Background <p>Heterotopic pregnancy is a rare but potentially life-threatening condition for which both laparoscopy and laparotomy are treatment options. This meta-analysis aimed to compare the efficacy and safety of laparoscopy and laparotomy in the treatment of heterotopic pregnancies.</p> Methods <p>PubMed, Web of Science, ScienceDirect, Wanfang, CNKI, and VIP databases were searched for articles published up to January 2025. Studies were included if they involved women with heterotopic pregnancies, used laparoscopy as the intervention and laparotomy as the comparator, and reported pregnancy-related outcomes. Effect estimates were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and pooled analyses were performed using a random-effects model.</p> Results <p>Twenty-two studies involving 1,133 patients with heterotopic pregnancies were included in the final meta-analysis. No significant differences were found between laparoscopy and laparotomy regarding live birth rate (OR: 0.93; 95% CI: 0.59–1.46; <i>P</i> = 0.743), abortion rate (OR: 1.28; 95% CI: 0.84–1.97; <i>P</i> = 0.254), preterm birth rate (OR: 1.00; 95% CI: 0.66–1.53; <i>P</i> = 0.988), full-term birth rate (OR: 0.91; 95% CI: 0.65–1.27; <i>P</i> = 0.575), cesarean section (OR: 0.82; 95% CI: 0.41–1.61; <i>P</i> = 0.560), and vaginal delivery (OR: 1.12; 95% CI: 0.49–2.55; <i>P</i> = 0.788). Subgroup analysis indicated that laparoscopy may be associated with an increased abortion rate when only high-quality studies were pooled (OR: 1.98; 95% CI: 0.81–4.84; <i>P</i> = 0.135).</p> Conclusion <p>This study found that intrauterine pregnancy outcomes in patients with heterotopic pregnancies in the studied population (all Chinese) were comparable between laparoscopy and laparotomy. However, the generalizability of these findings to other populations requires further investigation.</p> Study registration <p>INPLASY202530131</p>