Adenomyosis

Ans. is a, b, c  i.e. Fibroid uterus; Endometriosis; Adenomyosis; and PID

Before going into the details of the causes of Infertility, lets first have a look at the prevalence of various causes.

    Etiology of Inlertility

Male W                              25%

Ovulatory                         27%

Tubal / Uterine                 22%

Others                              9%

Unexplained                     17%

Common causes of female Infertility are :

a.     Decreased ovarian reserve

b.     Ovarian Factor It is the most easily diagnosed and most treatable cause of infertility°. It includes :

Anovulation / Dysovulation

• Like in case of hypothalamic dysfunction°, Kaltman syndrome
• Hyperprolactinemia (due to drugs, pituitary adenoma°)
• Primary hypothyroidism°

•  
• Sub clinical adrenal failure
• Diabetes mellitus

Luteinized unruptured follicle Luteal phase defect

c. Tubal Factors : Partial or Complete Bilateral tubal obstruction resulting from previous salpingitis / PID. It could be : — Postabortal°

—  Gonococcal°

—  Chlamydial°

—  Tuberculous°

• Tubal inflammation related to endometriosis
• Following Inflammatory bowel disease
• Following surgical trauma

d.   Peritoneal Factors : — Pelvic adhesions — Endometriosis

e.   Uterine Factors :

• Uterine absence, atrophy
• Congenital malformations (Among all congenital uterine abnormalities, septate uterus is the M/C and most highly associated with reproductive failure and obstetrics complications).
• Intrauterine adhesions (Asherman’s syndrome)°
• Endometrial polyps
• Leiomyomas (most common with sub mucous variety)°
• Chronic endometritis (TB)°
• Exposure to DES in utero

f. Cervical Factors :

• Impenetrable cervical mucus or poorly penetrable cervical mucus due to presence of local sperm antibodies.
• Loss of mucus due to amputation of cervix, cone biopsy or over enthusiastic cervical diathermy.
• Faulty direction of cervix as seen in retroversion or severe prolapse.
• Cervical stenosis.

g. Others : Anxiety / apprehension use of contraceptives; anorexia nervosa.

As such adenomyosis is not given as a cause of infertility but if you go through the chapter of adenomyosis: (In chapter on Adenomyosis) : “The patient may also complain of infertility”. So, I am including it in the correct options

 Ans. is c i.e. Presents with menorrhagia, dysmenorrhea and an enlarged uterus 

Adenomyosis is a condition where there is ingrowth of endometrium (both gland + stroma) directly into the myometrium°.

Age group :        • Elderly patients > 40 years°

Parity :               • Multiparous°

Symptoms : • Most common symptom : Menorrhagia°

• 2nd most common symptom : Dysmenorrhea°
• Others : Pelvic discomfort, Backache, Dyspareunia.

On per vaginal examination : Painful symmetrical enlargement of uterus° (not more than 12-14 weeks of pregnancy)°.

Diagnosis :            • Diagnostic hysteroscopy combined with curettage is the best diagnostic modality°.

Management :       • TOC – Surgery (Total hysterectomy)° in most of the patient, as most of the patients are elderly.

• In younger women – localized excision can be tried.

Option A and B both

Total hysterectomy

Hysterectomy is the definitive treatment and as with other conditions, the type of surgical procedure depends on uterine size and associated uterine or abdominopelvic pathology.

Endometrial ablation or resection using hysteroscopy has been used to successfully treat dysmenorrhea and menorrhagia caused by adenomyosis.

Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 9. Pelvic Mass. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.