Original Article Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
Received: May 27, 2013 Accepted after revision: August 9, 2013 Published online: October 15, 2013
Effect of Adenomyosis on In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes in Infertile Women: A Retrospective Cohort Study Lei Yan Lingling Ding Rong Tang Zi-Jiang Chen Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Provincial Hospital Affiliated to Shandong University, Jinan, PR China
Abstract Aims: To study the effect of adenomyosis on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes in infertile patients. Methods: We performed a retrospective, database-searched cohort study based on 10,268 patients undergoing controlled ovarian hyperstimulation and IVF/ICSI between 2009 and 2011 in our unit. Adenomyosis was diagnosed by transvaginal ultrasound. A high-quality matched cohort study with strict inclusion criteria was conducted. We compared the basic characteristics and main IVF/ ICSI outcomes between the two groups. Results: We identified 83 patients with adenomyosis, of whom we included 77, and strictly matched them to 77 patients without adenomyosis. Higher day 3 estrogen levels and a longer duration of gonadotropin stimulation days were found in women with adenomyosis compared to control subjects. Patients with adenomyosis had a nonsignificant trend toward a lower clinical pregnancy rate and a higher miscarriage rate (p = 0.103 and 0.09, respectively). The delivery rate was significantly lower in the adenomyosis group in comparison to the matched controls (p = 0.022). Conclusions: Within the limitations of a retrospective study (albeit with a remarkably large number of observations), our results suggest that transvagi-
© 2013 S. Karger AG, Basel 0378–7346/13/0771–0014$38.00/0 E-Mail [email protected] www.karger.com/goi
nal ultrasound-diagnosed adenomyosis could have a negative impact on the main IVF/ICSI outcomes. Improving the diagnostic validity and scoring of disease severity in patients with adenomyosis is suggested. © 2013 S. Karger AG, Basel
Introduction
Uterine adenomyosis is characterized by the presence of heterotypic endometrial glands and stroma in the myometrium, and it may be an epigenetic disease [1]. Recently, reports have focused on the relationship between adenomyosis and infertility, but with controversial conclusions and no consensus. Salim et al. [2] reported that the clinical pregnancy rate (CPR) and ongoing pregnancy rate were significantly lower, and the miscarriage rate significantly higher, in 19 women with adenomyosis versus 256 women without adenomyosis. Costello et al. [3] reported that the presence of adenomyosis did not adversely affect the outcome in women undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) treatment. The most recent systematic review of five existing studies failed to draw any definite conclusions about the effect of adenomyosis on the outcomes of as-
All of the authors state that they have no conflict of interest.
Zi-Jiang Chen, MD, PhD Center for Reproductive Medicine, Department of Obstetrics and Gynecology Provincial Hospital affiliated to Shandong University JingWu Road 324, Jinan 250021 (PR China) E-Mail chenzijiang @ hotmail.com
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Key Words Adenomyosis · Assisted reproduction · Pregnancy · Cohort study
sisted reproductive technology because of major differences in study design and populations [4]. Here we conducted a cohort study with a relatively large sample size to eliminate many confounding factors and to explore the extent of the effect of adenomyosis on IVF/ICSI. As far as we know, none of the previous studies were systematically controlled for age, number of cycles, comorbidities, and other confounding factors on this subject.
11,830 cycles of 10,268 patients over 3 years 893 endometriosis and adenomyosis cases 108 cycles of 83 patients with adenomyosis
77 patients finally included (group 1)
Match
77 patients specifically matched (group 2)
Fig. 1. Database search pathway and group division.
Materials and Methods
Adenomyosis and IVF/ICSI
miscarriage rate (calculated as defined in our previous articles) [6, 7]. Follow-up on pregnancy outcome was performed by phone and recorded in our electronic medical records. Statistical Analysis Statistical analysis was performed using SPSS 17.0. A t test and χ2 test or Fisher’s exact test were applied to compare groups. Data are presented as means ± SE. Differences were considered significant when p < 0.05. Baseline characteristics that were found to differ between the groups (p < 0.05) were entered into 2-category logistic regression models.
Results
A total of 11,830 fresh cycles were conducted over 3 years. Initially, there were 83 patients included in the study group. Six patients were excluded according to the exclusion criteria. Therefore, 77 fresh embryo transfer cycles of 77 patients and matched controls were included in the analysis (fig. 1). The baseline characteristics of the two study groups are shown in table 1. There were no significant differences between the two groups concerning BMI, duration of infertility, the age of partners, ovarian reserve, or choice of ovarian stimulation protocols. Mean day 3 estrogen (E2) in group 1 was significantly higher than in group 2 (p = 0.039). More patients in group 1 had endometriosis (p = 0.047) than in group 2. The ovarian stimulation and IVF/ICSI outcomes are shown in tables 2 and 3. There was no significant difference in any of the listed ovarian response parameters or embryological parameters between the two groups. More patients in group 1 used the ultralong pituitary downregulation protocol with gonadotropin-releasing hormone agonists. The mean total dose of gonadotropin in group 1 was slightly larger than that in group 2 (p = 0.064). The duration of gonadotropin stimulation days was significantly longer in group 1 than in group 2 (p = 0.035). Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
15
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Study Design We performed a retrospective, database-searched cohort study. This study was approved by the institutional review board of Shandong University. Relevant information was collected from the electronic records of women who underwent IVF/ICSI between January 2009 and December 2011 in the Center for Reproductive Medicine, Provincial Hospital Affiliated to Shandong University. All transvaginal ultrasound scans (TVS) were performed by two highly skilled and experienced clinicians. The main criteria for the sonographic diagnosis of adenomyosis were the appearance of heterogeneous areas in the myometrium with poorly defined borders [5]. The diagnosis was further corroborated by the presence of clinical symptoms such as dysmenorrhea and irregular uterine bleeding or surgical pathology reports. Patients were monitored and managed according to the standardized clinical protocols used at the hospital [6]. The study group (group 1) met the following inclusion criteria: (1) aged 42 years or less at the time of commencement of IVF/ICSI treatment, (2) fresh stimulated and transferred cycles, and (3) diagnosis of adenomyosis by transvaginal ultrasound on two separate occasions, with or without the presence of symptoms and a surgical pathologic diagnosis. The control group (group 2), which did not have adenomyosis, was matched to the study group by the following criteria: (1) age (±1 year), (2) number of cycles, (3) type of infertility (primary or secondary), (4) presence of tubal disease (as diagnosed by history of ectopic pregnancy, tubal obstruction, or history of tubal surgery), (5) history of surgery for endometrial polyps, (6) presence of male factors (oligospermia, asthenospermia, and azoospermia), (7) presence of polycystic ovary syndrome, and (8) type of protocol used for controlled ovarian hyperstimulation. We required exact matching for criteria 1–3. For criteria 4–8, we attempted to match as closely as possible, and in most cases were able to match at least three of these criteria. Researchers performing the matching were blinded to the IVF/ICSI outcome. If multiple cycles were present, one cycle was chosen at random. Exclusion criteria consisted of: (1) oocyte donor treatment cycles, (2) presence of multiple confounding factors which prevented matching, (3) history of myomectomy, and (4) presence of uterine fibroids. If patients with adenomyosis had undergone several cycles, we only considered their first-attempt cycle so as to exclude the bias in the statistical analysis. Outcomes measured included the delivery rate (DR), CPR, fertilization rate, implantation rate, biochemical pregnancy rate, and
Table 1. Baseline characteristics
Item
Group 1
Group 2
p
Agea, years Mean age of partner at ART, years Previous IVF cyclesa 0 1 ≥2 Previous pregnanciesa BMI, kg/m2 History of infertility, years Previous gynecological surgery Day 3 serum FSH, IU/ml Mean day 3 E2, pg/ml Number of poor ovarian reserveb Number of ICSI Endometriosis Indication to IVF Male factor Tubo factor Combination Ovary and unknown
34.18±4.19 35.77±4.97
34.23±4.17 35.75±4.97
NS NS
65 (84.4) 10 (13) 2 (2.6) 42 (54.5) 23.2±3.1 4.7±3.2 53 6.88±2.33 67.2±90.3 8 9 21/77 (27.3) 9 25 41 2
65 (84.4) 10 (13) 2 (2.6) 45 (58.4) 23.0±2.7 4.2±2.5 52 7.24±1.67 45.1±20.6 9 10 11/77 (14.3) 8 30 37 2
NS NS NS NS NS NS NS NS 0.039 NS NS 0.047 NS NS NS NS
Values are given as means ± SE or n (%). ART = Assisted reproductive technology; FSH = follicle-stimulating hormone; NS = not significant. a Exposed and unexposed women were matched at least for age, number of treatment cycles, and infertility type (primary or secondary infertility). b Day 3 serum FSH >10 IU/ml.
Table 2. Ovarian stimulation outcomes in groups 1 and 2
Item Cycles Protocol of ovary stimulation, n (%) Short agonist Long agonist Ultralong GnRH agonists Mild stimulation Other Starting dose of Gn Total dosage of Gn per cycle, IU Duration of Gn stimulation, days Endometrial thickness on hCG day, cm Serum LH at the time of hCG injection, IU/ml Serum E2 at the time of hCG injection, pg/ml Mean number of oocytes retrieved Mean number of embryos obtained 2PN zygote rate, % Good-quality embryo rate, % Mean number of embryos transferred Number of embryos transferred 1 2 3
Group 1
Group 2
77
77
17 (22) 28 (36.4) 29 (37.7) 2 (2.6) 1 (1.3) 225.3±68.0 2,693±1,207 11.2±2.0 1.08±0.22 2.5±1.7 2,973±1,903 9.2±5.7 3.9 67.6 56.9 1.93 149 7 34 19
18 (23.4) 30 (38.9) 24 (31.2) 3 (3.9) 2 (2.6) 207.9±59.1 2,348±1,084 10.8±2.1 1.10±0.22 2.8±3.5 3,289±1,755 9.8±5.9 3.5 64.4 56.8 1.96 151 11 36 15
p
NS NS NS NS NS 0.089 0.020 0.092 NS NS NS NS NS NS NS NS NS NS NS
16
Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
Yan/Ding/Tang/Chen
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hCG = Human chorionic gonadotropin; Gn = gonadotropin; GnRH = Gn-releasing hormone.
Table 3. IVF/ICSI outcome in groups1 and 2
Item
Group 1
Group 2
p
Adjusted ORa
Cancellation rate Biochemical pregnancy rate Miscarriage rate Ectopic pregnancy Clinical pregnancies CPR per started cycle CPR per ET cycle ET cycles Implantation rate Delivery cycles DR per started cycle DR per ET cycle Preterm DR per cycle
12/77 (15.6) 38/77 (49.4) 19/38 (50) 9/28 (32.1) 1 28 28/77 (36.4) 28/65 (43.1) 2.35±0.59 59/210 (28.1) 19 19/77 (24.8) 19/65 (29.2) 3/77 (3.9)
6/77 (7.8) 46/77 (59.7) 17/46 (36.9) 6/35 (17.1) 0 35 35/77 (45.5) 35/71 (49.3) 2.26±0.70 61/215 (28.4) 29 29/77 (33.3) 29/71 (40.8) 3/77 (3.9)
0.122 0.119 0.103 0.125 NS NS 0.09 NS NS NS
2.44 (0.79–7.69) 1.71 (0.87–3.36) 2.17 (0.86–5.52) 2.76 (0.76–10.1)
0.022 NS NS
0.42 (0.19–0.91)
0.83 (0.46–1.48)
Table 3 shows the main outcomes of the IVF/ICSI treatment cycles of the two groups. The delivery rate was significantly lower in the patients with adenomyosis than in the matched controls. Other important rates related to IVF/ICSI, including the biochemical pregnancy rate and CPR (p < 0.12), were slightly lower in group 1 than in group 2. Additionally, cancellation rates and miscarriage rates were slightly higher in group 1 than in group 2 (p < 0.13). The preterm birth rate was the same in the two groups.
Discussion
An association between adenomyosis and adverse IVF/ICSI outcomes has not been fully established. In order to minimize the impact of confounding factors and more clearly investigate the effect of adenomyosis on IVF/ICSI, we conducted a matched analysis with a large sample size in our unit. A definite diagnosis of adenomyosis is based on surgical pathologic diagnosis. However, TVS is also well defined, with a sensitivity and specificity equivalent to that of magnetic resonance imaging (MRI). For this reason, and given its efficacy, safety, and lower cost, TVS is the first-line method for diagnosis of suspected adenomyosis [8, 9]. Therefore, it is acceptable that we used TVS as our main diagnostic tool. We believe the matching procedures are one of the most important strengths of this study. Matching was based on the criteria referenced in Somigliana et al. [10]; Adenomyosis and IVF/ICSI
however, it was performed in a stricter fashion to decrease the effect of confounders, although some characteristics of the two groups did differ slightly. Matching also for controlled ovarian hyperstimulation protocols and complications would have been ideal, and we tried our best to do this. We considered myomas and myomectomies as exclusion criteria because the presence of an alteration of the myometrium may confound the ultraosonographic features of adenomyosis. The prevalence of adenomyosis in our unit was only 0.8%, which is lower than published reports (between 1 and 14% in the literature) [4]. This may be because 65% of our patients were less than 35 years of age and the prevalence of adenomyosis is lower at that age [11]. However, the low prevalence rate may also indicate that our diagnostic sensitivity for adenomyosis might be lower, and some patients with mild adenomyosis might have been included in our control group, weakening the differences between groups 1 and 2. Overall, women with adenomyosis showed a trend toward lower pregnancy rates and higher miscarriage and cancellation rates, which did not reach statistical significance. The most important IVF/ICSI outcome, delivery rate, was significantly lower in group 1 after adjusting for confounders in our logistic analysis. Our results indicated a clear negative effect of adenomyosis on the final IVF/ICSI outcomes. The implantation rate did not differ between groups, which is in accordance with a previous study by Martínez-Conejero et al. [12] that reported a similar endometrial gene expression pattern in both the Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
17
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Values are given as n (%) or means ± SE unless otherwise indicated. DR = Delivery rate; ET = embryo transfer; OR=odds ratio. a OR with 95% CI: logistic regression analysis was conducted by adjusting for mean day 3 E2, total dosage of gonadotropin per cycle, duration of gonadotropin stimulation, and with or without endometriosis.
adenomyosis group and nonadenomyosis group, suggesting that adenomyosis does not affect implantation. However, Vercellini et al. [13] suggested that adenomyosis could adversely interfere with normal implantation as well as with sperm transport as a consequence of the destruction of the normal architecture of the myometrium. The prevalence of endometriosis in group 1 was higher than in group 2, a finding which is consistent with published reports suggesting a strong association between adenomyosis and endometriosis. The elevated mean day 3 E2 in group 1 may be related to the pathology and progression of adenomyosis. Our study has several important strengths. First, it demonstrated in a large sampling of patients that women with adenomyosis have similar basic ovarian stimulation outcomes but a negative effect on fertility outcomes (after IVF/ICSI) as compared to patients without adenomyosis. Second, the age- and cycle-matched design of our study eliminates many potential confounders, which are known to affect IVF success [11]. Some limitations of our research should be noted. This is a retrospective study which may be associated with selection bias. Despite a large sample size, the 95% CI of some of our estimated ORs remained relatively wide. Additionally, our screening criteria for adenomyosis were dependent on TVS results. It is acknowledged that mild or
occult adenomyosis might have been misclassified as not affected, given that the prevalence of adenomyosis in our study was lower than previously reported. Future efforts should be aimed at scoring the severity of adenomyosis and including these factors in analysis. Mehasseb et al. [14] demonstrated that the myometrium of uteri with adenomyosis was distinct from that of normal uteri, which could lead to a higher miscarriage rate during pregnancy. Myometrial thickening of more than 2.5 cm on TVS can result in overall adverse effects on IVF/ICSI outcomes [15]. Therefore, myometrial thickness could be considered as a reflection and marker of the severity of adenomyosis in our future study. Improvement of the diagnosis and scoring of disease severity in patients with adenomyosis might add to the strength of these observations.
Acknowledgments The authors thank Dr. Amanda Kallen (Department of Reproductive Endocrinology and Infertility, Yale University School of Medicine) for editing/proofreading. They would also like to thank Yu Wang (School of Statistics, Renmin University of China) for helping in the statistical analysis. This study was financially supported by the National Basic Research Program of China (973 program; 2012CB944700, 2011CB944502) and the National Key Technology Research and Development Program (2011BAI17B00).
References
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6 Guo T, Qin Y, Gao X, Chen H, Li G, Ma J, Chen ZJ: The role of male chromosomal polymorphism played in spermatogenesis and the outcome of IVF/ICSI-ET treatment. Int J Androl 2012;35:802–809. 7 Yan J, Wu K, Tang R, Ding L, Chen ZJ: Effect of maternal age on the outcomes of in vitro fertilization and embryo transfer (IVF-ET). Sci China Life Sci 2012;55:694–698. 8 Bazot M, Cortez A, Darai E, Rouger J, Chopier J, Antoine JM: Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology. Hum Reprod 2001; 16: 2427– 2433. 9 Meredith SM, Sanchez-Ramos L, Kaunitz AM: Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. Am J Obstet Gynecol 2009;201:107.e1–e6. 10 Somigliana E, De Benedictis S, Vercellini P, Nicolosi AE, Benaglia L, Scarduelli C, Ragni G, Fedele L: Fibroids not encroaching the endometrial cavity and IVF success rate: a prospective study. Hum Reprod 2011; 26: 834– 849.
Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
11 Levy G, Dehaene A, Laurent N, Lernout M, Collinet P, Lucot JP, Lions C, Poncelet E: An update on adenomyosis. Diagn Interv Imaging 2013;94:3–25. 12 Martínez-Conejero JA, Morgan M, Montesinos M, Fortuño S, Meseguer M, Simón C, Horcajadas JA, Pellicer A: Adenomyosis does not affect implantation, but is associated with miscarriage in patients undergoing oocyte donation. Fertil Steril 2011;96:943–950. 13 Vercellini P, Vigano P, Somigliana E, Daguati R, Abbiati A, Fedele L: Adenomyosis: epidemiological factors. Best Pract Res Clin Obstet Gynecol 2006;20:465–477. 14 Mehasseb MK, Bell SC, Brown L, Pringle JH, Habiba M: Phenotypic characterisation of the inner and outer myometrium in normal and adenomyotic uteri. Gynecol Obstet Invest 2011;71:217–224. 15 Youm HS, Choi YS, Han HD: In vitro fertilization and embryo transfer outcomes in relation to myometrial thickness. J Assist Reprod Genet 2011;28:1135–1140.
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1 Liu X, Guo SW: Aberrant immunoreactivity of deoxyribonucleic acid methyltransferases in adenomyosis. Gynecol Obstet Invest 2012; 74:100–108. 2 Salim R, Riris S, Saab W, Abramov B, Khadum I, Serhal P: Adenomyosis reduces pregnancy rates in infertile women undergoing IVF. Reprod Biomed Online 2012; 25: 273– 277. 3 Costello MF, Lindsay K, McNally G: The effect of adenomyosis on in vitro fertilisation and intra-cytoplasmic sperm injection treatment outcome. Eur J Obstet Gynecol Reprod Biol 2011;158:229–234. 4 Maheshwari A, Gurunath S, Fatima F, Bhattacharya S: Adenomyosis and subfertility: a systematic review of prevalence, diagnosis, treatment and fertility outcomes. Hum Reprod Update 2012;18:374–392. 5 Devlieger R, D’Hooghe T, Timmerman D: Uterine adenomyosis in the infertility clinic. Hum Reprod Update 2003;9:139–147.
Received: May 27, 2013 Accepted after revision: August 9, 2013 Published online: October 15, 2013
Effect of Adenomyosis on In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes in Infertile Women: A Retrospective Cohort Study Lei Yan Lingling Ding Rong Tang Zi-Jiang Chen Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Provincial Hospital Affiliated to Shandong University, Jinan, PR China
Abstract Aims: To study the effect of adenomyosis on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes in infertile patients. Methods: We performed a retrospective, database-searched cohort study based on 10,268 patients undergoing controlled ovarian hyperstimulation and IVF/ICSI between 2009 and 2011 in our unit. Adenomyosis was diagnosed by transvaginal ultrasound. A high-quality matched cohort study with strict inclusion criteria was conducted. We compared the basic characteristics and main IVF/ ICSI outcomes between the two groups. Results: We identified 83 patients with adenomyosis, of whom we included 77, and strictly matched them to 77 patients without adenomyosis. Higher day 3 estrogen levels and a longer duration of gonadotropin stimulation days were found in women with adenomyosis compared to control subjects. Patients with adenomyosis had a nonsignificant trend toward a lower clinical pregnancy rate and a higher miscarriage rate (p = 0.103 and 0.09, respectively). The delivery rate was significantly lower in the adenomyosis group in comparison to the matched controls (p = 0.022). Conclusions: Within the limitations of a retrospective study (albeit with a remarkably large number of observations), our results suggest that transvagi-
© 2013 S. Karger AG, Basel 0378–7346/13/0771–0014$38.00/0 E-Mail [email protected] www.karger.com/goi
nal ultrasound-diagnosed adenomyosis could have a negative impact on the main IVF/ICSI outcomes. Improving the diagnostic validity and scoring of disease severity in patients with adenomyosis is suggested. © 2013 S. Karger AG, Basel
Introduction
Uterine adenomyosis is characterized by the presence of heterotypic endometrial glands and stroma in the myometrium, and it may be an epigenetic disease [1]. Recently, reports have focused on the relationship between adenomyosis and infertility, but with controversial conclusions and no consensus. Salim et al. [2] reported that the clinical pregnancy rate (CPR) and ongoing pregnancy rate were significantly lower, and the miscarriage rate significantly higher, in 19 women with adenomyosis versus 256 women without adenomyosis. Costello et al. [3] reported that the presence of adenomyosis did not adversely affect the outcome in women undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) treatment. The most recent systematic review of five existing studies failed to draw any definite conclusions about the effect of adenomyosis on the outcomes of as-
All of the authors state that they have no conflict of interest.
Zi-Jiang Chen, MD, PhD Center for Reproductive Medicine, Department of Obstetrics and Gynecology Provincial Hospital affiliated to Shandong University JingWu Road 324, Jinan 250021 (PR China) E-Mail chenzijiang @ hotmail.com
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Key Words Adenomyosis · Assisted reproduction · Pregnancy · Cohort study
sisted reproductive technology because of major differences in study design and populations [4]. Here we conducted a cohort study with a relatively large sample size to eliminate many confounding factors and to explore the extent of the effect of adenomyosis on IVF/ICSI. As far as we know, none of the previous studies were systematically controlled for age, number of cycles, comorbidities, and other confounding factors on this subject.
11,830 cycles of 10,268 patients over 3 years 893 endometriosis and adenomyosis cases 108 cycles of 83 patients with adenomyosis
77 patients finally included (group 1)
Match
77 patients specifically matched (group 2)
Fig. 1. Database search pathway and group division.
Materials and Methods
Adenomyosis and IVF/ICSI
miscarriage rate (calculated as defined in our previous articles) [6, 7]. Follow-up on pregnancy outcome was performed by phone and recorded in our electronic medical records. Statistical Analysis Statistical analysis was performed using SPSS 17.0. A t test and χ2 test or Fisher’s exact test were applied to compare groups. Data are presented as means ± SE. Differences were considered significant when p < 0.05. Baseline characteristics that were found to differ between the groups (p < 0.05) were entered into 2-category logistic regression models.
Results
A total of 11,830 fresh cycles were conducted over 3 years. Initially, there were 83 patients included in the study group. Six patients were excluded according to the exclusion criteria. Therefore, 77 fresh embryo transfer cycles of 77 patients and matched controls were included in the analysis (fig. 1). The baseline characteristics of the two study groups are shown in table 1. There were no significant differences between the two groups concerning BMI, duration of infertility, the age of partners, ovarian reserve, or choice of ovarian stimulation protocols. Mean day 3 estrogen (E2) in group 1 was significantly higher than in group 2 (p = 0.039). More patients in group 1 had endometriosis (p = 0.047) than in group 2. The ovarian stimulation and IVF/ICSI outcomes are shown in tables 2 and 3. There was no significant difference in any of the listed ovarian response parameters or embryological parameters between the two groups. More patients in group 1 used the ultralong pituitary downregulation protocol with gonadotropin-releasing hormone agonists. The mean total dose of gonadotropin in group 1 was slightly larger than that in group 2 (p = 0.064). The duration of gonadotropin stimulation days was significantly longer in group 1 than in group 2 (p = 0.035). Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
15
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Study Design We performed a retrospective, database-searched cohort study. This study was approved by the institutional review board of Shandong University. Relevant information was collected from the electronic records of women who underwent IVF/ICSI between January 2009 and December 2011 in the Center for Reproductive Medicine, Provincial Hospital Affiliated to Shandong University. All transvaginal ultrasound scans (TVS) were performed by two highly skilled and experienced clinicians. The main criteria for the sonographic diagnosis of adenomyosis were the appearance of heterogeneous areas in the myometrium with poorly defined borders [5]. The diagnosis was further corroborated by the presence of clinical symptoms such as dysmenorrhea and irregular uterine bleeding or surgical pathology reports. Patients were monitored and managed according to the standardized clinical protocols used at the hospital [6]. The study group (group 1) met the following inclusion criteria: (1) aged 42 years or less at the time of commencement of IVF/ICSI treatment, (2) fresh stimulated and transferred cycles, and (3) diagnosis of adenomyosis by transvaginal ultrasound on two separate occasions, with or without the presence of symptoms and a surgical pathologic diagnosis. The control group (group 2), which did not have adenomyosis, was matched to the study group by the following criteria: (1) age (±1 year), (2) number of cycles, (3) type of infertility (primary or secondary), (4) presence of tubal disease (as diagnosed by history of ectopic pregnancy, tubal obstruction, or history of tubal surgery), (5) history of surgery for endometrial polyps, (6) presence of male factors (oligospermia, asthenospermia, and azoospermia), (7) presence of polycystic ovary syndrome, and (8) type of protocol used for controlled ovarian hyperstimulation. We required exact matching for criteria 1–3. For criteria 4–8, we attempted to match as closely as possible, and in most cases were able to match at least three of these criteria. Researchers performing the matching were blinded to the IVF/ICSI outcome. If multiple cycles were present, one cycle was chosen at random. Exclusion criteria consisted of: (1) oocyte donor treatment cycles, (2) presence of multiple confounding factors which prevented matching, (3) history of myomectomy, and (4) presence of uterine fibroids. If patients with adenomyosis had undergone several cycles, we only considered their first-attempt cycle so as to exclude the bias in the statistical analysis. Outcomes measured included the delivery rate (DR), CPR, fertilization rate, implantation rate, biochemical pregnancy rate, and
Table 1. Baseline characteristics
Item
Group 1
Group 2
p
Agea, years Mean age of partner at ART, years Previous IVF cyclesa 0 1 ≥2 Previous pregnanciesa BMI, kg/m2 History of infertility, years Previous gynecological surgery Day 3 serum FSH, IU/ml Mean day 3 E2, pg/ml Number of poor ovarian reserveb Number of ICSI Endometriosis Indication to IVF Male factor Tubo factor Combination Ovary and unknown
34.18±4.19 35.77±4.97
34.23±4.17 35.75±4.97
NS NS
65 (84.4) 10 (13) 2 (2.6) 42 (54.5) 23.2±3.1 4.7±3.2 53 6.88±2.33 67.2±90.3 8 9 21/77 (27.3) 9 25 41 2
65 (84.4) 10 (13) 2 (2.6) 45 (58.4) 23.0±2.7 4.2±2.5 52 7.24±1.67 45.1±20.6 9 10 11/77 (14.3) 8 30 37 2
NS NS NS NS NS NS NS NS 0.039 NS NS 0.047 NS NS NS NS
Values are given as means ± SE or n (%). ART = Assisted reproductive technology; FSH = follicle-stimulating hormone; NS = not significant. a Exposed and unexposed women were matched at least for age, number of treatment cycles, and infertility type (primary or secondary infertility). b Day 3 serum FSH >10 IU/ml.
Table 2. Ovarian stimulation outcomes in groups 1 and 2
Item Cycles Protocol of ovary stimulation, n (%) Short agonist Long agonist Ultralong GnRH agonists Mild stimulation Other Starting dose of Gn Total dosage of Gn per cycle, IU Duration of Gn stimulation, days Endometrial thickness on hCG day, cm Serum LH at the time of hCG injection, IU/ml Serum E2 at the time of hCG injection, pg/ml Mean number of oocytes retrieved Mean number of embryos obtained 2PN zygote rate, % Good-quality embryo rate, % Mean number of embryos transferred Number of embryos transferred 1 2 3
Group 1
Group 2
77
77
17 (22) 28 (36.4) 29 (37.7) 2 (2.6) 1 (1.3) 225.3±68.0 2,693±1,207 11.2±2.0 1.08±0.22 2.5±1.7 2,973±1,903 9.2±5.7 3.9 67.6 56.9 1.93 149 7 34 19
18 (23.4) 30 (38.9) 24 (31.2) 3 (3.9) 2 (2.6) 207.9±59.1 2,348±1,084 10.8±2.1 1.10±0.22 2.8±3.5 3,289±1,755 9.8±5.9 3.5 64.4 56.8 1.96 151 11 36 15
p
NS NS NS NS NS 0.089 0.020 0.092 NS NS NS NS NS NS NS NS NS NS NS
16
Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
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hCG = Human chorionic gonadotropin; Gn = gonadotropin; GnRH = Gn-releasing hormone.
Table 3. IVF/ICSI outcome in groups1 and 2
Item
Group 1
Group 2
p
Adjusted ORa
Cancellation rate Biochemical pregnancy rate Miscarriage rate Ectopic pregnancy Clinical pregnancies CPR per started cycle CPR per ET cycle ET cycles Implantation rate Delivery cycles DR per started cycle DR per ET cycle Preterm DR per cycle
12/77 (15.6) 38/77 (49.4) 19/38 (50) 9/28 (32.1) 1 28 28/77 (36.4) 28/65 (43.1) 2.35±0.59 59/210 (28.1) 19 19/77 (24.8) 19/65 (29.2) 3/77 (3.9)
6/77 (7.8) 46/77 (59.7) 17/46 (36.9) 6/35 (17.1) 0 35 35/77 (45.5) 35/71 (49.3) 2.26±0.70 61/215 (28.4) 29 29/77 (33.3) 29/71 (40.8) 3/77 (3.9)
0.122 0.119 0.103 0.125 NS NS 0.09 NS NS NS
2.44 (0.79–7.69) 1.71 (0.87–3.36) 2.17 (0.86–5.52) 2.76 (0.76–10.1)
0.022 NS NS
0.42 (0.19–0.91)
0.83 (0.46–1.48)
Table 3 shows the main outcomes of the IVF/ICSI treatment cycles of the two groups. The delivery rate was significantly lower in the patients with adenomyosis than in the matched controls. Other important rates related to IVF/ICSI, including the biochemical pregnancy rate and CPR (p < 0.12), were slightly lower in group 1 than in group 2. Additionally, cancellation rates and miscarriage rates were slightly higher in group 1 than in group 2 (p < 0.13). The preterm birth rate was the same in the two groups.
Discussion
An association between adenomyosis and adverse IVF/ICSI outcomes has not been fully established. In order to minimize the impact of confounding factors and more clearly investigate the effect of adenomyosis on IVF/ICSI, we conducted a matched analysis with a large sample size in our unit. A definite diagnosis of adenomyosis is based on surgical pathologic diagnosis. However, TVS is also well defined, with a sensitivity and specificity equivalent to that of magnetic resonance imaging (MRI). For this reason, and given its efficacy, safety, and lower cost, TVS is the first-line method for diagnosis of suspected adenomyosis [8, 9]. Therefore, it is acceptable that we used TVS as our main diagnostic tool. We believe the matching procedures are one of the most important strengths of this study. Matching was based on the criteria referenced in Somigliana et al. [10]; Adenomyosis and IVF/ICSI
however, it was performed in a stricter fashion to decrease the effect of confounders, although some characteristics of the two groups did differ slightly. Matching also for controlled ovarian hyperstimulation protocols and complications would have been ideal, and we tried our best to do this. We considered myomas and myomectomies as exclusion criteria because the presence of an alteration of the myometrium may confound the ultraosonographic features of adenomyosis. The prevalence of adenomyosis in our unit was only 0.8%, which is lower than published reports (between 1 and 14% in the literature) [4]. This may be because 65% of our patients were less than 35 years of age and the prevalence of adenomyosis is lower at that age [11]. However, the low prevalence rate may also indicate that our diagnostic sensitivity for adenomyosis might be lower, and some patients with mild adenomyosis might have been included in our control group, weakening the differences between groups 1 and 2. Overall, women with adenomyosis showed a trend toward lower pregnancy rates and higher miscarriage and cancellation rates, which did not reach statistical significance. The most important IVF/ICSI outcome, delivery rate, was significantly lower in group 1 after adjusting for confounders in our logistic analysis. Our results indicated a clear negative effect of adenomyosis on the final IVF/ICSI outcomes. The implantation rate did not differ between groups, which is in accordance with a previous study by Martínez-Conejero et al. [12] that reported a similar endometrial gene expression pattern in both the Gynecol Obstet Invest 2014;77:14–18 DOI: 10.1159/000355101
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Values are given as n (%) or means ± SE unless otherwise indicated. DR = Delivery rate; ET = embryo transfer; OR=odds ratio. a OR with 95% CI: logistic regression analysis was conducted by adjusting for mean day 3 E2, total dosage of gonadotropin per cycle, duration of gonadotropin stimulation, and with or without endometriosis.
adenomyosis group and nonadenomyosis group, suggesting that adenomyosis does not affect implantation. However, Vercellini et al. [13] suggested that adenomyosis could adversely interfere with normal implantation as well as with sperm transport as a consequence of the destruction of the normal architecture of the myometrium. The prevalence of endometriosis in group 1 was higher than in group 2, a finding which is consistent with published reports suggesting a strong association between adenomyosis and endometriosis. The elevated mean day 3 E2 in group 1 may be related to the pathology and progression of adenomyosis. Our study has several important strengths. First, it demonstrated in a large sampling of patients that women with adenomyosis have similar basic ovarian stimulation outcomes but a negative effect on fertility outcomes (after IVF/ICSI) as compared to patients without adenomyosis. Second, the age- and cycle-matched design of our study eliminates many potential confounders, which are known to affect IVF success [11]. Some limitations of our research should be noted. This is a retrospective study which may be associated with selection bias. Despite a large sample size, the 95% CI of some of our estimated ORs remained relatively wide. Additionally, our screening criteria for adenomyosis were dependent on TVS results. It is acknowledged that mild or
occult adenomyosis might have been misclassified as not affected, given that the prevalence of adenomyosis in our study was lower than previously reported. Future efforts should be aimed at scoring the severity of adenomyosis and including these factors in analysis. Mehasseb et al. [14] demonstrated that the myometrium of uteri with adenomyosis was distinct from that of normal uteri, which could lead to a higher miscarriage rate during pregnancy. Myometrial thickening of more than 2.5 cm on TVS can result in overall adverse effects on IVF/ICSI outcomes [15]. Therefore, myometrial thickness could be considered as a reflection and marker of the severity of adenomyosis in our future study. Improvement of the diagnosis and scoring of disease severity in patients with adenomyosis might add to the strength of these observations.
Acknowledgments The authors thank Dr. Amanda Kallen (Department of Reproductive Endocrinology and Infertility, Yale University School of Medicine) for editing/proofreading. They would also like to thank Yu Wang (School of Statistics, Renmin University of China) for helping in the statistical analysis. This study was financially supported by the National Basic Research Program of China (973 program; 2012CB944700, 2011CB944502) and the National Key Technology Research and Development Program (2011BAI17B00).
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