Association between endometriosis and adverse reproductive and perinatal outcomes in women undergoing assisted reproductive technology: a systematic review and meta-analysis

Background With the increasing use of assisted reproductive technology (ART), more women with endometriosis are achieving pregnancy through ART. However, the impact of endometriosis on pregnancy and perinatal outcomes following ART remains controversial. This study aimed to clarify the association between endometriosis and adverse pregnancy and perinatal outcomes through a meta-analysis. Methods A systematic search of PubMed, Embase, Web of Science, and Cochrane Library was conducted to identify relevant studies published before March 12, 2025. Cohort studies comparing adverse pregnancy and perinatal outcomes between women with and without endometriosis undergoing ART were included. Meta-analysis was performed using STATA 12.0 and R 4.3.2 software to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for the association between endometriosis and adverse outcomes. Heterogeneity among studies was quantified using Cochran’s Q test, I 2 statistics, and 95% prediction intervals (PIs). Subgroup analyses, sensitivity analyses, and publication bias assessments were also conducted. Results A total of 29 cohort studies, including 93,071 women with endometriosis and 1,350,005 controls, were included in the meta-analysis. Compared with women without endometriosis, those with endometriosis undergoing ART had significantly lower clinical pregnancy rate (RR 0.850, 95% CI 0.726–0.994, 95% PI 0.570–1.267) and live birth rate (RR 0.716, 95% CI 0.556–0.923, 95% PI 0.341–1.504). They were also at higher risk for preterm birth (RR 1.277, 95% CI 1.187–1.373, 95% PI 1.024–1.591), placenta previa (RR 2.246, 95% CI 1.759–2.869, 95% PI 1.028–4.910), postpartum hemorrhage (RR 1.310, 95% CI 1.198–1.432, 95% PI 1.154–1.486), cesarean section (RR 1.296, 95% CI 1.165–1.441, 95% PI 0.944–1.779), low birth weight (RR 1.159, 95% CI 1.050–1.279, 95% PI 1.025–1.310), stillbirth (RR 1.219, 95% CI 1.032–1.440, 95% PI 0.930–1.597), and hypertensive disorders of pregnancy (RR 1.161, 95% CI 1.096–1.231, 95% PI 1.057–1.276). However, no significant differences were observed between the two groups in the risk of small for gestational age, miscarriage, preeclampsia, large for gestational age, or ectopic pregnancy (all p > 0.05). Subgroup analyses revealed variations in outcomes based on ethnicity, endometriosis stage, and mode of ART, but the overall results were robust. Conclusion Endometriosis significantly impacts pregnancy and perinatal outcomes following ART, increasing the risk of multiple adverse outcomes. These findings provide critical evidence for individualized reproductive treatment and perinatal care in women with endometriosis.