238 women having more severely impaired fertility and thereby seek treatment in the first place. It is possible this is due to an added uterine or implantation factor in these women, as matching and correcting embryo quality did not diminish this effect. In general clinical practice, when undergoing IVF/ICSI, arguably little attention is paid to whether a patient has adenomyosis, due to inconsistent diagnostic criteria and a lack of symptoms in many women. As a result, few clinical guidelines exist to tailor fertility treatments to women with adenomyosis (or endometriosis for that matter), and in many cases they simply follow the locally established IVF/ICSI protocols. The results presented here suggest that screening for adenomyosis in (infertile) endometriosis patients (on MRI) is clinically useful in an IVF/ICSI setting. Furthermore, due to the suspected severity of disease in the combined group, these patients represent a potential target group for additional hormonal therapy or surgery before undergoing IVF/ICSI, resulting in disease attenuation/regression (279) . Investigating this patient group separately, as done in this study, thus constitutes one of its strengths: it was possible to investigate the independent influence of adenomyosis and endometriosis on fertility. A further strength of this study is that only women with adenomyosis based on MRI were included, a more reliable method of diagnosing adenomyosis, as opposed to TVUS (29). Moreover, the extensive re-evaluation of the MRIs by three experienced pelvic radiologists in the context of this study also reduces the risk of bias that inevitably accompanies a retrospectively designed study. To the best of our knowledge, this is the first study which investigates fertility outcomes of adenomyosis and endometriosis separately and combined, based on MRI diagnosis. This study does however have several limitations. First, the control group as a rule were healthy women, with no indication for MRI. This means no definitive assessment of adenomyosis presence in these women could be carried out. Hence, it is possible that some of these women had undiagnosed adenomyosis. To account for this eventuality, we chose to match the control group 1:2 with the study group. Second, although our study group was larger than many previously executed studies investigating the relationship between adenomyosis and infertility, the sample size was still relatively small, which
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