237 DISCUSSION Overall, infertile women with combined endometriosis and adenomyosis on MRI undergoing their first IVF/ICSI fresh embryo transfer had significantly worse fertility outcomes than matched male subfertility controls. These women had a 55% decreased chance of biochemical pregnancy (OR 0.453), a 70% decreased chance of ongoing pregnancy (OR 0.302) and a 69% decreased chance of a live birth (OR 0.309). Women with only adenomyosis or endometriosis did not appear to have significantly reduced chance of achieving pregnancy compared to male subfertility controls. This effect persisted after matching for age, parity and number of transferred embryos, and correcting for embryo quality. Our results are largely in line with current literature. Sharma et al. looked at similar patient groups as this study, (albeit with a diagnosis based on TVUS). They reported a significantly reduced clinical pregnancy rate after IVF of 34.55% for the adenomyosis group, 36.62% in the endometriosis group and 22.72% for the combined group versus tubal factor controls. This is in accordance with our results, showing that a combined presence of adenomyosis and endometriosis results in the lowest clinical pregnancy rate in IVF/ICSI patients (86). Similarly, a study by Ballester et al. in colorectal endometriosis patients reported that an added presence of adenomyosis lead to significantly reduced cumulative clinical pregnancy rates (19% vs. 82.4%) (87). Not all studies have reported significant associations between the presence of adenomyosis in endometriosis patients and IVF/ICSI outcome however, with the topic still being contentious (93,274). It has been recently been suggested that the age-associated nature of adenomyosis forms an important confounder for worse fertility outcomes in this population (274). For this reason, we chose to match for maternal age during IVF, with our results still reaching statistical significance. Based on our results therefore, we do suggest that patients with combined adenomyosis and endometriosis have a more severe form of the disease thus more impaired fertility compared to women with only one of the two disorders. The current data also seems to show that this is the case regardless of the individual adenomyosis or endometriosis phenotype. It is noteworthy also that the combined group constitute the largest proportion of infertile women undergoing IVF/ICSI treatment in our study: it suggests that these
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