Endometriosis and Fertility

How endometriosis can affect fertility

• Anatomy: adhesions, distorted tubes, and endometriomas can affect ovulation, egg pickup, and pelvic function
• Ovarian reserve: endometriomas — and prior ovarian surgery — can reduce the number of remaining eggs
• Inflammation: the pelvic environment in endometriosis may affect fertilization and implantation
• Adenomyosis: commonly coexists with endometriosis and may affect implantation and pregnancy outcomes
• Deep disease: bowel, bladder, or ureteral involvement may affect pelvic anatomy and surgical planning before pregnancy

Effects vary widely between patients. Many people with endometriosis conceive without difficulty; others require specialist support.

Fertility evaluation

A fertility workup for someone with known or suspected endometriosis typically includes:

• Ovarian reserve testing (AMH, antral follicle count)
• Tubal assessment when indicated
• Semen analysis when applicable
• Review of endometriomas and their size, location, and history
• Assessment of deep infiltrating disease and adenomyosis
• Review of prior surgery, hormonal therapy, and imaging

This evaluation guides whether surgery, IVF, or a combined pathway is the best next step.

Timing surgery and IVF

Infertility is commonly defined as difficulty achieving pregnancy after 6 to 12 months of regular unprotected intercourse, depending on age and clinical context. Endometriosis is found in a significant proportion of patients presenting with infertility.

When surgery may be prioritized

• Significant pain limiting quality of life
• Symptomatic endometriomas
• Deep infiltrating disease affecting anatomy or organ function
• Bowel, bladder, or ureteral disease
• Prior failed IVF cycles with untreated endometriosis
• Patient preference after informed discussion

When IVF may be prioritized first

• Older reproductive age
• Diminished ovarian reserve
• Male-factor infertility component
• Prior effective excision without recurrence
• Time-sensitive family building goals

Endometriomas and ovarian reserve

Excision of endometriomas removes cyst tissue and can reduce recurrence and pain, but ovarian reserve may decrease — especially with repeat surgery or when both ovaries are involved. Surgeon technique matters. Ovarian reserve testing before and after helps individualize planning, and fertility preservation (egg or embryo freezing) may be considered before extensive ovarian surgery.

Fertility preservation

Fertility preservation is a discussion for many patients with endometriosis, especially those with:

• Bilateral or recurrent endometriomas
• Declining ovarian reserve
• Planned extensive ovarian surgery
• Delay of pregnancy for personal reasons

Coordinated care between surgery and reproductive specialists

The best outcomes generally come from coordinated planning between an experienced endometriosis surgeon and a reproductive endocrinologist. Together they weigh disease pattern, ovarian reserve, age, pain, anatomy, prior treatments, and goals — then agree on sequence and timing.

Learn more about the surgical side on Excision Surgery and the multidisciplinary model on Multidisciplinary Team. For persistent symptoms after prior treatment, see Failed Prior Treatment.

Pregnancy after endometriosis surgery

Many patients conceive after excision surgery, either naturally or with IVF assistance. Some studies suggest a modestly increased risk of miscarriage and obstetric complications in patients with endometriosis, but many pregnancies are uncomplicated. Individualized obstetric care is appropriate, especially after bowel or urinary tract surgery.