The Impact of Endometriosis on Female Fertility: A Systematic Review of Natural and Assisted Conception Outcomes (2010–2025)

This systematic review examines the relationship between endometriosis and female fertility, evaluating outcomes from both natural conception and assisted reproductive technologies (ART). A structured search of PubMed and Cochrane Library (2010–2025) identified 499 studies, of which 18 met the inclusion criteria. Reported infertility rates among women with endometriosis ranged from 24% to over 60%, with the greatest reproductive impairment observed in deep infiltrating endometriosis and ovarian endometriomas. These phenotypes were consistently linked to lower spontaneous pregnancy rates, reduced oocyte quality, impaired implantation, and decreased live birth rates. Selected patients benefited from surgical treatment and individualized ART protocols, while predictive tools such as the endometriosis fertility index supported prognostic assessment. Obstetric complications—including preeclampsia, placenta previa, and cesarean section—were also more frequent in this population. The 2022 European Society of Human Reproduction and Embryology Endometriosis Guideline emphasizes early and accurate diagnosis with advanced imaging and, when necessary, targeted laparoscopy; customizing treatment based on the lesion type; protecting ovarian reserve; and integrating timely ART referral or fertility preservation strategies. Avoiding unnecessary surgery is a key recommendation. Neglecting these measures can contribute to irreversible fertility loss, increased recurrence risk, higher rates of obstetric complications, delayed intervention, and significant psychological distress. Given the multifactorial nature of endometriosis-related infertility, this review highlights the complex interplay between lesion type, reproductive function, and treatment outcomes. A personalized, guideline-based, multidisciplinary approach is essential to optimize reproductive potential and improve quality of life for affected women.