A stepwise approach to the hysteroscopic management of cystic adenomyosis

Background: Adenomyosis may alter the functional architecture of the inner myometrium and has been associated with impaired reproductive outcomes. Focal cystic adenomyotic lesions can persist despite hormonal suppression and may be challenging to identify and treat hysteroscopically. Objectives: To demonstrate a reproducible, stepwise, hysteroscopic technique for the identification and management of focal cystic adenomyosis of the inner myometrium. Participant: Women with infertility and recurrent implantation failure, defined as failure to achieve a clinical pregnancy after repeated embryo transfers, diagnosed with focal cystic adenomyosis of the inner myometrium based on transvaginal ultrasound and hysteroscopic assessment. Intervention: Procedures were performed in an ambulatory digital hysteroscopy setting at the Life Expert Centre (Leuven, Belgium) under conscious sedation. The approach combined hysteroscopy and transvaginal ultrasound throughout diagnosis, treatment, and follow-up. Preoperative hormonal suppression was used to identify lesions persisting despite medical therapy. Key steps were: (1) lesion mapping using ultrasound-hysteroscopic correlation, including bipolar-marker topographic correlation of lesions not directly visible during hysteroscopy; (2) meticulous dissection and resection using 5Fr mechanical instruments and / or a bipolar loop within a 15Fr mini-resectoscope; (3) application of a crosslinked hyaluronic acid anti-adhesion barrier; and (4) structured postoperative follow-up, including second-look hysteroscopy when indicated. Conclusions: Combination of hysteroscopy and transvaginal ultrasound enables minimally invasive management of focal cystic adenomyosis of the inner myometrium. This video demonstrates a reproducible approach based on precise lesion identification, targeted treatment, and structured postoperative assessment. What is New?: This video introduces a novel technique of topographic ultrasound-hysteroscopic correlation using bipolar-marker localisation, facilitating the identification and treatment of adenomyotic cysts not directly visible during hysteroscopy.