304 STRENGTHS AND LIMITATIONS We are of the opinion that the research conducted as a part of this thesis has several strengths which make its results valuable and of interest for gynaecological practice. The majority of the studies conducted in the context of this thesis included patient data from a regional referral centre of expertise for endometriosis care, meaning access to a wide range of (complex) patient data and a larger than average eligible patient population. Additionally, regarding the diagnosis of adenomyosis, the developed prediction model was based on an exhaustive and expansive investigation of the available literature, using valid statistical methods. A preference was also given to objective measurements (excepting patient-reported symptoms) of adenomyosis on MRI, to make the diagnosis as reproducible and accurate as possible. The resultant prediction model then showed good performance in the patient population used, and shows promise for clinical applicability. The broad scope of this thesis regarding not only the diagnosis but also the potential reproductive clinical impact of adenomyosis, means that we give a clear indication of the wide-ranging effect adenomyosis may have on the women that suffer from it. We also offer a new method for the assessment of how adenomyosis could affect uterine function in terms of an ultrasound-based quantitative assessment of uterine contractile function. We thus present an innovative and promising new measurement tool which has the potential to become a relevant assessment method of normal and abnormal uterine function in the context of fertility, but also symptomatology and treatment success. - Limitations The studies presented in this thesis admittedly have several limitations that should be considered when interpreting their results. First and foremost, the majority of chapters include retrospective analysis of patient data. This research design is classically considered more prone to forms of bias such as selection bias. Furthermore, there is a higher level of missing data as we are dependent on what has been reported in the patient files. MRI is not (always) part of standard work up procedures in (Dutch) endometriosis care, meaning that the conclusions drawn here based on MRI data cannot necessarily be extrapolated to the general (suspected) endometriosis patient visiting any outpatient clinic. In this vein, many of the patients included in the studies
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