262 study to consider when interpreting our findings is the choice of control group. The majority of our control group did not undergo MRI, which means that the presence of adenomyosis in this group cannot be completely excluded, despite normal TVUS findings and lack of clinical adenomyosis symptoms. It is possible therefore that there are some undiagnosed adenomyosis patients in the control group, which may affect the final analysis. Furthermore, patients in our study cohort could have had other indications for infertility treatment in addition to endometriosis/adenomyosis, whereas our control group in theory only had male infertility. This inevitably introduces a further element of bias into our case group. Clinical & future implications: Our results support that specific MRI markers of adenomyosis and endometriosis severity may be associated with worse IVF/ICSI outcomes compared to male infertility controls. In this context, there is arguably value in thoroughly assessing severity and extent of adenomyosis pre-conceptionally, especially when in combination with endometriosis. Detailed mapping of adenomyosis on MRI may improve clinical counselling and management of adenomyosis and/or endometriosis patients considering IVF/ICSI. Our data shows that the lower IVF/ICSI pregnancy rates are mainly seen in patients with combined adenomyosis and endometriosis, with adenomyosis alone seemingly not enough to cause convincingly worse fertility outcomes in our study population. If adenomyosis and endometriosis are seen as a spectrum of the same disease, the combined diseases constitute more severe disease, and thus have a greater impact on reproductive ability. We did not include patients with only endometriosis so could not assess its potentially confounding effect here. However, previous work by our group has shown that endometriosis alone has less effect on IVF/ICSI outcomes than combined disease (283). Larger future studies with a prospective design should confirm these results, and aid in creating more personalised management and treatments for (infertile) adenomyosis patients.
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