Abstract
OBJECTIVE: The incidence of endometrial cancer is rising, especially among younger women. Given the strong need to preserve fertility, robust evidence is required to evaluate the effectiveness of progestin-based fertility-preserving treatment regimens. We conducted a systematic review and meta-analysis to summarize the oncological and reproductive outcomes of patients with endometrial cancer (EC) and endometrial atypical hyperplasia patients (EAH) undergoing progestin-based therapies, and to compare outcomes across different fertility-preserving treatment regimens. METHODS: We searched PubMed and EMBASE to identify relevant studies published online up to 2 Apr 2025. This proportional meta-analysis was performed using a random-effects model to combine the data. A checklist based on the Newcastle-Ottawa Scale and the Methodological Index for Non-randomized Studies was used for quality assessment. The primary outcomes for this meta-analysis were complete response, pregnancy rate, and live birth rate following fertility-preserving treatment in patients with EC or AH. The secondary outcomes are was the recurrence rate (RR). Cochran’s Q test and I(2) were used to evaluate the degree of heterogeneity of eligible studies. Sensitivity analyses were performed with the leave-one-out strategy. Publication bias was assessed using funnel plots and Egger’s test. RESULTS: Of 1332 identified studies, 54 were included in the final analysis. Including 2148 patients with endometrial cancer and 1418 with endometrial atypical hyperplasia. For patients with EC, 78% achieved complete response (CR). Patients treated with LNG-IUD alone had the highest CR rate (85%). Among patients who achieved CR and contempt to conceive, 60% achieved clinical pregnancy and 57% achieved live delivery. While about 1/3 patients will undergoing relapse (33%). For patients with EAH, 87% achieved CR, 48% achieved pregnancy and 37% achieved live delivery, while approximately one-fifth experienced relapse (22%). Sensitivity analysis demonstrated robust results. CONCLUSION: Different progestin-based therapy regimens are effective for fertility preservation in patients with EC and EAH. The results of this meta-analysis may inform clinical management and support personalized treatment decisions. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12905-026-04352-y.