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Yorain Sri Ranjan, Nida Ziauddeen, Beth Stuart, Nisreen Alwan, and Ying Cheong

Endometriosis is a chronic and debilitating condition which can affect the entire reproductive life course of women with a potentially detrimental effect on pregnancy. Pregnancy (and increasing parity) can affect endometriosis by modulating disease severity and suppressing symptoms. Multiparous women could be less likely to suffer from endometriosis related pregnancy complications than primiparous women. We aimed to systematically review the evidence examining the role of parity in the relationship between pregnancy outcomes and endometriosis. A systematic search of MEDLINE, EMBASE, CINAHL, Web of science and Cochrane library was performed from inception to May 2022. We searched for experimental and observational studies. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence with the risk of bias in non-randomised studies of interventions (ROBINS-I) tool incorporated. Eleven studies were included in the meta-analysis. Primiparous women with endometriosis had almost double the risk of hypertensive disorders of pregnancy (OR 1.99, 95%CI 1.50-2.63, P <0.001) compared to multiparous women with endometriosis. Primiparous women with endometriosis were at significantly increased risk of preterm delivery, caesarean delivery, and placenta praevia compared to primiparous women without endometriosis. There were no significant differences in outcomes when multiparous women with endometriosis were compared to multiparous women without endometriosis. There is limited evidence to suggest that primiparous women with endometriosis maybe at higher risk of adverse pregnancy outcomes compared to multiparous women. The modulatory role of parity in the pathophysiology of endometriosis and impact on pregnancy outcomes should be investigated.