166 conducted in previous work (229), with comparable results. Additionally, the majority of ultrasounds were conducted in the late follicular phase which may influence the significance of results. Furthermore, due to the novel and still experimental nature of the quantitative analysis employed in this study, its clinical application in routine practice is not yet possible. It was also necessary to exclude a significant number of recordings from analysis (n=18) due to insufficient quality of the ultrasounds, which indicates that a learning curve is present which could (initially) affect clinical useability. In some cases this was avoidable (e.g. insufficient resolution or out-of-plane motion), but incidentally it is not possible to analyse contractions despite good ultrasound technique (for instance due to the orientation of the uterus, or shadows caused by intestinal contents for example). It is also not yet feasible to gain contraction feature results in real time while performing the ultrasound scan, as the implemented analysis still relies on offline, post-ultrasound data processing. In the future, steps need to be made in order to make our TVUS speckle tracking method for quantitative analysis of uterine contractions utilisable in daily clinical practice. The results presented here are able to give us further insight into uterine behaviour at different phases of the menstrual cycle, whereby each cycle phase shows an individual contraction pattern. Our results clearly show that the late follicular phase is the most active with the highest contraction frequency and velocity. One could surmise that these features are thus of importance for the sperm transport and ovulation that occurs in this period of the menstrual cycle. Furthermore, the relatively reduced activity in the late luteal to menstrual phases suggest a relevance of these characteristics with regard to facilitation of embryo implantation and/or menstruation symptoms. The coordination feature has not before been investigated; however, our initial results show that increased contraction frequency and velocity seem to be accompanied by reduced coordination of contractions. The clinical importance of simultaneous (coordinated) anterior and posterior contractions and how it could relate to fertility outcomes or clinical symptoms for example merits further investigation. Potentially, this coordination feature could be seen as a measure of uterine dysperistalsis, which has been previously described in patients with infertility and endometriosis (77,219,232) with significant clinical consequences, especially with regards to fertility.
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