302 In Chapters 9 and 10, results showed that it was women with both adenomyosis and endometriosis that had worse IVF/ICSI outcomes compared to women with only adenomyosis or endometriosis (also compared to male factor controls). As endometriosis and adenomyosis are often found together (50%-70% prevalence of combined disease in our study populations alone) it is difficult to separate the influence of adenomyosis from that of endometriosis. It is also still debated whether adenomyosis affecting the outer myometrium should be seen as external endometriosis invading the uterine wall, or as adenomyosis with a more atypical location. The challenge in answering this question is compounded by the fact that histologically both entities are similar (300). It is difficult, if not impossible, in the absence of hysterectomy, to absolutely exclude the presence of one disease in the presence of the other. Adenomyosis is in fact seen by many as an entity sharing physiological mechanisms with endometriosis (194,296,301), and should and could be seen as a subtype of endometriosis rather than a separate disease in and of itself. Having combined disease represents a patient population with a more widely affected reproductive system by the same disease process (ovarian function being affected by endometrioma’s and uterine function by adenomyosis), and this logically leads to worse reproductive outcomes overall. It is also possible that these patients may exhibit characteristics that lead them to be more susceptible to severe endometriosis/adenomyosis in the first place (i.e. immune or genetic factors) which may in turn also affect their fertility. The two diseases should therefore be seen as part of a continuum or spectrum of disease, where their impact is assessed together. We hence advocate that clinicians should be aware that when (sub-fertile) patients are diagnosed with one of the two diseases, conscious effort should be made to exclude or confirm that presence of either concomitant endometriosis or adenomyosis. Our results are in line with the theory that these patients constitute a group of with a high IVF/ICSI failure rate, and they should be appropriately counselled for this eventuality. Individualised (medical or surgery) treatment protocols could also be a possibility in this group. Research up to now has not yet convincingly shown which (pre-) ART treatment protocol is most effective in adenomyosis patients (302). Further prospective studies should be conducted, and specific guidelines for this group of patients do not yet exist.
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