IVF in endometriosis: emerging evidence of exacerbation of pelvic pain and potential predictors

Hum Reprod Open. 2026 Mar 27;2026(2):hoag027. doi: 10.1093/hropen/hoag027. eCollection 2026.

ABSTRACT

STUDY QUESTION: Does IVF worsen pelvic pain in women with endometriosis?

SUMMARY ANSWER: Nearly half of women with endometriosis reported perceived worsening of pelvic pain after IVF.

WHAT IS KNOWN ALREADY: Prior studies generally suggested no IVF-related pain worsening, but few assessed delayed flares or longer-term trajectories.

STUDY DESIGN SIZE DURATION: International cross-sectional study based on an online survey conducted between September 2024 and April 2025 including 546 respondents.

PARTICIPANTS/MATERIALS SETTING METHODS: Women aged ≥18 years with surgically or imaging-confirmed endometriosis and at least one completed IVF cycle. A 25-item questionnaire captured demographics, reproductive history, comorbidities, and patient-reported pain trajectories before, during, and after IVF. The primary outcome was perceived worsening of pelvic pain after IVF (patient-reported outcome measure; PROM). Secondary outcomes were worsening of dysmenorrhoea and dyspareunia. Group comparisons and exploratory multivariable logistic regressions were performed. Predictor analyses were exploratory.

MAIN RESULTS AND THE ROLE OF CHANCE: Among 546 respondents, 48.9% reported worsening pelvic pain after IVF, 49.1% reported worsening dysmenorrhoea, and 35.5% worsening dyspareunia. Current pain scores were significantly higher in women reporting worsening versus no worsening (all P < 0.001). In multivariable analyses, immediate post-cycle pain flare emerged as the strongest and most consistent predictor across all pain outcomes, independently associated with worsening of pelvic pain (adjusted odds ratio [aOR] 5.91, 95% CI 3.88-9.14), dysmenorrhoea (aOR 4.03, 95% CI 2.08-8.05), and dyspareunia (aOR 3.17, 95% CI 2.07-4.90) (all P < 0.001). For the primary outcome, reporting oocyte retrieval as the most painful IVF step (aOR 0.53, 95% CI 0.31-0.88; P = 0.016) and achieving a live birth after IVF (aOR 0.63, 95% CI 0.42-0.92; P = 0.020) were independently associated with lower odds of pelvic pain worsening. In secondary outcome models, live birth was associated with lower odds of dysmenorrhoea worsening, while bladder pain syndrome/interstitial cystitis independently predicted worsening of dyspareunia. A formal response rate could not be calculated due to open online dissemination without a known denominator.

LIMITATIONS REASONS FOR CAUTION: Self-reported, retrospective data are prone to recall and selection bias, and the cross-sectional design precludes causal inference. Recruitment via associations and social media without a denominator limits generalizability, absence of baseline pain scores impedes assessment of change, and incomplete capture of peri-IVF hormonal regimens may confound results.

WIDER IMPLICATIONS OF THE FINDINGS: IVF may not be pain-neutral in endometriosis. Monitoring pain trajectories at key IVF milestones may help identify women at risk of long-term exacerbation. Prospective studies should test whether early monitoring combined with tailored interventions-optimized analgesia, psychological support, or adapted stimulation protocols-can mitigate chronic pain trajectories throughout the IVF journey and ultimately improve quality of life.

STUDY FUNDING/COMPETING INTERESTS: No specific funding; authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER: N/A.

PMID:42004728 | PMC:PMC13091650 | DOI:10.1093/hropen/hoag027