287 relationships. Nevertheless, if clear signs of adenomyosis are present, it is worth contemplating high-risk obstetric management of these patients. One could advocate for these patients needing more frequent foetal growth monitoring, or aspirin use from the first trimester for instance. Further studies should investigate the effect of severity and type of adenomyosis on obstetric outcomes. Our study has confirmed that women with adenomyosis experience more obstetric and neonatal adverse outcomes, but this needs to be confirmed in prospective clinical studies. Subsequently, appropriate follow-up and adenomyosis treatments (hormonal, surgical or otherwise) can be assessed for their effect on obstetric complications. Our study has several important strengths. First, the use of large populationbased cohorts spanning a number of years, enabled us to conduct the largest study investigating this topic up to now. Moreover, this is the first study to use the gold standard of histologically confirmed adenomyosis. This gives our study a clear advantage due to the undisputed presence of adenomyosis in our study population. Third, contrary to the majority of existing studies, our study population includes both women who conceived naturally and used ART, making our conclusions more widely generalizable. Despite its strengths, this study does have important limitations which should be considered. First, when conducting studies with a large (imbalanced) population, there is a higher chance of receiving statistically significant results. One then has to consider whether this statistical significance immediately translates to clinical significance. Nevertheless, as our results are generally in line with the existing literature, and remain significant after correction for a large number of confounders, they should be taken as clinically relevant. Second, as only women with histologically confirmed adenomyosis were included, a potential bias may have been introduced. It is possible that women with more severe adenomyosis (symptoms) opt for operative over hormonal treatment, and are thereby able to receive histologically-confirmed diagnosis. Moreover, as not all women with adenomyosis undergo histological examination, the control group likely contains a substantial proportion of women with imaging-diagnosed adenomyosis. Hence, our results could be an over- (or under-) estimation of adenomyosis’ true
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