The AURA Trial seeks to improve fertility treatment for women affected by a condition known as adenomyosis. Adenomyosis often leads to heavy menstrual bleeding, pelvic pain, dyspareunia and can make it more difficult to achieve and maintain a healthy pregnancy.

In this randomized controlled trial participating women ≥ 18 years of age with a confirmed imaging diagnosis of adenomyosis according to Morphological Uterus Sonographic Assessment (MUSA) consensus will first undergo a thorough assessment. This initial workup includes reviewing medical history, assessing the characteristics of the uterus (volume, myometrial architecture, shape of the uterine cavity, stiffness, etc.) via 2D/3D transvaginal ultrasound, and obtaining blood tests to establish baseline hormone levels.

Once enrolled, each participant will be assigned at random-without prior knowledge by either the woman or her care team-to one of two 90-day pre-treatment regimens. The first group will receive monthly injections of a GnRH agonist, a medication that temporarily suppresses ovarian function and lowers estrogen levels. The second group will follow the same injection schedule but will also take daily letrozole tablets, an aromatase inhibitor that further reduces estrogen production. The hope is that this combined approach will calm the inflammatory environment caused by adenomyosis, promote a more receptive uterus, and ultimately increase the likelihood of an embryo developing beyond the critical 12-week mark.

At the end of the 90-day protocol, and after repeating all evaluations carried out during the enrolment phase, all women will proceed with the planned assisted reproductive technology cycle with the usual careful monitoring until the day of emrbyo transfer. To ensure correct interpretation of the results and to minimise the potential effect of any incompetent oocytes, only euploid embryos evaluated by pre-implantation genetic test or embryos derived from donated oocytes will be transferred. Pregnancy will be assessed first with a blood test, followed by an ultrasound scan at approximately six or seven weeks to confirm a clinical pregnancy. An ongoing pregnancy, defined by the detection of the fetal heartbeat beyond the 12th week, is the main measure of success.

By participating in AURA, women and their families not only gain access to cutting-edge clinical care but also contribute valuable knowledge that could shape future standard treatments for adenomyosis-related infertility. For further information or to explore participation, please reach out to the Instituto Bernebu Assisted Reproduction Center, where our team is ready to guide you through every step of this important study.

Inclusion Criteria:

- Infertile patients affected by adenomyosis diagnosed by 2D-3D transvaginal ultrasound according to revised Morphological Uterus Sonographic Assessment consensus.

Exclusion Criteria:

• concomitant uterine fibroids,
• Müllerian malformations,
• endometrial pathology,
• thin endometrium,
• hydrosalpinx,
• mucometra,
• previous surgery except for previous cesarean section,
• coagulation disorders,
• untreated endocrinopathies,
• severe seminal pathologies,
• double ET,
• ET different from the first one after adenomyosis treatment.