2 95 change according to menstrual cycle phase, and defined reference value ranges for all contraction features. Next, in Chapter 7, we evaluated the relevant literature to assess the existing evidence for if uterine contractility has been found to be affected by uterine abnormalities. The few available studies tended to be small, and used subjective and difficult to compare measurement tools. The majority of the studies did suggest that uterine contractile function is impaired in abnormal versus normal uteri in the natural menstrual cycle. Having established a baseline for healthy uterine contractile function, and examining the existing evidence for aberrant uterine contractility in abnormal uteri, we conducted a prospective observational cohort study in Chapter 8. We used the aforementioned 2D TVUS-based speckle tracking analysis method to evaluate uterine contractility features in women with adenomyotic uteri versus healthy controls throughout the menstrual cycle. Study results showed that uterine contractility shows most significant differences from healthy uteri in the periovulatory and luteal phases of the menstrual cycle for a variety of contractility features. In addition, specifically uterine contraction coordination seems most significantly impaired in adenomyosis patients compared to healthy controls, identifying this feature as a promising marker of normal uterine function. Chapters 9 and 10 examine if patients with adenomyosis on MRI have worse IVF/ICSI outcomes compared to male infertility controls. In Chapter 9, it is shown that women with combined endometriosis and adenomyosis disease have statistically significantly worse IVF/ICSI outcomes than controls. This can suggest that more severe disease has a proportionally more severe effect on IVF/ICSI success rates. Chapter 10 then delves deeper into which MRI markers may be specifically associated with the worst fertility outcomes. We observed that the added presence of (deep invasive) endometriosis and especially the presence of myometrial cysts is associated with fewer successful IVF/ICSI pregnancies. Finally, in Chapter 11, the association of adenomyosis with adverse obstetric outcomes is explored. In this retrospective population-based cohort study, the obstetric and neonatal outcomes of patients with histologically proven adenomyosis (based on hysterectomy) are compared to that of the general Dutch population. After correcting for relevant confounders, we found that
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