Three-dimensional ultrasound diagnosis of adenomyosis is not associated with adverse pregnancy outcomes following single thawed euploid blastocyst transfer: a prospective cohort study.

OBJECTIVES: The objectives of this study were 1) to assess the prevalence of ultrasound features of adenomyosis in an infertile population undergoing in vitro fertilization (IVF), 2) to define the inter- and intra-rater agreement in three-dimensional ultrasound (3D US) assessment of adenomyosis, and 3) to evaluate sonographic features of adenomyosis with respect to pregnancy outcomes following transfer of a single thawed euploid blastocyst. METHODS: A prospective cohort study was undertaken. Subjects planning to undergo a single thawed euploid blastocyst transfer between April and December 2017 at a large IVF center were eligible for inclusion. Enrolled subjects underwent endometrial preparation for frozen embryo transfer. 3D US was performed on the day prior to embryo transfer, with images stored for subsequent evaluation. Subjects then underwent transfer of a single thawed euploid blastocyst and pregnancy outcomes were accrued. All 3D US images were de-identified and independently reviewed by five reproductive endocrinologists for the presence of seven sonographic features of adenomyosis: global uterine enlargement, myometrial wall asymmetry, heterogeneous echogenicity, irregular junctional zone, myometrial cysts, fan-shaped shadowing, and ill-defined myometrial lesions. Inter- and intra-rater agreement was evaluated using Fleiss' kappa. Clinical and cycle characteristics of subjects with and without sonographic markers of adenomyosis were compared. The primary outcome of interest was live birth rate. Secondary outcomes included clinical pregnancy rate and miscarriage rate. Logistic regression was performed to account for potential confounders. RESULTS: A total of 648 subjects were included. The prevalence of adenomyosis was 15.3% (99/648). The inter- and intra-rater agreement amongst five independent reproductive endocrinology and infertility specialists conducting 3D US assessment of adenomyosis were poor (kappa= 0.23) and moderate (kappa= 0.58), respectively. Subjects with adenomyosis were older (37.1 vs. 35.9 years, P=0.02) and more likely to undergo a gonadotropin-releasing hormone (GnRH) agonist downregulation protocol when compared to subjects without adenomyosis (16.2% vs. 5.1%, P=0.02). Clinical pregnancy (80.0% vs. 75.0%) and live birth rates (69.5% vs. 66.5%) were similar between groups. When adjusting for potential confounders, there was no difference in clinical pregnancy [aOR 1.47 (0.85-2.56)], miscarriage [aOR 1.3 (0.62-2.72)] or live birth [aOR 1.28 (0.78-2.08)] in subjects with adenomyosis and those without adenomyosis. No individual sonographic marker of adenomyosis was predictive of pregnancy outcomes. CONCLUSIONS: The inter-rater agreement of 3D US assessment of adenomyosis is poor. Furthermore, sonographic markers of adenomyosis may not be associated with altered pregnancy outcomes following transfer of a single thawed euploid blastocyst. These findings suggest that routine screening for adenomyosis in an unselected infertile patient population undergoing frozen embryo transfer may not be warranted. This article is protected by copyright. All rights reserved.