261 IVF/ICSI pregnancy outcomes has been described before (106,283,284). One recent study also found that women with combined adenomyosis (irrespective of subtype) and endometriosis on MRI had fewer live births compared to endometriosis alone (282). Bourdon et al. additionally reported a significantly lower live birth rate in women with adenomyosis and endometriosis exhibiting myometrial cysts (282). Our study showed a similar relationship between live birth rate in relation to myometrial cysts (aOR 0.420, p=0.049). Overall therefore, our results support that adenomyosis in combination with (extensive) endometriosis could be seen as a more severe form of disease, and that these patients may form a specific subgroup potentially needing specific treatment protocols. Strength & limitations Our study has several strengths. First, the fact that the measurements were performed by two independent study investigators, reduces information bias. We also re-assessed all included MRIs during the study instead of relying on radiology report, accounting for differences in adenomyosis diagnosis over time and thereby increasing the internal consistency of our data. Correcting our results for relevant IVF/ICSI confounders also increases the reliability of our findings. This study admittedly has limitations. First, despite our sample size being comparable to previous studies, the number of absolute pregnancies achieved in our study group is low (only 14% live births in patients with adenomyosis), reducing the power of the results. This is also reflected in the larger confidence intervals in the multivariate logistic regression analysis. It is possible that our study population represents a group of women with more severe disease (due to their infertility and indication for MRI in the first place), introducing an element of selection bias, and adding to the low pregnancy rate. Additionally, most MRI diagnoses of adenomyosis were made after IVF/ICSI treatment (78/124 patients). One could question whether the adenomyosis was present to a similar extent at the time of fertility treatment. We do not believe this to be a relevant issue however, as a sub-analysis based on the timing of the MRI in relation to IVF/ICSI treatment did not affect the results. Moreover, adenomyosis is known to be a disorder that develops over a lifetime, and can be assumed to be present throughout the reproductive life-phase (63). Another element of our
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