Pregnancy outcomes in women with endometriosis-associated pelvic pain: an observational cohort study of natural and assisted conceptions

Pelvic pain is a cardinal symptom of endometriosis, but whether it independently predicts reproductive outcomes, and whether this association differs between spontaneous conception and assisted reproductive technology (ART), remains unclear. This study aimed to evaluate the association of moderate-to-severe pelvic pain with live birth and obstetric complications in women with endometriosis, and to examine whether these associations differed by conception pathway. In this observational cohort study, we analyzed data from 1,063 women with endometriosis who intended to conceive, stratified by conception pathway (ART vs. spontaneous). Moderate-to-severe pain was defined as a visual analog scale (VAS) score ≥ 4 in at least one pain domain. Pathway-specific multivariable logistic regression models were used to assess the independent association between pain severity and reproductive outcomes, with live birth as the primary outcome. Obstetric complications were analyzed as secondary exploratory outcomes using unadjusted comparisons. Moderate-to-severe pain was not independently associated with live birth in either pathway after adjustment for clinically relevant confounders. In the ART pathway, exploratory analyses showed a higher observed incidence of placenta accreta spectrum disorders among women with moderate-to-severe pain than among those with no/mild pain (9.0% vs. 3.2%). However, this finding was based on a small number of events and unadjusted comparisons. No comparable pattern was observed in the spontaneous conception pathway. In women with endometriosis, moderate-to-severe pelvic pain was not independently associated with live birth in either the ART or spontaneous conception pathway. Exploratory findings suggested a possible association between more severe pain and a higher incidence of placenta accreta spectrum disorders in the ART pathway, but this observation should be interpreted cautiously and regarded as hypothesis-generating.