Adenomyosis and Pregnancy: Fertility, Risks and Care in India

• Adenomyosis is endometrial-type tissue growing inside the muscular wall of the uterus, causing heavy, painful periods and an enlarged, tender womb.
• It can reduce fertility by affecting implantation and uterine contractions, but natural conception is still possible, especially with focal or mild disease.
• Treatments such as GnRH analogue pre-treatment can improve IVF outcomes, while hormonal options manage symptoms when you are not actively trying.
• In pregnancy, adenomyosis modestly raises the risk of miscarriage, preterm birth, placental problems, and postpartum bleeding, so antenatal monitoring is stepped up.
• With diagnosis at an experienced centre and individualised care, most women with adenomyosis have good pregnancy outcomes.
• Heavy or severely painful periods are not 'just normal' and deserve evaluation, not endurance.

Adenomyosis is a benign condition in which endometrial tissue, the lining that normally sits inside your uterine cavity, grows into the myometrium, the thick muscular wall of the uterus. This misplaced tissue still responds to your monthly hormones, so it swells and bleeds inside the muscle each cycle. The result is inflammation, muscle thickening, and a uterus that becomes diffusely enlarged, boggy, and tender. It is most often diagnosed between ages 35 and 50, though it is increasingly recognised in younger women too.

There are two main patterns. Diffuse adenomyosis spreads widely through the uterine wall (often the back wall), thickening it all over. Focal adenomyosis (adenomyomas) forms discrete patches that can look like fibroids on a scan. Both patterns can affect fertility and pregnancy, and a woman can have both.

It helps to keep three similar-sounding conditions apart:

• Adenomyosis is endometrial tissue growing within the uterine wall.
• Endometriosis is endometrial tissue growing outside the uterus, on the ovaries, tubes, bowel, or pelvic lining. The differences in symptoms and treatment are covered in our guide to how adenomyosis and endometriosis differ.
• Uterine fibroids are benign muscle-and-fibrous growths, not endometrial tissue at all, though they can mimic adenomyomas on imaging. See our explainer on uterine fibroids.

Adenomyosis is linked to reduced fertility, and managing it is an important part of fertility care. But 'reduced' is not 'impossible', and the size of the effect varies a great deal from woman to woman.

Researchers think adenomyosis lowers fertility in several overlapping ways:

• Poorer implantation. The altered, inflamed lining is less receptive, so embryos struggle to attach and stay attached.
• Abnormal uterine contractions. The coordinated waves that help move sperm and position an embryo become disordered.
• An inflammatory uterine environment that is less friendly to sperm, embryo, and implantation.
• Frequent overlap with endometriosis, which adds its own fertility hurdles such as adhesions and ovarian cysts, explained in our guide to endometriosis and infertility.

• GnRH analogue pre-treatment. Drugs such as leuprolide, goserelin, or triptorelin create a temporary menopause-like state that shrinks adenomyotic tissue. A typical course of 2 to 6 months before IVF or a natural-conception attempt can improve outcomes, especially in diffuse disease. Monthly depot injections cost roughly Rs 3,000 to Rs 12,000 in India.
• IVF with adapted protocols. Longer suppression and a frozen embryo transfer in a later cycle, rather than a fresh transfer, give the lining time to recover. IVF in India typically costs Rs 1.5 to 5 lakh per cycle, with adenomyosis management adding to this.
• Surgery for focal disease. Adenomyomectomy removes a focal adenomyoma while sparing the uterus. It is technically demanding because adenomyotic tissue has no clean 'capsule' like a fibroid, and it carries risks of bleeding, adhesions, and a weakened uterine wall, so it is reserved for selected cases at experienced centres.

Once you are pregnant, adenomyosis modestly raises the chance of certain complications. The point of knowing this is not to worry, but to make sure your care team watches the right things. With enhanced monitoring at a FOGSI/ICOG-aligned centre, most of these risks can be caught early and managed.

The complications seen a little more often include:

• Early miscarriage. Research suggests roughly 1.5 to 2 times the baseline risk, driven by the same implantation and uterine-environment problems. Our guide to miscarriage types and recovery explains what this involves; for those with repeated losses, see recurrent miscarriage.
• Ectopic pregnancy, slightly more likely especially with coexisting endometriosis, which is why an early scan to confirm the pregnancy is in the uterus is sensible. Learn the warning signs of ectopic pregnancy.
• Placental problems, including placenta previa, placenta accreta spectrum (an abnormally stuck placenta), and placental abruption. Prior caesarean adds to accreta risk.
• Preterm birth, with rates about 1.5 to 2 times higher; cervical-length checks in mid-pregnancy help flag this early. See preterm labour.
• Pre-eclampsia and high blood pressure, modestly increased, which is why blood pressure and urine are monitored closely. Read about pre-eclampsia in pregnancy.
• Fetal growth restriction, picked up through serial growth scans. See intrauterine growth restriction.
• Postpartum haemorrhage, because a thickened, abnormal uterine wall may not contract well after delivery. See postpartum haemorrhage warning signs.

• Globular, enlarged uterus on transvaginal ultrasound
• Asymmetric (often posterior) thickening of the uterine muscle
• Tiny myometrial cysts and a speckled, heterogeneous texture
• Blurred border between the endometrium and the muscle
• Junctional-zone thickening above 12 mm on MRI

Treatment is not one-size-fits-all. The right plan depends on your symptoms, age, fertility goals, and whether your disease is focal or diffuse. The aim for women planning pregnancy is to control symptoms while protecting fertility and improving the odds of a healthy pregnancy.

When you are not currently trying to conceive, symptom control is the priority:

• Hormonal methods. Combined pills and progestin-only options reduce bleeding and pain. The levonorgestrel (Mirena) IUD is increasingly used for adenomyosis and lasts about five years; the device plus insertion costs roughly Rs 5,000 to Rs 12,000.
• GnRH analogues for severe symptoms or as pre-treatment before fertility procedures. Side effects (hot flushes, mood changes, bone-density loss with long use) can be eased with low-dose add-back therapy.
• Non-hormonal support such as NSAIDs and tranexamic acid for bleeding, plus iron to correct anaemia. These ease symptoms but do not treat the underlying disease.

Antenatal care for women with adenomyosis follows the usual schedule but adds a few extra checks at the points where risk is higher. FOGSI, ICOG, and ACOG all support this kind of individualised care.

Early pregnancy. A transvaginal scan at 6 to 8 weeks confirms the pregnancy is inside the uterus and shows the heartbeat, given the slightly raised ectopic and miscarriage risks. Some women benefit from closer first-trimester monitoring for reassurance.

First trimester. Dating scan, nuchal translucency, and serum screening (PAPP-A and free beta-hCG, with cell-free DNA as an option) proceed as usual, with a careful look at the uterus and placenta. A pre-eclampsia risk assessment helps decide on aspirin.

Low-dose aspirin (75 to 162 mg daily) from 12 to 16 weeks is offered when there are added pre-eclampsia risk factors, which women with adenomyosis often have, in line with FOGSI, ACOG, and FIGO guidance.

Second trimester. The 18 to 22 week anatomy scan checks the baby and documents the placenta's position. A low or covering placenta is followed up; features suggesting accreta prompt referral to a tertiary centre. Cervical-length measurement around 18 to 24 weeks assesses preterm-birth risk, and a short cervix may lead to vaginal progesterone or, in selected cases, a cervical stitch.

Glucose screening. Gestational diabetes screening using the Indian DIPSI/IADPSG approach happens at 24 to 28 weeks. Adenomyosis does not specifically raise GDM risk, but standard screening applies.

Third trimester. Serial growth scans (often monthly) track the baby's growth and catch restriction early, with amniotic fluid and Doppler checks as needed. Blood pressure, urine protein, and symptom checks continue throughout.

Delivery planning. Many women with adenomyosis can still aim for a vaginal birth. A planned caesarean is advised for placenta previa, suspected accreta, or a prior adenomyomectomy. High-risk cases should deliver where obstetric, anaesthetic, neonatal, and surgical support is available. Because postpartum bleeding is more likely, active management of the third stage with a uterotonic and ready access to blood products are part of the plan.

Afterwards, breastfeeding is completely safe and encouraged, and most contraceptive methods are compatible with adenomyosis, so you can plan spacing or future pregnancies with your doctor.

Adenomyosis is a chronic, hormone-driven condition, so it tends to persist until menopause, when falling oestrogen usually brings dramatic relief. Before then, symptoms can fluctuate but often need ongoing management.

The symptom burden can be real: heavy bleeding and anaemia, fatigue, severe pain, painful sex, and the emotional strain of fertility difficulties, sometimes amplified in India by family expectations around childbearing. None of this is something to simply tolerate, and psychological support is a legitimate part of care, not an afterthought.

The encouraging news on fertility: many women with adenomyosis conceive and deliver healthy babies, with or without assisted reproduction, and outcomes are better when the condition is properly diagnosed and managed and any coexisting problems are treated. Multiple pregnancies are possible, and sensible spacing allows the body to recover between them.

A few reassurances worth holding onto: adenomyosis is benign and does not cause uterine cancer (though any new or persistent abnormal bleeding should still be checked). Menopause usually settles the condition for good, and hormone therapy afterwards, if needed for menopausal symptoms, can be discussed on an individual basis.

Adenomyosis has long been under-recognised and under-treated. The more women and clinicians know about it, the better the care. You deserve to ask questions, seek information, and pursue treatment that fits your life and your goals.

• Heavy vaginal bleeding at any stage of pregnancy
• Severe or one-sided lower abdominal pain in early pregnancy (possible ectopic)
• Regular tightening or cramping before 37 weeks (possible preterm labour)
• Severe headache, blurred vision, or upper-abdominal pain (possible pre-eclampsia)
• Reduced or absent baby movements in the third trimester
• Heavy bleeding, large clots, or feeling faint after delivery (possible postpartum haemorrhage)

• ESHRE Guideline: Endometriosis (2022), with adenomyosis recommendations
• ACOG: Management of Heavy Menstrual Bleeding and Dysmenorrhea
• NHS: Adenomyosis (overview, symptoms, treatment)
• FOGSI (Federation of Obstetric and Gynaecological Societies of India)
• National Family Health Survey (NFHS-5), India: caesarean and maternal health data