To investigate whether herbal pair Rheum palmatum L. (R. palmatum; Da Huang)–Prunus persica (L.) Batsch (P. persica; Tao Ren) (RP) can restore endometrial receptivity and mitigate adenomyosis (AM)-associated infertility by regulating dysregulated glycolytic metabolism.

An AM mouse model was established by pituitary transplantation. Mice receiving RP were divided into the low-dose (RP-L) and high-dose (RP-H) groups based on the RP dose administered. Pregnancy outcomes were assessed based on embryo implantation sites, progesterone levels, and levels of endometrial receptivity markers, including homeobox A10 (Hoxa10), leukemia inhibitory factor (LIF), and integrin beta 3 (Itgβ3). Molecular docking was used to analyze the interactions between the RP components and glycolytic enzymes.

AM mice exhibited pathological features of infertility, including reduced implantation sites, suppressed progesterone (P < .001), and downregulated receptivity markers (Hoxa10 and Itgβ3, P < .01; LIF, P < .05), alongside glycolytic dysfunction characterized by depleted glucose (P = .003) and accumulated pyruvate/lactate (both P < .05). RP treatment reversed these defects, restoring embryo implantation (P = .001 for RP-L; P = .013 for RP-H) and upregulating Hoxa10 (P = .001), LIF (P = .04), and Itgβ3 (P = .004). Crucially, RP normalized glycolytic flux, increasing glucose (P = .046) while reducing pyruvate (P = .01) and lactate (P = .003). RP significantly reduced LDH activity in the RP-H group (P = .025) and PK activity in the RP-H (P < .001) and RP-L (P = .007) groups compared to the AM group, with greater suppression than that with gestrinone treatment (LDH, P = .023; PK, P = .003). Molecular docking confirmed strong binding (energy, <−5.0 kcal/mol) between RP components and LDHA/PKM2, primarily via hydrogen bonds. In vitro, RP rescued lactate-impaired trophoblast adhesion (P = .002).

RP ameliorated AM-associated infertility by regulating glycolytic metabolism and improving endometrial receptivity.