239 reduces the power of the results. This was reflected in the broad reported confidence intervals. Third, while the endometriosis and adenomyosis diagnosis was based on the MRI closest to the IVF/ICSI start date, in many cases the adenomyosis diagnosis was made after IVF/ICSI (see Table 1). Therefore, it is not known whether the adenomyosis was already present (to a similar extent) at the time of IVF/ICSI. However, when conducting a sensitivity analysis for only patients receiving an MRI prior to IVF, our results did not significantly differ. We believe this reflects the theory that adenomyosis is a disease which develops gradually over a life-time rather than representing a de novo diagnosis (63). Finally, there are some women (n=5, see Table 1) in the adenomyosis group that underwent assumed complete surgery for endometriosis before undergoing IVF, as the pelvic MRI showed no signs of endometriosis. Therefore, these patients were assigned to the adenomyosis only group, whilst they did show a history of endometriosis. Finally, several IVF/ICSI treatment parameters are not reported in our study population as part of standard treatment procedures, and thus could not be assessed for their potential confounding effect (e.g. baseline follicle count, AMH levels, (peak) serum oestradiol). Overall, it can be said that adenomyosis negatively affect fertility outcomes, especially in conjunction with endometriosis. It is suspected that in IVF/ICSI patients with combined adenomyosis and endometriosis, the disease is more severe than in patients with only adenomyosis or endometriosis and thus has a greater impact on fertility. Accurate diagnosis of adenomyosis and endometriosis before undergoing IVF/ICSI is crucial. Therefore, making a pelvic MRI to diagnose or eliminate the presence of adenomyosis/endometriosis is recommended. More research is needed to further identify the relationship between adenomyosis and endometriosis and infertility. Especially large-scale studies with patient subdivision into adenomyosis only, endometriosis only and combined adenomyosis and endometriosis groups is valuable so as to tailor (pre) treatment per patient sub-type.
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