Want Pregnancy With Adenomyosis Without a Hysterectomy?

If you’re living with suspected adenomyosis, based on imaging, and you want a baby, it can feel like your body is forcing an impossible choice: control the pain and bleeding, or protect your fertility. Many standard treatments that work well for symptoms (like certain hormonal options or hysterectomy) don’t fit when pregnancy is the goal.

That’s why “fertility-sparing” procedures come up so often in consultations—especially adenomyomectomy (surgery to remove adenomyosis tissue while keeping the uterus) and image-guided thermal ablation (procedures like HIFU or RFA that heat and destroy adenomyosis tissue without cutting the uterus open). Recent pooled evidence from many observational studies gives you something you deserve: more realistic numbers to set expectations, ask better questions, and plan safely.

The two main fertility-sparing options you’ll hear about

Adenomyosis can be diffuse (spread out) or focal (more like a localized adenomyoma). The two often co-exist. The focal-predominant pattern, plus how deep and extensive the disease is, often shapes which option is even feasible.

Adenomyomectomy (uterine-sparing surgery). A surgeon cuts out adenomyosis-affected tissue and reconstructs the uterine wall. It can help symptoms in selected patients, but it also creates uterine scars or weakness—important when you later carry a pregnancy. Scars can interfere with implantation and weakness in the uterine wall can lead to rupture of the uterus (1-6%), most often later in pregnancy or during labor. Also, it is highly likely that even those with focal visible adenomyomas have diffuse disease as well. This means that even after resection, the persistent diffuse disease (like a spiderweb throughout the uterus in some cases) will continue to incite inflammation which reduces successful and durable embryo implantation.

Image-guided thermal ablation (HIFU/RFA). These treatments aim heat energy at adenomyosis tissue under imaging guidance. They’re usually less invasive than surgery and may mean shorter initial recovery, but pregnancy safety data is less standardized and outcomes vary widely between centers.

You may also hear about uterine artery embolization (UAE) for adenomyosis symptoms. But when fertility is the goal, evidence in adenomyosis-specific populations is still too limited to rely on for clear expectations. For the more common uterine myomas (fibroids), published data is not clear either but suggests reduced overall pregnancy success.

How often do people get pregnant after these procedures?

If you’re considering a procedure, you probably want the honest bottom line: “Do people actually get pregnant afterward?”

Across the compiled studies in this meta-analysis, about half of patients became pregnant after either of the two main approaches:

• After adenomyomectomy, the pooled pregnancy rate was 50.1% (95% CI 40.0–60.2).
• After thermal ablation (HIFU/RFA), the pooled pregnancy rate was 52.0% (95% CI 32.4–71.6).

What this means for you: pregnancy is clearly possible after both approaches, and many patients do conceive. What it does not mean: that you personally have a “50/50 chance.” These were mostly non-randomized, real-world studies, and people selected for one procedure versus another may have had different disease severity, ages, fertility histories, and other factors that weren’t consistently reported.

How often does pregnancy lead to a live birth?

This is the next question that matters when you’re making a big decision (and often paying a big price physically, emotionally, financially): “If I do get pregnant, what are the chances I bring home a healthy baby?”

In the pooled data:

• After adenomyomectomy, the live-birth/delivery rate was 39.5% (95% CI 29.9–49.2).
• After thermal ablation, the delivery rate was 32.5% (95% CI 26.0–38.9).

In plain terms: across these studies, roughly one-third to two-fifths of patients had a delivery after these "fertility-sparing" interventions.

This gap between pregnancy and delivery is exactly why you should ask for counseling that covers the whole journey—not just “can you conceive,” but also miscarriage risk, pregnancy monitoring, and delivery planning.

Miscarriage and pregnancy loss are not rare—plan for support and monitoring

If you’ve already experienced miscarriage, seeing these numbers can land hard. If you haven’t, it can still be scary. But it’s better to go in with eyes open and a plan for support.

Among people who became pregnant, the pooled estimates were:

• Pregnancy loss (overall):
• 19.8% after adenomyomectomy
• 39.5% after thermal ablation (note the very wide uncertainty range here)

• Spontaneous miscarriage:
• 16.3% after adenomyomectomy
• 27.1% after thermal ablation (again, wide uncertainty)

What this means for you: pregnancy loss happened in a substantial portion of pregnancies after both interventions, and the thermal ablation estimates are particularly uncertain (wide confidence intervals), suggesting results may vary a lot depending on patient selection in these studies, technique of the procedures, and follow-up (this can limit data accuracy if not all patients remain in contact after the procedure).

If you pursue a fertility-sparing procedure, it’s reasonable to ask your team in advance how they handle early pregnancy monitoring, progesterone/luteal support if indicated, and what thresholds they use for referral to maternal-fetal medicine (MFM).

Delivery planning matters—especially after adenomyomectomy

One of the most actionable findings for real life is this: after adenomyomectomy, nearly all live births were by C-section in the pooled data—99.6% (95% CI 98.3–100.8).

After thermal ablation, the pooled C-section rate among reported births was lower (44.6%, with very wide range around that number).

What this means for you:

• If you choose adenomyomectomy, you should assume that a planned cesarean may be the default recommendation in many practices, because the uterine wall has been cut and reconstructed and thereby weakened. That has implications for where you deliver, what your pregnancy monitoring looks like, and how your OB team assesses uterine scar safety. For example, it would not be prudent to try a home birth after an adenomyomectomy. Emergency services should literally be in the same building.
• Even if your surgeon is optimistic, you deserve a clear written plan for pregnancy spacing, monitoring, and delivery recommendations.

This isn’t about the data pushing you toward one procedure or the other—it’s about making sure you’re not surprised later.

What about IVF after these procedures?

Many people with adenomyosis end up doing IVF—not always by choice, but because time, age, co-existing endometriosis, tubal factors, or male factor infertility force the issue.

In the pooled data, IVF-ET conception rates were reported as:

• 40.5% after adenomyomectomy
• 27.5% after thermal ablation (with very wide range)

Use this as a starting point for discussion, not a promise. The big “real-world” issue is coordination: if IVF is likely, you’ll want your surgeon and fertility specialist aligned on timing, uterine healing, imaging follow-up, and what counts as “ready” for embryo transfer.

Who might be a better candidate for which approach?

Because the available evidence is mostly observational, you can’t use these numbers like a scoreboard. But you can use them to guide the right workup and the right specialist conversations.

Adenomyomectomy may be more often considered when you have:

• A focal adenomyosis/adenomyoma that can be surgically excised, or symptoms severe enough that debulking is necessary
• Access to a surgeon experienced in uterine reconstruction
• Willingness to accept that C-section is extremely likely if you do achieve a live birth

Thermal ablation may be considered when:

• You want a less invasive approach and your lesion pattern is suitable for targeted treatment
• You have access to a center with extensive experience in adenomyosis ablation and follow-up
• You understand that pregnancy loss estimates are uncertain and may vary widely by patient selection and technique

If someone is suggesting UAE as a fertility-friendly option specifically for adenomyosis, be cautious: this review could not provide pooled fertility outcomes for UAE because only one tiny eligible study existed. The recommendations are usually based on myomas, which represent a different disease and the data even in that situation is not robust.

Practical takeaways you can use at your next appointment

Bring your goals into the room clearly: symptom relief is important, but if pregnancy is the priority, the plan has to be built around that.

Here are questions worth asking (and writing down) before choosing a procedure:

• “Based on my MRI/ultrasound pattern (focal vs diffuse), which fertility-sparing options are truly realistic for me?”
• “What is the likely pregnancy rate and live-birth rate after this exact procedure for adenomyosis—not fibroids?”
• “How long should I wait before trying to conceive or doing embryo transfer?”
• “After adenomyomectomy, do you recommend planned C-section? At what gestational age, and why?”
• “What is your plan for pregnancy monitoring (cervical length, placenta concerns, scar assessment, MFM involvement)?”
• “If I don’t conceive within X months, what’s the next step—repeat imaging, IVF referral, medical suppression, or something else?”

Reality check: why your personal odds may be higher—or lower

It’s tempting to cling to a single number (50% pregnant! 40% live birth!). But adenomyosis outcomes are heavily influenced by factors that many studies don’t consistently capture: age, ovarian reserve, prior infertility duration, co-existing endometriosis, fibroids, prior uterine surgery, lesion size and location, how “diffuse” the disease really is and surgeon expertise.

Also, these pooled results come from non-randomized studies. That means:

• People offered surgery vs ablation may have been different from the start.
• Centers with strong expertise in complex surgery may get better results than lower-volume centers.
• Some studies may only report outcomes for patients who returned to follow-up and not those that were lost to contact.

So use these numbers for what they’re good at: setting expectations and guiding decisions, not predicting your future with certainty.