Hysteroscopic Surgery for Adenomyosis: When It May Help
Key Takeaways
Hysteroscopic surgery may be discussed for selected adenomyotic lesions accessible from the uterine cavity. It does not remove all deep or diffuse disease, and a live-birth benefit has not been established. GnRH agonists before frozen embryo transfer are an individual option, not a routine treatment with proven benefit for every patient.
Key evidence: Review: hysteroscopy and adenomyosis Small surgical series: selected patients Meta-analysis: GnRH pretreatment before FET
Hysteroscopy: When Is It Necessary? — Dr. Senai Aksoy
This video is in French; English and Arabic subtitles are available in the YouTube player.
When hysteroscopy may help
Adenomyosis means that tissue like the uterine lining is present within the uterine muscle. It may cause heavy periods, pain and difficulties with fertility, although symptoms and disease extent vary (Pados and colleagues’ review).
Hysteroscopy uses a thin camera passed through the cervix to examine the uterine cavity. An operative procedure may remove or drain selected superficial or cystic adenomyotic lesions accessible from that cavity. This is a different operation from removing disease through an abdominal incision or laparoscopy (review of hysteroscopic treatment).
For broader treatment planning, see adenomyosis and IVF.
What makes a lesion suitable?
The question is whether a particular lesion can be reached and treated safely. A focal lesion projecting towards the cavity, troublesome bleeding and the response to previous medical treatment may inform the discussion. Wanting to preserve the uterus is important, but does not by itself make hysteroscopy appropriate.
Ultrasound helps assess the location and depth of disease. MRI may add information when the ultrasound findings are unclear or the anatomy needs further mapping. The choice of imaging and procedure should follow the individual assessment (review of diagnosis and treatment).
There may be no clear boundary between an adenomyotic lesion and healthy muscle. That limits how much tissue can safely be removed. Deep or widespread adenomyosis is not eliminated simply by treating tissue accessible from the cavity (hysteroscopic treatment review).
What do we know about fertility benefit?
Relieving bleeding or treating a cavity lesion is a surgical goal. It does not establish that the operation will improve implantation or live birth.
A 2025 report by Campo and colleagues described 15 women under 37 who had failed to conceive after medical treatment and at least two transfers of high-quality blastocysts. Four had delivered and seven had ongoing pregnancies at the time of reporting. This small series cannot show how much surgery helped compared with continuing another treatment, or predict the outcome for other patients.
Results from abdominal or laparoscopic adenomyosis surgery should not be presented as results of hysteroscopic treatment. The available techniques, patients and risks differ (review of medical and surgical approaches).
GnRH agonists before frozen embryo transfer
GnRH agonists suppress hormonal activity for a time. They may be discussed as preparation before a frozen embryo transfer (FET); this is distinct from choosing the ovarian stimulation protocol for egg retrieval.
A 2025 systematic review and meta-analysis did not demonstrate better live-birth outcomes when GnRH agonist pretreatment was added to hormone replacement preparation for FET. The studies were mostly retrospective and results varied. This leaves uncertainty about whether particular subgroups benefit.
Reducing symptoms or uterine volume should therefore not be described as proof of a higher chance of live birth.
Risks and recovery
General hysteroscopy risks include bleeding, infection and uterine perforation (RCOG patient information). For adenomyosis surgery, also discuss intrauterine adhesions and symptoms that persist or recur (procedure-specific review; small surgical series). Risks depend on the lesion and the procedure; preserving the uterus does not make surgery risk-free.
Recovery and follow-up depend on the extent of treatment. Your team should explain when to resume activities and how healing will be assessed before a transfer. A small surgical series does not establish a recovery timetable for every patient.
FAQ
Is hysteroscopy a standard treatment for every patient with adenomyosis?
No. It is considered selectively when there is an accessible lesion and a clinical reason to treat it. Deep or diffuse disease cannot simply be removed through the uterine cavity.
Does preserving the uterus mean that fertility will improve?
No. Preserving the uterus and improving the chance of live birth are different outcomes. Procedure-specific evidence remains limited.
Should everyone have GnRH agonists before FET?
No. Current evidence does not establish a live-birth benefit for all patients. Symptoms, disease extent, previous transfers, age and the implications of delaying treatment belong in the individual discussion.
Dr. Aksoy’s approach
I do not use a GnRH agonist in every patient with adenomyosis. I discuss short-term suppression individually, especially before FET, when disease is extensive or marked, the uterus is enlarged or symptoms are severe. Previous transfer results also matter.
For mild, asymptomatic disease, proceeding directly to transfer may be appropriate. With advancing age or limited ovarian reserve, we also need to weigh the cost of waiting for months.
The available studies do not show that GnRH agonists before FET improve live birth in every patient with adenomyosis. Even in selected severe cases, I do not regard the benefit as established.
Dr. Senai Aksoy — clinical input provided on 27 September 2026.
Sources
- Royal College of Obstetricians and Gynaecologists. Outpatient hysteroscopy — patient information. General hysteroscopy information; its outpatient risk estimates should not be transferred to adenomyosis surgery.
- Di Spiezio Sardo A, Calagna G, Santangelo F, Zizolfi B, Tanos V, Perino A, De Wilde RL. The Role of Hysteroscopy in the Diagnosis and Treatment of Adenomyosis. Biomed Res Int. 2017;2017:2518396. doi:10.1155/2017/2518396.
- Campo R, Gillet E, Gordts S, Valkenburg M, Van Kerrebroeck H, Sugihara A, Argay I, Tanos P. Stepwise approach of hysteroscopic cytoreductive surgery for adenomyosis in patients with recurrent implantation failure. Fertil Steril. 2025;123(2):370–372. doi:10.1016/j.fertnstert.2024.10.051.
- Pados G, Gordts S, Sorrentino F, Nisolle M, Nappi L, Daniilidis A. Adenomyosis and Infertility: A Literature Review. Medicina (Kaunas). 2023;59(9):1551. doi:10.3390/medicina59091551.
- Szubert M, Koziróg E, Olszak O, Krygier-Kurz K, Kazmierczak J, Wilczynski J. Adenomyosis and Infertility: Review of Medical and Surgical Approaches. Int J Environ Res Public Health. 2021;18(3):1235. doi:10.3390/ijerph18031235.
- Steinmann M, Anthon C, Kohl Schwartz AS, Mackens S, Blockeel C, Kalaitzopoulos DR, Vidal A. 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.
Add as a Preferred Source on Google
You can add draksoyivf.com as one of your preferred health information sources on Google.
The content has been created by Dr. Senai Aksoy and medically approved.