13 or peristalsis. Previous research has suggested that abnormal uterine contractility affects fertility, and may thus represent a causal link between adenomyosis and infertility. Therefore, we introduced a novel quantitative speckle-tracking method on trans-vaginal ultrasound for the quantitative analysis of the uterine contractile function and investigated its potential to predict the success of in-vitro fertilisation (IVF) treatment. We then suggested a set of reference values for normal uterine contractile function in a prospective cohort of healthy women using this dedicated speckle tracking algorithm. Next, we investigated existing literature for the reported effect that uterine abnormalities (including adenomyosis, leiomyomas and congenital uterine anomalies) have on uterine contractile function. We found that whilst knowledge is scarce, uterine contractile behaviour seems to be affected by uterine pathology. Finally, uterine contractility features of healthy women were compared to women with adenomyosis. We observed significant differences in uterine contractility across the menstrual cycle between women with adenomyosis versus those without. To explore if fertility outcomes are significantly affected in women with adenomyosis, we investigated IVF/ICSI (intra-cytoplasmatic sperm injection) outcomes of a retrospective cohort of patients with MRI-diagnosed adenomyosis, endometriosis or both, compared to matched male infertility controls. We found that women with both adenomyosis and endometriosis have significantly fewer live births compared to the control group. We further report that adenomyosis patients with following characteristics have worse IVF/ICSI outcomes compared to male infertility controls: combined endometriosis, a larger (relative) junctional zone, and the presence of myometrial cysts. Finally, we investigated if the presence of adenomyosis was associated with adverse obstetric outcomes. To do so, we carried out a retrospective analysis of Dutch population-level data looking at obstetric outcomes in women with histologically diagnosed adenomyosis over a period of 23 years. Women with proven adenomyosis demonstrated a higher prevalence of a wide range of adverse obstetric outcomes including: hypertensive disorders, a higher rate of caesarean sections, more small-for-gestational-age children and failure to progress in labour.
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