Fertility Preservation and Pregnancy Outcomes
At a Glance
Fertility-sparing treatment for atypical polypoid adenomyoma can preserve the possibility of pregnancy, but it requires expert pathology review and repeated monitoring because the lesion may persist, recur, or be associated with endometrial cancer.
For many patients, a diagnosis of atypical polypoid adenomyoma (APA) comes during their reproductive years. Because this growth has the potential to become cancerous, a hysterectomy is often a definitive treatment. However, if you wish to preserve your fertility, “uterus-sparing” treatments may be an option. It is important to understand that this path requires a high level of commitment to monitoring and carries specific risks that must be balanced against your desire for a future pregnancy [1][2].
The Fertility-Sparing Surgical Approach
The goal of fertility-sparing surgery is to remove the entire lesion while leaving the rest of the uterus intact. The operative plan depends on lesion depth and location [3].
The “Four-Step” Method
Many specialist centers recommend a specific, staged approach called the four-step method [2][4]. This observational approach involves:
- Removal of the visible growth: The main part of the APA is removed using a camera (hysteroscopy) [4].
- Sampling the base: The tissue directly underneath where the growth was attached is removed [4].
- Sampling the surrounding muscle: The layer of muscle beneath the base is sampled [4].
- Sampling the surrounding lining: The rest of the uterine lining is checked for any other signs of overgrowth or cancer [4].
While some observational series report better outcomes with this systematic approach, it is one specialist technique rather than a universal standard. Deeper sampling carries risks, including uterine perforation, bleeding, intrauterine adhesions, and potential impacts on future pregnancy [2].
Risks: Persistence, Recurrence, and Progression
Choosing to keep your uterus means accepting that the APA may not be gone forever. Based on pooled research of patients who chose conservative treatment:
- Persistence: In about 20% of cases, some “residual” APA is still found during follow-up checks [5].
- Recurrence: Estimates for recurrence vary, but retrospective cohorts have reported rates of 29% to 35% [6][5].
- Progression: The most serious risk is the association with concurrent or future endometrial cancer (carcinoma), reported in some series at 10% to 16% over time [2][5].
Because of these risks, you will need personalized follow-up, which may involve regular hysteroscopy and biopsies [1][4].
Pregnancy Outcomes and Challenges
While a successful pregnancy is possible after APA treatment, “preserving the uterus” is not a guarantee of a live birth.
- Success Rates: In small, selected groups of patients who actively tried to conceive after surgery, pregnancy rates have been reported between 56% and 79% [3][5]. These are not live-birth rates and are heavily influenced by age and fertility treatment. In Vitro Fertilization (IVF) is sometimes chosen for fertility reasons or to shorten time to conception, though it is not established to reduce APA recurrence [7].
- Preconception Clearance: The key safety message is to obtain expert pathology review and documented absence of residual APA, EIN, or carcinoma before attempting conception. An IUD must be removed before trying to conceive.
- Missed Carcinoma: A rare but very serious reason for this clearance is the risk of a missed carcinoma. If suspected cancer is found, the plan must change to involve urgent gynecologic-oncology input [8].
- Obstetric Risks: After uterine surgery, patients face potential risks like intrauterine adhesions, uterine scar complications (such as rupture), abnormal placentation, and a possible planned cesarean.
The Role of Hormonal Therapy
After your surgery, your doctor may recommend progestin therapy (such as an IUD) [3]. The goal is to keep the uterine lining thin and “quiet” to help manage the risk of recurrence [9]. While some studies suggest this may help, the evidence is not yet strong enough to prove that hormones significantly reduce recurrence compared to surgery alone [1][10].
Ultimately, fertility preservation in the context of APA is a temporary strategy for many. Some specialists recommend that once you have completed your family, a hysterectomy should be considered to eliminate the long-term risk of cancer [2].
Common questions in this guide
Can I become pregnant after fertility-sparing treatment for atypical polypoid adenomyoma?
What does the four-step method for APA treatment involve?
What needs to be checked before I try to conceive after APA treatment?
How likely is APA to persist, recur, or be linked with cancer if I keep my uterus?
Does IVF lower the chance that atypical polypoid adenomyoma will recur?
What pregnancy complications can occur after surgery for APA?
Will I need hormone treatment after fertility-sparing APA surgery?
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References
References (10)
- 1
Oncologic outcomes of conservative treatment of atypical polypoid adenomyoma of the uterus: A two-center experience.
Casadio P, Raffone A, Travaglino A, et al.
International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2022; (159(1)):79-85 doi:10.1002/ijgo.14077.
PMID: 34921691 - 2
Management of women with atypical polypoid adenomyoma of the uterus: A quantitative systematic review.
Raffone A, Travaglino A, Saccone G, et al.
Acta obstetricia et gynecologica Scandinavica 2019; (98(7)):842-855 doi:10.1111/aogs.13553.
PMID: 30714089 - 3
Atypical polypoid adenomyoma follow-up and management: Systematic review of case reports and series and meta-analysis.
Biasioli A, Londero AP, Orsaria M, et al.
Medicine 2020; (99(26)):e20491 doi:10.1097/MD.0000000000020491.
PMID: 32590732 - 4
Clinical analysis of 44 cases of atypical polypoid adenomyoma of the uterus.
Wang X, Guo Y
BMC women's health 2022; (22(1)):60 doi:10.1186/s12905-022-01643-y.
PMID: 35246106 - 5
Clinical presentation and management of atypical polypoid adenomyomas: Systematic review of the literature.
Mikos T, Tsolakidis D, Grimbizis GF
European journal of obstetrics, gynecology, and reproductive biology 2019; (236()):14-21 doi:10.1016/j.ejogrb.2019.02.027.
PMID: 30875539 - 6
Hysteroscopic Transcervical Resection for Atypical Polypoid Adenomyoma of the Uterus: A Valid, Fertility-Preserving Option.
Chiyoda T, Lin BL, Saotome K, et al.
Journal of minimally invasive gynecology 2018; (25(1)):163-169.e1 doi:10.1016/j.jmig.2017.08.659.
PMID: 29038039 - 7
Pregnant outcomes of atypical polypoid adenomyoma treated with progestin therapy.
Chen Q, Lu W, Lu B
The journal of obstetrics and gynaecology research 2018; (44(2)):323-330 doi:10.1111/jog.13527.
PMID: 29121416 - 8
A case of endometrial carcinoma progressed during pregnancy resulting in fetal death.
Ota E, Nomura H, Omatsu K, et al.
International cancer conference journal 2020; (9(3)):159-161 doi:10.1007/s13691-020-00417-3.
PMID: 32582523 - 9
Maintenance hormonal therapy after treatment with medroxyprogesterone acetate for patients with atypical polypoid adenomyoma.
Nomura H, Sugiyama Y, Tanigawa T, et al.
Japanese journal of clinical oncology 2018; (48(3)):255-258 doi:10.1093/jjco/hyx193.
PMID: 29351618 - 10
A Clinicopathological Review of 203 Cases of Atypical Polypoid Adenomyoma of the Uterus.
Sun Y, Tian L, Liu G
Journal of clinical medicine 2023; (12(4)) doi:10.3390/jcm12041511.
PMID: 36836047
This page is for informational purposes only and does not constitute medical advice about fertility preservation or pregnancy after atypical polypoid adenomyoma. Discuss your individual plan with your gynecologist, gynecologic oncologist, fertility specialist, and obstetrician.