Endometriosis is common during the reproductive years. It may be discovered because of painful periods, chronic pelvic pain or infertility, while some women have few or no obvious symptoms.
A diagnosis of endometriosis does not automatically mean natural pregnancy is impossible, and it does not mean every patient should proceed directly to IVF.
At the same time, fertility treatment should not be delayed unnecessarily when time-sensitive factors are present, such as advancing reproductive age, reduced ovarian reserve, tubal disease, significant male-factor infertility or previous unsuccessful treatment.
The most useful question is therefore not simply:
Does endometriosis cause infertility?
It is:
How much is endometriosis affecting this particular patient's fertility, and which strategy provides a reasonable chance of pregnancy without wasting reproductive time or exposing the ovaries to unnecessary intervention?
ESHRE's current endometriosis guideline emphasises that fertility decisions should consider pain, age, patient preference, previous surgery, other infertility factors and ovarian reserve rather than relying on disease stage alone.
What is endometriosis?
Endometriosis is a condition in which tissue resembling the endometrium is found outside the uterine cavity.
Disease may involve:
The ovaries.
Pelvic peritoneum.
Ligaments behind the uterus.
Rectovaginal areas.
The bowel or bladder in some forms of deep endometriosis.
When it affects the ovary, an ovarian endometrioma may form.
Endometriosis varies considerably between patients. One woman may have limited superficial disease, while another may have deep disease with substantial adhesions and altered pelvic anatomy.
How can endometriosis affect fertility?
There is no single mechanism.
Distortion of pelvic anatomy
Advanced disease and adhesions can alter the relationship between the ovaries and fallopian tubes, making natural fertilization more difficult.
Tubal function
Inflammation and adhesions can interfere with fallopian-tube function.
Ovarian involvement
Endometriomas, particularly bilateral disease and previous ovarian surgery, may be associated with lower ovarian reserve.
Inflammatory environment
Endometriosis is associated with biological and inflammatory changes that may influence oocyte, sperm, fertilization and implantation processes.
However, a plausible biological mechanism does not automatically mean that a diagnostic test or treatment exists that improves live birth.
Other fertility factors
Endometriosis may be only one part of the couple's fertility problem.
Other factors may include:
Male-factor infertility.
Diminished ovarian reserve.
Ovulatory disorders.
Tubal disease.
Reproductive age.
Fertility evaluation should therefore assess the couple rather than attributing every difficulty to endometriosis.
Can women with endometriosis conceive naturally?
Yes.
Many women with endometriosis conceive without IVF, particularly when:
They are younger.
Ovarian reserve is adequate.
The fallopian tubes are functional.
Semen parameters are suitable.
Disease is limited.
Infertility duration is relatively short.
A diagnosis alone cannot predict an individual's chance of natural conception.
When should fertility evaluation begin?
General infertility evaluation often begins after 12 months of trying in women younger than 35 and after 6 months at age 35 or older.
Evaluation can begin earlier when there is a known condition that may impair fertility, including suspected or diagnosed endometriosis.
ASRM recognises endometriosis and pelvic pathology as potential contributors that should be considered in fertility evaluation when the history, examination or imaging raises suspicion.
What should fertility evaluation include?
Assessment should extend beyond endometriosis itself.
Relevant information may include:
Female age.
Duration of infertility.
Ovulatory and menstrual history.
AMH when appropriate.
Antral follicle count.
Pelvic ultrasound.
Tubal evaluation when indicated.
Semen analysis.
Previous pelvic or ovarian surgery.
Presence and characteristics of an endometrioma.
Symptoms suggesting deep disease.
See AMH and Ovarian Reserve for the role and limitations of AMH.
Is laparoscopy required to diagnose every case?
No.
Diagnostic laparoscopy used to play a much larger role.
It is no longer appropriate to perform laparoscopy routinely in every infertile patient simply to look for minimal endometriosis.
ASRM states that laparoscopy is not recommended as part of routine infertility evaluation without suspected pelvic pathology or another specific surgical indication.
Modern assessment increasingly uses:
Clinical history.
Symptoms.
Expert ultrasound.
MRI in selected cases.
Surgery is considered when it may meaningfully change management or treat an important clinical problem.
Does severe pain mean severe infertility?
Not necessarily.
Symptoms and disease extent do not correlate perfectly.
Some women with significant pain may have relatively limited disease, while others with advanced disease may have few symptoms.
Pain alone therefore cannot determine fertility prognosis or the need for IVF.
When can natural conception still be reasonable?
A time-limited period of natural trying can be reasonable when:
The woman is younger.
Ovarian reserve is reassuring.
Tubal function appears suitable.
Semen analysis is satisfactory.
Disease is limited.
Infertility duration is not prolonged.
The important point is to define when the plan will be reviewed rather than waiting indefinitely.
Is ovarian stimulation with IUI an option?
For selected women with stage I/II endometriosis, ovarian stimulation with IUI may be considered when the tubes are functional and there is no severe male factor.
ESHRE indicates that stimulated IUI can increase pregnancy rates compared with expectant management or unstimulated IUI in selected stage I/II disease.
Age, ovarian reserve and infertility duration should influence how many cycles are reasonable before moving to IVF.
When does IVF become a reasonable option?
IVF may become increasingly appropriate when one or more of the following are present:
Advancing reproductive age.
Reduced ovarian reserve.
Significant tubal damage.
Severe pelvic adhesions.
Important male-factor infertility.
Previous unsuccessful fertility treatment.
Moderate or severe endometriosis.
Failure to conceive after appropriate surgery.
A need to avoid losing additional reproductive time.
IVF does not cure endometriosis.
Instead, it bypasses some of the barriers caused by pelvic disease by retrieving oocytes directly, fertilizing them in the laboratory and transferring embryos into the uterus.
Does endometriosis reduce IVF success?
Studies have reported differences in ovarian response or IVF outcomes in some women with endometriosis compared with other infertility groups, but results are influenced by age, ovarian reserve, disease severity and previous surgery.
Endometriosis does not make IVF ineffective.
ASRM has long recognised IVF as an effective treatment option, particularly when pelvic anatomy is significantly distorted or moderate/severe disease is present.
What is an ovarian endometrioma?
An endometrioma is an ovarian cyst associated with endometriosis.
It can be:
Unilateral or bilateral.
Small or large.
Symptomatic or asymptomatic.
Its presence matters because treatment decisions must balance control of ovarian disease against protection of ovarian reserve.
Should an endometrioma be removed before IVF?
Not routinely.
This is one of the most important evidence-based points in fertility management.
ESHRE recommends against routinely performing surgery for an ovarian endometrioma before ART solely to improve live-birth rates because available evidence shows no benefit and surgery is likely to negatively affect ovarian reserve.
This is particularly important when:
Endometriomas are bilateral.
Ovarian reserve is already low.
Previous ovarian surgery has been performed.
Reproductive age is advancing.
Preserving remaining ovarian tissue is especially important.
When can surgery before IVF still make sense?
Avoiding routine surgery does not mean surgery is never appropriate.
It may be considered when there is another meaningful indication, such as:
Significant pain.
Atypical imaging or diagnostic concern.
Difficulty accessing follicles for oocyte retrieval.
Another surgical problem requiring treatment.
Symptomatic deep endometriosis.
ESHRE specifically allows endometrioma surgery before ART to be considered for pain or to improve follicle accessibility rather than as a routine method of increasing live birth.
Why can ovarian surgery reduce reserve?
Removing an endometrioma can inadvertently remove or injure healthy ovarian tissue.
Potential mechanisms include:
Stripping ovarian cortex with the cyst wall.
Haemostasis.
Thermal injury.
Repeated surgery.
AMH may decrease after surgery, with particular concern after bilateral or repeated ovarian procedures.
ESHRE notes that severe endometriosis, especially bilateral endometriomas, is already associated with a greater risk of reduced reserve, while surgery can add further ovarian damage.
Is egg retrieval dangerous when an endometrioma is present?
Not automatically.
Many women undergo oocyte retrieval with an endometrioma in place.
The fertility specialist evaluates:
Cyst location.
Cyst size.
Surrounding follicles.
Access to the ovary.
Likelihood of puncturing the cyst.
Symptoms.
Imaging characteristics.
The best sequence—retrieval first or treatment first—therefore depends on the individual anatomy and fertility priorities.
What about repeat ovarian surgery?
Repeat surgery deserves particular caution.
A second or third ovarian procedure can cause additional loss of functional ovarian tissue.
In women with advanced endometriosis who have already undergone fertility surgery, IVF may often be more appropriate than repeating surgery solely to improve fertility.
ASRM has similarly recognised that IVF can be preferable to repeat surgery in selected women with stage III/IV disease after previous operations.
Should women with endometriosis freeze their eggs?
Not every patient needs fertility preservation.
It can nevertheless be discussed when there is:
Severe disease.
Bilateral endometriomas.
Planned ovarian surgery.
Previous ovarian procedures.
A need to delay pregnancy.
ESHRE notes that severe disease, particularly bilateral endometriomas, is associated with increased risk of lower AMH and premature loss of ovarian function, although evidence does not support recommending egg freezing automatically to every patient.
See Modern Egg-Freezing Techniques.
Do hormonal treatments improve natural fertility?
Hormonal treatments such as:
Combined hormonal contraceptives.
Progestins.
GnRH agonists.
can be effective for controlling endometriosis-associated pain.
However, they suppress ovulation or reproductive function while being used.
They therefore should not be confused with treatment that increases spontaneous conception during therapy.
Treating pain and treating infertility are different objectives.
Does suppression before IVF improve success?
Long-term GnRH agonist suppression before IVF was historically used after older studies suggested a possible benefit.
Current ESHRE guidance does not recommend prolonged GnRH agonist administration routinely before ART solely to improve live birth because the benefit remains uncertain.
There is also insufficient evidence to recommend prolonged oral contraceptive or progestogen pretreatment specifically to increase live birth.
Therefore:
“You have endometriosis, so you must undergo several months of suppression before every IVF cycle”
is not an evidence-based universal rule.
What if embryo transfers repeatedly fail?
Repeated failed transfers require broader reassessment rather than automatically blaming endometriosis.
ASRM's 2026 recurrent implantation failure opinion notes that endometriosis and adenomyosis are relatively common among patients with RIF, but high-quality evidence guiding diagnosis and treatment remains limited.
Pretreatment with a GnRH agonist, with or without an aromatase inhibitor, may be considered in selected patients with known or suspected endometriosis or adenomyosis and RIF, but this is not routine treatment for every transfer cycle.
See Recurrent Implantation Failure After IVF.
Are endometriosis and adenomyosis the same condition?
No.
Endometriosis
Endometrium-like tissue is located outside the uterus.
Adenomyosis
Endometrium-like tissue is present within the muscular wall of the uterus, the myometrium.
The conditions may coexist but are anatomically and clinically distinct.
Adenomyosis may be associated with heavy menstrual bleeding, dysmenorrhoea, uterine enlargement and reproductive problems.
Does endometriosis cause implantation failure?
It may be associated with reduced implantation probability in some patients, but a failed embryo transfer should not automatically be attributed to endometriosis.
Other factors should be reviewed, including:
Oocyte age.
Embryo development.
Embryo ploidy when known.
Transfer technique.
Uterine cavity.
Endometrial preparation.
Possible adenomyosis.
Other medical factors.
This prevents patients from being pushed directly toward poorly supported add-on treatments.
Is PGT-A necessary because of endometriosis?
No.
Endometriosis by itself is not an automatic indication for PGT-A.
PGT decisions depend on factors such as:
Age.
Embryo number.
Reproductive history.
Genetic indications.
The clinical objectives of testing.
PGT-A should not be presented as treatment for endometriosis itself.
See PGT Embryo Testing.
Does endometriosis increase miscarriage risk?
Observational research has associated endometriosis with some adverse reproductive and obstetric outcomes, but individual risk varies considerably.
A diagnosis does not mean miscarriage is inevitable.
When pregnancy loss becomes recurrent, it should be evaluated as recurrent pregnancy loss rather than automatically attributed to endometriosis.
See Recurrent Miscarriage: Advanced Testing and IVF Options.
Choosing between trying naturally, surgery, IUI and IVF
No single formula applies to everyone.
Natural trying may remain reasonable when:
Age is favourable.
Infertility duration is short.
Ovarian reserve is adequate.
Tubes are functional.
Semen parameters are suitable.
Disease is limited.
IUI may be discussed when:
Disease is minimal or mild.
Tubes are open.
There is no severe male factor.
Age and reproductive time permit a limited number of attempts.
Surgery may become more relevant when:
Pain is significant.
Important anatomy needs correction.
Imaging is atypical.
Follicles may be inaccessible.
There is another surgical indication independent of fertility.
IVF may become the more efficient strategy when:
Reproductive age is advancing.
Ovarian reserve is reduced.
Tubal function is compromised.
Male factor is present.
Disease is advanced.
Previous treatment has failed.
Previous surgery did not restore fertility.
Losing additional time could reduce prognosis.
What information matters before deciding?
Before choosing surgery or IVF, it is useful to understand:
Female age.
AMH and AFC.
Size and location of any endometrioma.
Whether disease is unilateral or bilateral.
Number of previous ovarian surgeries.
Tubal status.
Pain burden.
Presence of deep disease.
Possible adenomyosis.
Semen analysis.
Duration of infertility.
Previous IVF results.
These factors are more informative than cyst size alone.
Does a large endometrioma automatically need surgery first?
Size matters, but it should not be the only determinant.
Older guidance sometimes used thresholds such as 4 cm more explicitly when considering surgery before IVF.
Modern ESHRE recommendations instead place greater emphasis on symptoms, ovarian reserve, previous surgery, follicle accessibility, diagnostic concern and patient preference and specifically recommend against routine surgery solely to improve ART live birth.
The most common mistake in fertility treatment with endometriosis
A major mistake is treating every patient with the same algorithm:
Endometrioma = surgery.
or:
Endometriosis = immediate IVF.
or:
Endometriosis = several months of suppression before every transfer.
None of these statements is universally correct.
Management often requires balancing two objectives that can occasionally conflict:
controlling disease and pain, while protecting ovarian reserve, fertility and reproductive time.
Conclusion
Endometriosis can affect fertility through adhesions, tubal dysfunction, ovarian disease, endometriomas and other biological mechanisms, but it does not make natural pregnancy impossible and does not mean every patient needs IVF.
The appropriate strategy depends on age, infertility duration, ovarian reserve, tubal status, semen results, disease severity, symptoms, endometriomas, previous surgery and previous fertility treatment.
One of the most important current ESHRE recommendations is that ovarian endometrioma surgery should not be performed routinely before IVF solely to improve live-birth rates, because benefit has not been demonstrated and surgery can reduce ovarian reserve. Surgery remains appropriate for selected reasons such as pain, follicle accessibility or diagnostic concern.
If you have endometriosis or an ovarian endometrioma and are considering pregnancy or IVF, Safemedigo can coordinate review of your ultrasound, ovarian reserve, previous surgery and fertility results with the fertility team to determine whether natural trying, staged treatment, surgery or IVF is the most appropriate next step. Contact Safemedigo on WhatsApp.
Frequently Asked Questions
Does endometriosis make pregnancy impossible?
No. Many women with endometriosis conceive naturally. The chance depends on age, ovarian reserve, tubal function, semen factors and disease extent.
Should an endometrioma be removed before IVF?
Not routinely. ESHRE advises against surgery solely to improve ART live birth because benefit has not been demonstrated and ovarian reserve may be harmed. Surgery can still be considered for pain, access to follicles or diagnostic reasons.
When is IVF preferable to waiting?
IVF becomes more reasonable with advancing age, reduced ovarian reserve, tubal damage, male-factor infertility, advanced disease, failed previous treatment or when reproductive time is becoming important.
Is several months of suppression required before IVF?
Not for every patient. ESHRE does not recommend prolonged GnRH-agonist pretreatment routinely before ART solely to improve live birth because benefit remains uncertain.
Are adenomyosis and endometriosis the same?
No. Endometriosis occurs outside the uterus, while adenomyosis involves endometrium-like tissue within the uterine muscle. They may coexist but require distinct clinical assessment.
