A rare case of extensive placenta accreta in twin pregnancy after GnRH agonist treatment of adenomyosis

Abstract

Background Adenomyosis remains an enigma for the reproductive endocrinologist. It is thought to contribute to sub-fertility, and its only curative treatment is hysterectomy. However, studies have documented increased live birth rates in women with adenomyosis who were treated with gonadotropin releasing hormone agonist (GnRHa). Case Here we present a case of a 52-year-old woman with adenomyosis who had three failed frozen embryo transfers (FETs) prior to initiating a 6-month trial of GnRHa. GnRHa therapy resulted in a decrease in uterine size from 11.5 × 7.9 × 7.0 cm to 7.8 × 6.2 × 5.9 cm and a decrease in the junctional zone (JZ) thickness from 19 to 9 mm. Subsequently, she underwent her fourth FET, which resulted in live birth of twins. The delivery was complicated by expansive accretas of both placentas requiring cesarean hysterectomy. The final pathology of the placentas demonstrated an extensive lack of decidualized endometrium that was even absent outside the basal plate. Conclusions GnRHa therapy in patients with adenomyosis may improve implantation rates after FET. Previous molecular studies indicate that genetic variance in the expression of the gonadotropin releasing hormone receptor (GnRHR) could explain the expansive lack of decidualized endometrium after GnRHa therapy. Further investigations are needed to determine if GnRHa therapy contributes to the pathologic process of placenta accreta.

The association between uterine adenomyosis and adverse obstetric outcomes: A propensity score‐matched analysis

“…The severity of adenomyosis was also unknown, that is, whether adenomyosis was diffuse or focal, and there may be missed cases of asymptomatic adenomyosis in the control group resulting in possible misclassification. Prior treatments for adenomyosis were not also captured in this dataset, and it has been suggested that treatments such as GnRH‐agonists may increase the risk for placental pathology 25 . Prior uterine curettage was also not assessable due to lack of specific codes, but this could be a possible unmeasured confounder for abnormal placentation.…”

“…Prior treatments for adenomyosis were not also captured in this dataset, and it has been suggested that treatments such as GnRH‐agonists may increase the risk for placental pathology. 25 Prior uterine curettage was also not assessable due to lack of specific codes, but this could be a possible unmeasured confounder for abnormal placentation.…”

Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach

“…In fact, according to a study of 45 subjects, triptorelin with add-back therapy may be beneficial to infertile patients irrespective of IVF, by reducing uterine size and enhancing elasticity, hence facilitating spontaneous pregnancy [ 85 ]. Several case reports have further demonstrated effectiveness in patients with severe adenomyosis suffering from secondary infertility [ 86 , 87 , 88 ]. One of these women later presented with severe pregnancy complications due to insufficiently decidualized endometrium, but it was not clear whether this event was related to the effect of GnRH agonist [ 88 ].…”

“…Several case reports have further demonstrated effectiveness in patients with severe adenomyosis suffering from secondary infertility [ 86 , 87 , 88 ]. One of these women later presented with severe pregnancy complications due to insufficiently decidualized endometrium, but it was not clear whether this event was related to the effect of GnRH agonist [ 88 ]. Niu et al reported a significant improvement in rates of clinical pregnancy, successful implantation, and ongoing pregnancy in 339 infertile patients with adenomyosis undergoing treatment with GnRH agonist prior to frozen embryo transfer [ 48 ].…”