Adenomyosis, Endometriosis, and Pregnancy: What Patients Need to Know

If you’re living with endometriosis and you’ve also been told you might have adenomyosis, it can feel like the ground shifts again: “Does this change my chances of getting pregnant?” “Does it make pregnancy more dangerous?” “Should I do surgery—or IVF—or both?”

The reality is that adenomyosis adds a layer of complexity to both fertility treatment and pregnancy care. Across multiple recent reviews and clinical studies, researchers consistently describe a pattern: adenomyosis is linked to lower success rates with assisted reproduction and higher miscarriage risk, especially in more extensive (“diffuse”) disease and when the junctional zone (the inner muscle layer of the uterus) is involved.

This article pulls together findings from several 2025–2026 publications to help you understand what the combined evidence suggests—what’s reasonably solid, what’s still uncertain, and what practical conversations to have with your care team.

First: what adenomyosis changes (and what it doesn’t)

Endometriosis and adenomyosis often overlap, but they aren’t the same condition. Endometriosis is endometrial-like tissue outside the uterus. Adenomyosis is endometrial tissue within the uterine muscle. When both are present, it becomes harder to tease apart which condition is driving symptoms, infertility, or pregnancy risks.

One reason this matters: evidence summarized in recent reviews suggests that miscarriage risk appears more consistently associated with adenomyosis than with endometriosis alone in some analyses. Meanwhile, for advanced endometriosis (stage III–IV), pregnancy complication risks (like preterm birth and placenta previa) are increased overall—but experts note it’s difficult to separate the effect of endometriosis from the effects of co-existing adenomyosis and the use of ART in many datasets.

So rather than thinking “I have endometriosis, therefore X will happen,” it’s often more accurate to think: “My risk depends on my specific combination of endometriosis severity, adenomyosis type, uterine imaging findings, and whether I’m using fertility treatment.”

How adenomyosis may affect fertility and IVF success

Across observational studies synthesized in a 2025 narrative review on ART outcomes in adenomyosis, adenomyosis is associated with lower clinical pregnancy and live birth rates and higher miscarriage rates compared with not having adenomyosis. A prior systematic review pooling seven comparative observational studies (summarized in that paper) found notably lower odds of clinical pregnancy and live birth, and higher odds of miscarriage, in women with adenomyosis.

Importantly, not all “adenomyosis” behaves the same. Multiple papers emphasize disease heterogeneity, and this shows up repeatedly as a theme:

• Focal adenomyosis (more localized lesions) tends to have better reproductive outcomes than
• Diffuse adenomyosis (more widespread involvement of the uterine muscle), especially when the junctional zone is thickened or disrupted.

In one large retrospective cohort described in the ART-focused review (nearly 1,000 women), IVF outcomes were poorer in the adenomyosis groups, while an endometriosis-only group did not show the same pattern—underscoring that adenomyosis can be a key driver of implantation failure or miscarriage in some patients.

Why might this happen?

The studies don’t prove a single mechanism, but they repeatedly discuss plausible contributors: altered uterine contractility, inflammation, impaired receptivity, changes in the junctional zone, and effects on placentation. In patient terms, adenomyosis can make the uterus a less “predictable landing environment” for an embryo—even when embryo quality is good.

“If I have adenomyosis, should I avoid fresh transfer and do freeze-all?”

This is one of the most practical, high-stakes questions patients ask. The combined message from recent evidence is: many clinics consider freeze-all plus a planned frozen embryo transfer (FET) after medical suppression a reasonable strategy, but the evidence is still largely retrospective (not randomized).

The ART review describes mixed findings across studies, but a pattern emerges:

• Ultra-long GnRH-agonist downregulation (a longer course of ovarian suppression before stimulation and/or transfer) may improve clinical pregnancy in some fresh-transfer datasets.
• But it may not clearly improve live birth, and it can reduce oocyte yield in some cases—raising a real concern: even if a fresh transfer looks better, the cumulative live birth across all embryos created might not improve (or could worsen) if fewer eggs/embryos are obtained.

That’s where freeze-all comes in. Several retrospective studies summarized in the review suggest that freezing embryos and transferring later—often after a period of suppression—may improve ongoing pregnancy or cumulative outcomes in adenomyosis populations compared with fresh transfer.

Some clinics also use other pre-transfer approaches (for example, an LNG-IUS before FET was associated with higher ongoing pregnancy in one retrospective report), but this is far from settled science. The key point is that your treatment plan should match your priorities: maximizing embryos for cumulative success, optimizing the uterine environment for a specific transfer, and minimizing time.

Does surgery help fertility in adenomyosis? Sometimes—but selection matters

When symptoms are severe and/or adenomyosis is diffuse, some patients are offered adenomyomectomy (surgical removal of adenomyosis with uterine reconstruction) as a fertility-sparing option. Reviews in 2025–2026 describe pregnancy after surgery as very possible, but outcomes vary widely and depend heavily on who is selected for surgery and what type of disease they have.

A 2026 review summarizing multiple studies reported postoperative clinical pregnancy rates across studies ranging broadly (roughly mid-20% up to 60%+), with miscarriage rates commonly in the teens to mid-20% range. A large systematic review cited within it (over 1,800 patients) reported a clinical pregnancy rate around the high 40% range and live birth in the mid-30% range after fertility-sparing surgery—again, with wide variability.

Across both the 2025 perspective review and the 2026 pregnancy-after-adenomyomectomy review, a consistent theme appears: focal disease tends to do better than diffuse disease. The 2026 review summarizes higher pregnancy and live birth rates in focal versus diffuse adenomyosis.

But here’s the part that patients deserve to hear clearly:

Surgery can be a fertility tool, but it may also create a high-risk pregnancy scenario (more on that below). That means the decision isn’t only “will surgery help me conceive?”—it’s also “am I prepared for the kind of monitoring and delivery planning that may be recommended afterward?”

What about non-excisional treatments (HIFU/RFA/UAE)?

The 2025 surgical perspective review discusses non-excisional options like HIFU (high-intensity focused ultrasound), RFA (radiofrequency ablation), and UAE (uterine artery embolization). A cited meta-analysis in that review found broadly similar fertility outcomes between excisional and non-excisional approaches, but the authors emphasize that data quality is limited and patients are highly selected—so outcomes can look better than what an “average” patient might expect.

What pregnancy risks are higher with endometriosis + adenomyosis?

Even without prior uterine surgery, advanced endometriosis is associated in population studies with higher risks of complications such as preterm birth and placenta previa. A 2025 review focusing on advanced endometriosis and adenomyosis emphasizes something important for decision-making: there is no consistent evidence that pre-pregnancy surgery for advanced endometriosis prevents these obstetric complications. Comparative studies are mostly retrospective and mixed, and randomized trials are lacking.

In other words: if surgery is being considered, it should usually be for symptom relief or fertility indications—not with the expectation that it will “normalize” pregnancy risk.

Adenomyosis adds another layer. Across multiple analyses summarized in the reviews, adenomyosis is repeatedly linked with miscarriage risk, and it may contribute to some of the pregnancy risks sometimes attributed to endometriosis alone—especially in people conceiving through ART.

Pregnancy after adenomyomectomy: why it’s treated as “higher risk”

Where the evidence is most consistent—and most clinically urgent—is the risk profile after adenomyomectomy.

Multiple reviews highlight two major concerns:

1. Uterine rupture (rare, but potentially catastrophic), and
2. Placenta accreta spectrum (PAS) (abnormally invasive placenta), which can cause severe bleeding at delivery.

A 2026 review reports uterine rupture rates across studies ranging from a few percent up to low double digits, with rupture described as potentially unpredictable and reported as early as the second trimester in some cases. The 2025 surgical perspective review also highlights rupture and PAS risk, with concern particularly after surgery for diffuse disease.

A small 2025 single-center retrospective study comparing groups who did vs didn’t undergo adenomyomectomy is a good illustration of real-world complexity: most non-surgical patients had focal disease and did relatively well, while most surgical patients had diffuse disease and more severe features (including thinner luteal-phase endometrium). After surgery, pain improved and the luteal-phase lining thickness increased significantly—suggesting potential benefit for symptoms and uterine lining in selected patients. In that small sample, there was no uterine rupture, but there were notable complications including threatened preterm labor and a case involving adherent placenta/placenta accreta requiring intervention.

The takeaway isn’t “surgery is unsafe” or “surgery is the answer.” It’s: if surgery is on the table, pregnancy planning must be part of the surgical decision from day one (surgeon experience, reconstruction technique, healing time, and a clear prenatal surveillance plan).

Timeline expectations: what patients often want to know

With adenomyosis, timelines matter because many interventions aim to change the uterine environment—and those changes can take time.

• Medical suppression before FET (often GnRH agonist-based) is commonly used for months in clinical practice; evidence suggests it may help some patients, but the optimal duration isn’t firmly established.
• After adenomyomectomy, a 2026 review discusses allowing substantial healing time and notes hysteroscopic observations that endometrial defects can persist and may recover over months; it suggests a waiting period on the order of 12–24 months for more complete recovery in its clinical recommendations (noting this is based on clinical literature and not definitive randomized evidence).

If you’re balancing age, ovarian reserve, symptoms, and time, this is where individualized planning becomes crucial—sometimes involving embryo banking first, then uterine-focused treatment, then transfer.

Practical takeaways: questions to ask your doctor

Use these questions to make appointments more productive:

• “Do my imaging findings suggest focal or diffuse adenomyosis? Is my junctional zone thickened, and does that change your recommendations?”
• “Given my history, would you recommend fresh transfer or freeze-all? What outcome are we optimizing—this first transfer or cumulative live birth?”
• “If you’re suggesting ultra-long suppression, how might it affect oocyte yield and my overall number of embryos?”
• “What’s our plan if we get embryos but implantation fails—do we change the uterine approach (suppression duration, FET protocol)?”
• “If we’re considering adenomyomectomy or another procedure: what are the uterine rupture and PAS risks in your practice, and what is the pregnancy monitoring and delivery plan afterward?”

What we still don’t know (and why your results may differ)

Even though the overall story is consistent—adenomyosis often worsens ART outcomes and can increase miscarriage risk—most of the evidence summarized in these papers is observational. That means:

• patients who undergo surgery often have more severe disease than those who don’t,
• clinics use different imaging definitions and thresholds,
• protocols vary widely (suppression type and duration, fresh vs frozen transfer approaches),
• and outcomes can be influenced by age, embryo genetics, co-existing endometriosis, fibroids, and prior uterine surgery.

We also still need better research to answer questions patients care about most: Who benefits most from prolonged suppression? When is freeze-all clearly superior? Which surgical techniques best balance fertility improvement with pregnancy safety? How should adenomyosis subtype and junctional zone metrics guide decisions?

Until then, the most evidence-aligned approach is a stratified plan: clearly define your adenomyosis pattern and severity on imaging, choose fertility strategies that match your goals (single-transfer success vs cumulative success), and—if surgery is part of the pathway—treat pregnancy planning and high-risk obstetric care as essential parts of the decision.