryo transfer for every patient.
Key evidence: SOGC Guideline No. 437 — diagnosis and management of adenomyosis Pados et al. 2023 — adenomyosis and infertility review González-Comadran 2025 — GnRH agonists before embryo transfer
Adenomyosis and fertility: what do we know?
Adenomyosis is often found during an assessment for painful periods, heavy bleeding or difficulty conceiving. It means that glands and supporting tissue similar to the endometrium—the lining of the uterus—are present within the uterine muscle, or myometrium.
For fertility treatment, the important question is not simply whether adenomyosis appears on a scan. What matters is whether it is likely to affect the uterine environment or embryo-transfer plan, and whether treatment before transfer offers enough benefit to justify the delay and side effects.
Dr. Aksoy’s approach
Adenomyosis on an ultrasound or MRI report does not mean that the uterus cannot carry a pregnancy. I avoid applying one protocol to everyone. Mild adenomyosis without symptoms does not, on its own, justify delaying transfer. If disease is clearly diffuse, the uterus is enlarged, or implantation has repeatedly failed without another explanation, I may discuss freezing all embryos and, in selected cases, temporary GnRH agonist suppression. Current research does not show a routine benefit from suppression for every patient. I also avoid surgery within the uterine muscle as a routine step because it may weaken the uterine wall in a future pregnancy. When endometriosis is also present, I assess the ovaries and the uterus separately, based on severity, age, ovarian reserve and earlier treatment results. I do not recommend surgery for an endometrioma, or for adenomyosis, only to improve IVF success unless there is severe pain or involvement of the bowel or urinary tract.
What is adenomyosis?
Adenomyosis involves endometrial-type glands and stroma within the muscle of the uterus. The surrounding muscle may thicken and the uterus may become enlarged. Some people have no symptoms; others experience painful periods, heavy bleeding, pelvic discomfort or pressure.
SOGC Guideline No. 437 describes two broad patterns:
- Diffuse adenomyosis: changes are spread across a wider part of the uterine wall.
- Focal adenomyosis or adenomyoma: changes form a more localised area that can resemble a fibroid on imaging.
The distinction matters, but neither label determines fertility treatment by itself.
How may adenomyosis affect fertility?
Adenomyosis does not make pregnancy impossible. Research summaries, including the review by Pados and colleagues (2023), describe several possible pathways. Their relative importance differs between patients:
- Endometrial receptivity: local inflammation and altered signalling may make the uterine environment less favourable for implantation.
- Uterine contractions: changes near the junction between the endometrium and myometrium may affect normal uterine contractions.
- Local inflammatory and oxidative changes: these changes may influence the environment around implantation, but the precise mechanisms remain under study.
- Pregnancy loss: observational studies—research that follows people over time without assigning treatments—report a higher miscarriage rate in some groups with adenomyosis. These findings cannot predict one patient’s absolute risk.
Age, embryo chromosomal status, coexisting endometriosis or fibroids, and how adenomyosis was diagnosed can all influence study results.
Where the disease sits and how far it extends also seem to matter. A 2026 review by Brandt and colleagues, which pooled the results of 29 studies, linked diffuse adenomyosis with a lower chance of live birth. It also suggested less favourable results when changes lie close to the endometrium or the uterus is larger. The authors rated their confidence in most results as low or very low, partly because studies used different ultrasound criteria. These findings are a guide for discussion, not a forecast for any one patient.
How is adenomyosis diagnosed?
Diagnosis usually begins with imaging rather than surgery.
- Specialist transvaginal ultrasound: an experienced examiner looks for features defined by the MUSA ultrasound consensus. Direct features include myometrial cysts, hyperechogenic islands and echogenic subendometrial lines or buds. Indirect features include a globular uterus, asymmetrical wall thickening, fan-shaped shadowing, translesional vascularity and an irregular or interrupted junctional zone.
- Pelvic MRI: MRI can help when ultrasound is inconclusive, detailed mapping is needed, or a focal adenomyoma must be distinguished from a fibroid.
Indirect ultrasound features alone are not conclusive. MRI findings such as junctional-zone changes may support the diagnosis, but no single measurement should decide every case. The SOGC guideline recommends interpreting imaging alongside symptoms and treatment history.
IVF planning: is treatment needed before embryo transfer?
Not every patient with adenomyosis needs pretreatment. Decisions should consider symptoms, the appearance and size of the uterus, age, ovarian reserve, previous IVF outcomes and the implications of delaying transfer.
Freeze-all and delayed transfer
In selected situations, embryos may be frozen rather than transferred immediately after ovarian stimulation. This separates egg collection from embryo transfer and allows time for reassessment or treatment.
That can be useful, but it is not a default requirement for every patient with adenomyosis.
GnRH agonist suppression
GnRH agonists temporarily reduce hormonal activity and may ease symptoms or reduce uterine volume. Pretreatment before transfer is sometimes discussed for selected patients, but there is no single standard duration.
This is not a routine step for everyone. A 2025 pooled analysis of studies on frozen embryo transfer (Steinmann and colleagues) found no clear improvement in live birth or clinical pregnancy when GnRH agonist pretreatment was added to hormone-replacement frozen transfer. Another 2025 review by González-Comadran and colleagues reached a similar conclusion for frozen-transfer pretreatment. A 2026 systematic review (Christina and colleagues) found that the only randomised trial (a study in which treatment is assigned by chance) showed no difference, while some observational studies suggested a possible benefit from longer suppression in selected patients with more severe disease. The authors called the evidence inconclusive.
Evidence box: GnRH agonist before frozen embryo transfer
A systematic review pools existing studies; a meta-analysis then combines their numbers. Steinmann and colleagues included seven retrospective (past-records) studies and one randomised trial. Overall, live birth, clinical pregnancy, miscarriage and implantation rates were not clearly better with GnRH agonist pretreatment plus hormone-replacement frozen transfer than with hormone-replacement frozen transfer alone.
González-Comadran and colleagues reviewed eight retrospective studies in total. Only three of those studies compared GnRH agonist pretreatment before frozen transfer with no pretreatment. In that frozen-transfer comparison, pooled reproductive outcomes were not improved. The other studies in that review mainly compared stimulation protocols around fresh transfer, which is a different clinical question.
Christina and colleagues included seven studies: one randomised trial and six observational studies. The trial found no significant difference in live birth, clinical pregnancy or miscarriage between GnRH agonist pretreatment plus hormone-replacement frozen transfer and hormone-replacement frozen transfer alone. Several observational studies suggested better results with long-term suppression, particularly in selected patients with more severe adenomyosis; such studies can be skewed by differences between the patients compared. The authors concluded that randomised evidence remains inconclusive and that trials are needed to define the best duration and which patients to select.
The decision should therefore weigh symptoms and imaging against side effects, age and the delay before transfer.
Surgery has a limited role
Diffuse adenomyosis has no clear surgical plane separating it from healthy uterine muscle. Extensive excision can leave a substantial scar and may increase the risk of uterine rupture in a future pregnancy.
Surgery is therefore not routine before IVF. In the specific context of recurrent implantation failure, the 2026 ASRM opinion also notes that evidence for surgery before embryo transfer remains limited. Surgery may be considered only in exceptional, carefully selected cases of focal disease after specialist review. A 2025 systematic review of fertility-sparing procedures (Liu and colleagues) reported pregnancies after surgery, but it found no randomised trials and noted that limited evidence, selection bias and differences between studies make the results hard to interpret. Our separate guide explains the indications and limits of surgery for adenomyosis.
When endometriosis is also present
Adenomyosis and endometriosis can occur together, and each affects IVF in a different way. Endometriosis on the ovaries can reduce the number of eggs collected (Horton and colleagues, 2019). Adenomyosis is linked mainly with the uterine environment, implantation and pregnancy loss, as described above.
When an endometrioma (a cyst of endometriosis on the ovary) is present, the 2022 ESHRE guideline advises against routine surgery before IVF to improve live birth, because no benefit is proven and surgery is likely to reduce ovarian reserve. Surgery can still be considered to ease pain or when the cyst makes the follicles hard to reach. For deep endometriosis, the decision depends mainly on pain and the patient’s preference. The ovaries and the uterus are therefore assessed separately. Our guide to endometrioma and IVF explains this in more detail.
Questions that can guide an individual plan
| Clinical situation | Features to review | Useful discussion point |
|---|---|---|
| Mild or asymptomatic adenomyosis | Incidental imaging finding; little change in uterine size | Would treatment add enough benefit to justify delaying transfer? |
| More extensive or symptomatic disease | Enlarged uterus, pain or several imaging features | What are the possible benefits and limitations of delaying transfer or using hormonal suppression? |
| Unexplained implantation failure | Previous transfers of good-quality embryos without implantation | Have embryo-related, cavity-related and other factors been reviewed before attributing failure to adenomyosis? |
| Focal disease affecting the cavity | A defined lesion that may alter the cavity | Is multidisciplinary review appropriate, and could the uncertain potential benefits of surgery outweigh uterine-wall risks? |
Video by Dr. Senai Aksoy
This video was recorded in French and has French subtitles. In the YouTube player settings, you can choose auto-translated English subtitles.
What should you take away?
An adenomyosis diagnosis does not mean pregnancy is impossible or that IVF will fail. It means that the scan needs to be interpreted in context.
The most useful plan considers symptoms, imaging, age, ovarian reserve and previous transfers together. The aim is to avoid unnecessary treatment and a transfer at the wrong time.
Frequently Asked Questions for Dr. Aksoy
Can I become pregnant with adenomyosis naturally or with IVF, and how does the diagnosis change the plan?
Yes. Women with adenomyosis can become pregnant naturally or with IVF. Extensive, clearly marked adenomyosis, however, can make implantation harder and may raise the risk of miscarriage. That is why I assess how widespread the disease is, the size of the uterus, and the patient’s symptoms.
For example, I do not immediately recommend IVF to a young woman with mild ultrasound findings and no other infertility problem. By contrast, if the uterus is clearly enlarged, periods are severely painful, or earlier transfers have failed, I may reassess the treatment plan.
What matters to me is not only that adenomyosis has been diagnosed, but how far the disease may affect the chance of pregnancy. I do not apply the same treatment to every patient with adenomyosis.
Is adenomyosis the same disease as endometriosis, and does the difference matter for pregnancy and IVF?
No. Adenomyosis and endometriosis are not the same disease. They are closely related, both respond to oestrogen, and they are often found together, but they are two different gynaecological conditions.
The main difference is where the endometrium-like tissue sits:
- Adenomyosis: endometrium-like glands and supporting tissue lie within the muscular wall of the uterus (the myometrium). The uterus can grow larger, and periods can be painful and heavy.
- Endometriosis: endometrium-like tissue lies outside the uterus, for example on the ovaries, the lining of the abdomen, the bowel or around the bladder. It is linked in particular with painful periods, long-term pelvic pain, pain during intercourse and infertility.
Both conditions can be present in the same woman, but having one does not mean having the other. The 2022 ESHRE endometriosis guideline likewise does not regard adenomyosis as a form or subtype of endometriosis.
For pregnancy and IVF, the distinction matters. Endometriosis can affect the ovaries, the tubes and the anatomy of the pelvis, whereas adenomyosis is more closely tied to the uterine muscle and the environment where the embryo implants. For this reason the treatment approach is not always the same.
Do you recommend GnRH suppression before every frozen embryo transfer, and how do you choose the duration?
No. I do not give GnRH suppression before transfer to every patient with adenomyosis. With these medicines we temporarily suppress ovarian hormones to reduce adenomyosis activity and some changes in the uterus. Research has not yet shown that this approach raises the chance of live birth in all patients.
In some patients with diffuse adenomyosis, clear uterine enlargement, or repeated failed transfers, I may consider suppression. When I consider it, a period of two or three months is usually discussed; that is not, however, a proven ideal duration for everyone.
The patient’s age, ovarian reserve and the status of her embryos also shape my decision. Waiting to prepare the uterus for transfer can make sense in some cases; in others it is more important not to delay treatment without need.
When do you consider adenomyosis surgery before IVF, and when do you avoid it?
I do not recommend surgery to every patient I diagnose with adenomyosis. Especially when disease is spread through the uterine wall, it is not always possible to remove all affected tissue. Operating on the uterine muscle can also create serious risks in a later pregnancy, including uterine rupture.
I may consider surgery when a clear adenomyotic focus affects the uterine cavity, when pain or bleeding is very severe, and when other treatments are not enough. In that decision I weigh the patient’s age, pregnancy plans, where the disease sits, and the damage surgery would leave in the uterus.
My aim is not to erase the adenomyosis image on ultrasound, but to protect the patient’s chance of a healthy pregnancy. That is why I prefer to avoid unnecessary surgery, especially in mild and diffuse cases.
Related reading
- Adenomyosis surgery: indications and limits
- When is hysteroscopy useful before IVF?
- How endometriosis is diagnosed
- Endometrioma and IVF: when is surgery considered?
Sources
- Society of Obstetricians and Gynaecologists of Canada (SOGC). Guideline No. 437: Diagnosis and Management of Adenomyosis. J Obstet Gynaecol Can. 2023;45(6):417-429.e1. doi:10.1016/j.jogc.2023.04.008.
- Pados G, et al. Adenomyosis and Infertility: A Literature Review. Medicina (Kaunas). 2023;59(9):1551. doi:10.3390/medicina59091551.
- González-Comadran M, et al. Utility of GnRH Agonists Before Embryo Transfer in Women with Adenomyosis: A Systematic Review and Meta-Analysis. JBRA Assist Reprod. 2025;29(3):507-519. doi:10.5935/1518-0557.20250012.
- Steinmann M, et al. GnRH agonist pretreatment prior to frozen embryo transfer in women with adenomyosis: a systematic review and meta-analysis. Reprod Biomed Online. 2025;51(5):105075. doi:10.1016/j.rbmo.2025.105075.
- Harmsen MJ, et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022;60(1):118-131. doi:10.1002/uog.24786.
- Practice Committee of the American Society for Reproductive Medicine. Recurrent implantation failure: a committee opinion. Fertil Steril. 2026;126(2):277-293. doi:10.1016/j.fertnstert.2026.03.026.
- Tan J, et al. Reproductive Outcomes after Fertility-Sparing Surgery for Focal and Diffuse Adenomyosis: A Systematic Review. J Minim Invasive Gynecol. 2018;25(4):608-621. doi:10.1016/j.jmig.2017.12.020.
- Brandt NB, et al. Adenomyosis and association between ultrasonographic features and pregnancy outcomes in women with infertility or pregnancy loss: a systematic review and meta-analysis. EBioMedicine. 2026;133:106518. doi:10.1016/j.ebiom.2026.106518.
- Christina NLL, et al. Endometrial Preparation Strategies for Frozen Embryo Transfer in Women with Adenomyosis: A Systematic Review of Hormone Replacement Therapy, Gonadotropin-Releasing Hormone Agonist, and Oxytocin Antagonists. Int J Womens Health. 2026;18:630205. doi:10.2147/IJWH.S630205.
- Liu L, et al. Reproductive outcomes after fertility-sparing interventions for symptomatic adenomyosis: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2025;25(1):1178. doi:10.1186/s12884-025-08323-3.
- ESHRE Endometriosis Guideline Development Group. ESHRE guideline: endometriosis (full guideline). European Society of Human Reproduction and Embryology; 2022. Summary article: Becker CM, et al. Hum Reprod Open. 2022;2022(2):hoac009. doi:10.1093/hropen/hoac009.
- Horton J, et al. Reproductive, obstetric, and perinatal outcomes of women with adenomyosis and endometriosis: a systematic review and meta-analysis. Hum Reprod Update. 2019;25(5):592-632. doi:10.1093/humupd/dmz012.
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The content has been created by Dr. Senai Aksoy and medically approved.