3 05 reported in this thesis may constitute patients that have a long(er) history of complex combined disease, which may influence our results in general. Moreover, it is arguably not always necessary to conduct an MRI where adenomyosis is clearly able to be diagnosed on ultrasound. Which patient populations would ideally be suited to undergoing MRI diagnosis, and would most benefit from the clinical prediction model presented in this thesis, was not explored here. Chapters 5, 6 and 8, investigating uterine contractility in women with healthy and adenomyotic uteri, have relatively small study populations due to the use of a new analysis method of uterine contractility. This means that generalising the results garnered here, and the hypothesis as to their clinical relevance, to adenomyosis patients in general is still theoretical and needs to be validated. Similarly, the review in Chapter 5 also includes studies with small numbers and heterogenous study design, due to the topic of uterine contractility still being a developing field. In Chapters 9 and 10 looking into IVF/ICSI outcomes, it is a possibility that the control group may contain (some) women with undiagnosed adenomyosis or endometriosis. Almost none of the women in the control group underwent MRI due to there not being an indication; therefore, we cannot discard the possibility that some of these women may have had (mild) adenomyosis or endometriosis present. This could mean that the results could be an underestimation of the true difference in outcomes. It should also be noted that it is not standard procedure for women with suspected endometriosis or adenomyosis to undergo an MRI. This introduces the possibility that the women in the study groups might have had more severe symptoms and adds element of selection bias in our study group. Our results could then alternatively potentially overestimate the true effect of adenomyosis/endometriosis on IVF/ICSI outcomes. Another relevant aspect that should be considered is the inclusion of only patients undergoing their first, fresh embryo transfer. The fact that worse outcomes are seen at this stage of the treatment does not necessarily mean that these patients could not achieve pregnancy at all. In fact, some studies suggest that frozen embryo transfer in the natural cycle (303–305) may lead to more clinical pregnancies in endometriosis and/or adenomyosis patients, something which we did not investigate.
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