Endometriosis and fertility: what you should know
Endometriosis is a common, chronic condition affecting about one in ten women of reproductive age. Many women discover it precisely when they are trying to conceive.
Its relationship with fertility is real but not absolute: many women with endometriosis conceive naturally. The key is a correct, individualized approach.
What is endometriosis and how does it affect fertility?
In endometriosis, tissue similar to the endometrium grows outside the uterus — on the ovaries, the peritoneum or elsewhere. It causes inflammation, adhesions and, in the ovaries, cysts (endometriomas).
Fertility can be affected in several ways: mechanical distortion of the anatomy of the tubes and ovaries, an inflammatory environment that harms eggs and sperm, and reduced ovarian reserve when endometriomas are present.
Do I always need surgery to get pregnant?
No. Many women with mild endometriosis conceive without any operation. Surgery is not a self-evident step, and the decision depends on disease stage, symptoms, age and ovarian reserve.
An important point: surgical removal of an endometrioma can reduce ovarian reserve. So ovarian surgery must be weighed carefully, especially if IVF is planned.
When does surgery help?
Surgery also has a role in treating pain and symptoms; the goal (fertility or symptom relief) determines the strategy.
When do we move to IVF?
IVF is recommended when there is advanced disease, when another factor coexists (e.g. male or tubal), when ovarian reserve is reduced, or when other approaches have failed and age does not allow delay.
For some women, IVF is the most direct and effective route — especially when the fertility clock is pressing.
Does endometriosis affect IVF success?
The reassuring answer is that, in modern practice, IVF live-birth rates in women with endometriosis are largely comparable to those of other patients of the same age.
The main limiting factor is not so much the disease itself as ovarian reserve — which is why protecting the ovaries from unnecessary surgery matters.
Should I consider fertility preservation?
Fertility preservation (egg freezing) is a valid option for women with severe ovarian endometriosis, especially when surgery that may reduce ovarian reserve is planned, or when the disease is bilateral.
ESHRE (2022) recognizes fertility preservation as an option that should be discussed, weighing the pros and cons with each patient.
Does hormonal suppression before trying help?
Not for fertility. ESHRE does not recommend hormonal suppression to improve pregnancy rates, either before or after surgery. These drugs treat pain, not infertility.
One exception concerns specific extended-suppression protocols before IVF in selected cases, decided on an individual basis.
Summary
Endometriosis affects fertility, but it does not mean an inability to have children. Many women conceive naturally. Surgery is not automatic — especially on the ovaries, where it can reduce ovarian reserve. IVF has a clear role in advanced disease or when time is pressing, with rates comparable to other patients. Fertility preservation is worth discussing in severe ovarian disease. Hormonal suppression does not improve fertility. Every decision is individualized (ESHRE 2022).
Sources: ESHRE, “Guideline: endometriosis”, Hum Reprod Open 2022; ESHRE recommendations on endometriosis-associated infertility.
⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340
ARTICLE 7 · RECURRENT LOSS & FAILURE
