Adenomyosis and association between ultrasonographic features and pregnancy outcomes in women with infertility or pregnancy loss: a systematic review and meta-analysis

Brandt NB, Nicolaj Bruun Brandt, Nicolaj Brandt, Lindner C, Cecilia Lindner, Abrahamsen KH, Karen Høgh Abrahamsen, Karen Høgh; id_orcid 0009-0008-0180-0866 Abrahamsen, Giuliana Beneduce, Beneduce G, Bliddal S, Sofie Bliddal, David Westergaard, Westergaard D, Steen Joop Bonnema, Bonnema SJ, Marianne Skovsager Andersen, Andersen MS, Pernille Ravn, Ravn P, Dorte Glintborg, Glintborg D, Henriette Svarre Nielsen, Nielsen HS
EBioMedicine · 2026 · vol. 133 , pp. 106518 · doi:10.1016/j.ebiom.2026.106518 · PMID:42906371 · W7223084330
Systematic review / meta-analysis OA: gold CC0
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Abstract

BACKGROUND: Adenomyosis has been shown to reduce live birth rates and increase the risk of pregnancy loss. The diagnosis is often established by ultrasonographic assessment using the revised Morphological Uterus Sonographic Assessment (MUSA) criteria. However, the reproductive impact of specific sonographic features remains unclear. A systematic review and meta-analysis was conducted to investigate whether individual ultrasonographic adenomyosis features influence pregnancy outcomes in women with infertility or pregnancy loss. METHODS: We searched MEDLINE (PubMed), Embase, Cochrane Library (CENTRAL), Web of Science, Scopus, and Google Scholar (most recent 200 records) from inception to May 11th, 2026. Observational and interventional studies reporting specific ultrasonographic features of adenomyosis in women with infertility and/or pregnancy loss were included. Primary outcomes were clinical pregnancy, live birth, and pregnancy loss. Two reviewers independently extracted data and assessed risk of bias using the Newcastle-Ottawa Scale and Joanna Briggs Institute critical appraisal tools, as appropriate by study design. Meta-analyses were performed using random-effects models, with common-effects models applied where appropriate; remaining evidence was synthesised narratively. Certainty of evidence was assessed by GRADE. The protocol was registered on PROSPERO (CRD420251077005). FINDINGS: Of 2322 records screened, 29 studies comprising 19,510 patients (7569 with adenomyosis) were included. Diffuse adenomyosis was associated with lower odds of live birth compared with no adenomyosis (OR 0.52, 95% CI 0.34-0.79; I2 = 63%), as well as internal adenomyosis compared with no adenomyosis (OR 0.49 95% CI 0.42-0.57 I2 = 0%). Narrative synthesis suggested poorer reproductive outcomes with adenomyosis features located near the endometrium and with larger uterine volume. The overall certainty was low or very low for 20 out of 21 outcomes, and moderate for one, primarily driven by imprecision and indirectness related to variation in diagnostic criteria across studies. INTERPRETATION: Reproductive outcomes in adenomyosis vary according to specific ultrasonographic features, supporting feature-based reporting beyond a binary diagnosis. Substantial clinical and methodological heterogeneity, including inconsistent ultrasonographic diagnostic criteria, variable application of MUSA definitions, and differences in fertility treatment protocols, warrants cautious interpretation of pooled estimates. Standardised definitions and reporting of adenomyosis features are needed to improve evidence synthesis and clinical translation. FUNDING: The Novo Nordisk Foundation and the Danish Research Council.

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