300 endometrium and myometrium and increase in intracellular space, which then facilitates further infiltration of adenomyosis into the myometrium (297). The dysperistalsis is also thought to lead to a chronic local inflammatory reaction (298). What is not yet clear however, and is not yet specifically investigated in our reported studies, is which threshold of JZ involvement will lead to objectifiable aberrant contraction activity, and if it is indeed the case that more severe adenomyosis shows equally severely affected contraction activity. The two phases of the menstrual cycle showing the most significant differences in uterine contractility were the late follicular (or periovulatory) phase and the luteal phases. These two phases are arguably the most essential in terms of fertility, and aberrant uterine contractions here may well be an important aetiological mechanism behind sub- and in-fertility seen in adenomyosis patients. Potential can also be seen for using the specific uterine contractile profile observed in adenomyosis patients versus normal patients to be further developed for clinical use as a diagnostic tool (for example in patients with symptoms suggestive of adenomyosis but with inconclusive imaging). We also hypothesise that uterine contractility most likely is affected by hormonal therapeutic agents used to treat adenomyosis symptoms. We then could take this method further and perhaps be able to assess changes in uterine contractility over time, and provide a therapeutic assessment tool. These applications are however still speculative - the speckle-tracking method employed is not yet useable for daily practice as additional validation and implementation studies should be carried out. As shown in Chapter 5, the method has proven to be reliable in terms of inter and intra-observer variability. Strides do still need to be made regarding the ease of the speckle tracking analysis, with real-time analysis during the TVUS procedure not yet feasible. Future (external) studies with larger populations should validate the results of the TVUS speckle-tracking method in the currently investigated patient groups. The speckle tracking method could also be easily applied to other uterine abnormalities. As seen in Chapter 7, uterine leiomyoma’s, endometritis, and congenital uterine anomalies are also most likely associated with aberrant
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