Cumulative Pregnancy Rates Among Patients With Bowel Endometriosis According to Therapeutic Approach. A Systematic Review and Meta-Analysis

Abstract

Objective: To establish the cumulative pregnancy rate for the different therapeutic options usually offered to patients with bowel endometriosis-associated infertility.

Data sources: A systematic search was conducted using the PubMed, Cochrane, LILACS, and Google Scholar databases to identify relevant studies published in English, French, or Spanish and limited to those published between 2009 and July 2025.

Methods of study selection: Observational and randomized studies that reported cumulative pregnancy rates in women with documented bowel endometriosis who wished to conceive (with or without proven infertility), after expectant management, first-line medically assisted reproduction, or primary bowel surgery (with or without further fertility treatments). For quality assessment, 2 reviewers independently assessed the risk of bias using the Newcastle-Ottawa scale for observational studies.

Tabulation, integration and results: A random-effects model meta-analysis was conducted to estimate the overall size effect for each outcome. Heterogeneity between studies was evaluated using I², Chi², and Tau² statistics. Publication bias was assessed using a funnel plot for meta-analyses and quantified using the Rosenthal method. 48 studies, including 5963 patients with bowel endometriosis, were included. Among patients without surgical intervention, the spontaneous cumulative pregnancy rate was 36% (95% CI: 15-57%) and 40% (95% CI: 25-55%) for those with first-line medically assisted reproduction. Among patients with a primary surgical approach, spontaneous cumulative pregnancy rate was 29% (95% CI: 25-34%) and 56% (95% CI: 49-63%) for those following strictly medically assisted reproduction; overall after surgery pooled cumulative pregnancy rate was 56% (95% CI: 51-62%). A sub-analysis among patients with previously confirmed infertility following surgery showed a spontaneous cumulative pregnancy rate of 24% (95% CI: 19-30%). High heterogeneity was observed among most studies, with an overall low risk of publication bias.

Conclusion: Available evidence advocates for a patient-centered approach. Surgical intervention followed by medically assisted reproduction is an effective strategy for many; therefore, the choice between surgery and medically assisted reproduction should not be binary but tailored to the specific patient goals and symptoms.

Keywords: Assisted reproduction; Colorectal endometriosis; Deep infiltrating endometriosis; Fertility outcomes; Laparoscopy.