Different subtypes of ultrasound-diagnosed adenomyosis and in vitro fertilization outcomes: A systematic review and meta-analysis.

INTRODUCTION: Adenomyosis prevalence among women with infertility is increasing; their management during in vitro fertilization is usually based on ultrasound diagnosis alone. Herein, we summarize the latest evidence on the impact of ultrasound-diagnosed adenomyosis on in vitro fertilization outcomes. MATERIAL AND METHODS: The study was registered with The International Prospective Register of Systematic Reviews (CRD42022355584). We searched PubMed, Embase, and Cochrane Library databases from inception to January 31, 2023, for cohort studies on the impact of adenomyosis on in vitro fertilization outcomes. Fertility outcomes were compared according to the presence of adenomyosis as diagnosed by ultrasound, concurrent endometriosis and adenomyosis, and MRI-based or MRI- and ultrasound-based adenomyosis diagnosis. Live birth rate was the primary outcome while clinical pregnancy and miscarriage rates were secondary outcomes. RESULTS: Women diagnosed with adenomyosis by ultrasound had lower live birth (odds ratio [OR] = 0.66; 95% confidence interval [CI]: 0.53-0.82, grade: very low), lower clinical pregnancy (OR = 0.64; 95% CI: 0.53-0.77, grade: very low), and higher miscarriage (OR = 1.81; 95% CI: 1.35-2.44, grade: very low) rates than those without adenomyosis. Notably, symptomatic and diffuse, but not asymptomatic adenomyosis as diagnosed by ultrasound, adversely affected in vitro fertilization outcomes, with lower live birth (OR = 0.57; 95% CI: 0.34-0.96, grade: very low), clinical pregnancy (OR = 0.69; 95% CI: 0.57-0.85, grade: low), and miscarriage (OR = 2.48, 95% CI: 1.28-4.82, grade: low) rates; and lower live birth (OR = 0.37; 95% CI: 0.23-0.59, grade: low) and clinical pregnancy (OR = 0.50; 95% CI: 0.34-0.75, grade: low), but not miscarriage rate (OR = 2.18; 95% CI: 0.72-6.62, grade: very low), respectively. Concurrent adenomyosis in endometriosis is associated with a significantly lower live birth rate (OR = 0.44; 95% CI: 0.26-0.75, grade: low) than endometriosis alone. Finally, the use of MRI-based or MRI- and ultrasound-based adenomyosis diagnosis showed no significant association with in vitro fertilization outcomes (grade: very low for all outcomes). CONCLUSIONS: Considering ultrasound findings, symptoms, and different subtypes of adenomyosis may aid in offering personalized counseling, improving treatment decisions, and achieving better outcomes of in vitro fertilization.