260 Discussion Previous studies have suggested that adenomyosis negatively affects reproductive outcomes, however, a lack of consensus in diagnostic criteria on MRI makes the relationship between disease severity and IVF/ICSI outcomes unclear. Hence, we investigated known MRI markers of adenomyosis severity in relation to IVF/ICSI outcomes. Our study showed a wide range of adenomyosis characteristics in infertile women, reflecting the varied nature of the disease, and highlighting the challenges in its diagnosis and clinical presentation. Results showed that within adenomyosis (and endometriosis) patients, patients with certain MRI markers (namely concomitant endometriosis, myometrial cysts, JZ Diff>5mm, and/or a JZ/Myometrium ratio >40%) exhibited significantly worse IVF/ICSI versus male infertility controls (p<0.05). These findings were confirmed when correcting for confounders in multivariate analysis. Despite the fact that there are limited comparable studies, it can be said that our results are consistent with the current literature. In a study by Meylaerts et al., a thickened AJZ and JZmax on MRI were associated with infertility (95). A similar study by Maubon et al. examined the influence of JZ thickness in infertile women on implantation rates during IVF, and showed that a thickened JZ was a negative predictor for embryo implantation (98). This study also investigated JZ cut-offs and showed a implantation failure rate of 95.8% for patients with an AJZ> 7 mm and a JZmax > 10 mm compared to patients with a smaller JZ (p < 0.0001). In our study on the other hand, a higher JZ cut-off of 12mm was significantly associated with worse IVF/ICSI outcomes. The majority of women in our population already had a relatively thickened junctional zone due to the presence of adenomyosis, so the threshold proffered in the aforementioned study may well not be applicable to our population. A handful of recent studies have investigated individual adenomyosis MRI characteristics and IVF/ICSI outcomes (15,142,282). A study by Iwasawa et al. found that patients with the extrinsic adenomyosis subtype had better fertility outcomes compared to other adenomyosis subtypes (15). Our study did not find a clear difference in IVF/ICSI outcomes between adenomyosis subtypes however. A possible explanation for this lies in the diverse categorisations of adenomyosis that exist, making consensus of certain MRI markers difficult (19). Our finding that the added presence of (deep invasive) endometriosis affects
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