Adenomyosis and IVF: What It Means for Fertility Treatment
Key Takeaways
Observational studies associate adenomyosis with less favourable fertility outcomes in some patients, but it does not make pregnancy impossible. IVF planning depends on symptoms, imaging, age, ovarian reserve and previous transfers; current evidence does not support routine hormonal suppression before 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.
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. Reviews including Pados and colleagues (2023) describe several possible pathways, although 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 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.
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, however, a routine evidence-based step for everyone. The 2025 systematic review and meta-analysis by González-Comadran and colleagues, based on eight retrospective studies, found no improvement in reproductive outcomes from GnRH agonist pretreatment before frozen embryo transfer.
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. Our separate guide explains the indications and limits of surgery for adenomyosis.
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 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. English subtitles are available in the YouTube player settings.
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.
FAQ
Can I become pregnant with adenomyosis?
Yes. Pregnancy can occur naturally or with IVF. The effect varies with age, embryo factors, symptoms, the extent of disease and other fertility conditions.
Does adenomyosis always reduce IVF success?
No. Observational research finds less favourable outcomes in some groups, but mild or incidental adenomyosis does not have the same clinical significance for every patient. No scan can predict an individual IVF result on its own.
How long does GnRH agonist pretreatment take?
There is no single standard duration. Its benefit before frozen embryo transfer has not been established for all patients, so side effects and the impact of delaying transfer must also be considered. The available evidence is summarised in the 2025 systematic review and meta-analysis.
Is ultrasound enough to diagnose adenomyosis?
Specialist transvaginal ultrasound can support the diagnosis in many cases when recognised imaging features are interpreted together. Indirect features alone are not conclusive. MRI can help when findings are uncertain, detailed mapping is required or fibroids complicate the picture.
Is surgery recommended before IVF?
Not routinely. Surgery may weaken the uterine wall, and its comparative effect on reproductive and live-birth outcomes remains uncertain because the available studies are heterogeneous. It is reserved for highly selected focal cases after specialist assessment.
What records should I bring to a fertility consultation?
Bring previous ultrasound and MRI reports, details of earlier IVF cycles and embryo transfers, hormone and ovarian-reserve results, and a brief note of any pain or bleeding symptoms.
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.
- Exacoustos C, et al. Consensus on revised definitions of MUSA features of adenomyosis. Ultrasound Obstet Gynecol. 2022;60(1):118-131. doi:10.1002/uog.24786.
- American Society for Reproductive Medicine. Recurrent implantation failure: a committee opinion. 2026.
- 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.
- Moawad G, et al. Adenomyosis and Infertility. J Assist Reprod Genet. 2022;39(5):1027-1031. doi:10.1007/s10815-022-02476-2.
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The content has been created by Dr. Senai Aksoy and medically approved.