Controversies on endometriosis and its impact on ovarian reserve, oocyte quality, and ART outcomes: a critical narrative review
Simona Anzhel, Emil KovachevBackground:
Endometriosis is a chronic gynecological disorder associated with infertility, diminished ovarian reserve, and variable outcomes after assisted reproductive technology (ART). However, its effects on oocyte competence, embryo quality, implantation, and live birth remain controversial.
Objective:
To critically synthesize current evidence regarding the impact of endometriosis on ovarian reserve, oocyte and embryo competence, and ART outcomes, with emphasis on ovarian endometrioma (OMA), disease stage, adenomyosis, surgery, and pretreatment strategies before IVF/ICSI.
Methods:
We conducted a targeted narrative literature review using PubMed, Embase, and Scopus for studies published between 2014 and 2025. We prioritized systematic reviews, meta-analyses, randomized trials, large cohort studies, guidelines, and clinically relevant recent publications on endometriosis-associated infertility and ART outcomes. This article is a critical narrative review rather than a systematic review; therefore, we did not report PRISMA flow or conduct a formal risk-of-bias assessment.
Results:
Endometriosis is consistently associated with reduced ovarian reserve and lower oocyte yield, particularly in women with OMA or previous ovarian surgery. Evidence on oocyte and embryo competence remains heterogeneous, although recent studies suggest that embryo euploidy and per-transfer live birth are often preserved when good-quality embryos are available. In contrast, cumulative live birth rate may decline because repeated ART cycles yield fewer oocytes and embryos. Adenomyosis appears to impair implantation and cumulative outcomes independently.
Conclusions:
Endometriosis predominantly affects oocyte quantity rather than uniformly impairing embryo competence. Routine surgery or prolonged medical pretreatment before IVF is not supported for all patients and should be individualized.