What Is Endometriosis?
Endometriosis is a chronic inflammatory condition in which tissue similar to the uterine lining grows outside the uterus, commonly involving the ovaries, pelvic peritoneum, uterosacral ligaments, and sometimes the bowel or bladder. It affects approximately 5–10% of women of reproductive age and is diagnosed in up to 30–50% of women presenting with infertility. The condition is estrogen-dependent and may progress over time, although the severity of symptoms does not always correlate with the extent of disease.
How Endometriosis Affects Fertility
The impact of endometriosis on fertility is multifactorial. Chronic pelvic inflammation can alter the immune environment, affecting fertilization and implantation. Adhesions may distort pelvic anatomy, interfering with ovulation, egg pickup, or tubal function. Ovarian endometriomas and previous ovarian surgery can reduce ovarian reserve, while changes within the follicular environment may impair egg quality.
In addition, endometriosis has been associated with altered endometrial receptivity, progesterone resistance, and changes in gene expression involved in implantation. These factors can reduce the chances of natural conception and may also influence outcomes with assisted reproductive techniques.
Common Symptoms to Look Out For
Endometriosis presents along a wide clinical spectrum. Some women remain completely asymptomatic and are diagnosed incidentally during infertility evaluation. Others experience symptoms such as severe dysmenorrhea, chronic pelvic pain, dyspareunia, bowel or bladder discomfort, or infertility.
Ovarian endometriomas may remain stable for years or, in some cases, increase rapidly in size. Importantly, symptom severity does not always reflect disease burden—women with advanced disease may have minimal pain, while others with limited disease experience significant symptoms.
How Endometriosis Is Diagnosed
Diagnosis is based on a combination of clinical history, pelvic examination, and imaging. Transvaginal ultrasound is useful for detecting ovarian endometriomas and deep infiltrating disease in experienced hands. MRI may be helpful in mapping extensive disease or evaluating bowel and ureteric involvement.
Laparoscopy remains the definitive diagnostic tool but is no longer routinely required for diagnosis alone. The decision to proceed with surgery should be guided by symptoms, fertility goals, and response to prior treatments rather than diagnostic certainty alone.
Treatment Options to Improve Fertility
Management must be individualized, and the first step is to clarify the primary goal: pain relief, fertility, or both. Medical therapy, including hormonal suppression, is effective for pain control but does not improve fertility while treatment is ongoing and therefore has a limited role in women actively trying to conceive.
In younger women with minimal or mild endometriosis, good ovarian reserve, patent tubes, and no male factor infertility, a short trial of ovulation induction with or without intrauterine insemination (IUI) may be considered. However, prolonged use of IUI should be avoided if pregnancy does not occur within a reasonable timeframe.
Surgery for Endometriosis and Its Impact on Fertility
Surgery has a selective role in fertility management. In women with severe pain, rapidly enlarging endometriomas, suspicion of malignancy, or complications such as bowel or ureteric involvement, surgery is often necessary. In these cases, the aim should be a single, well-planned, fertility-preserving debulking surgery performed by an experienced surgeon.
However, when infertility is the primary concern and pain is minimal, repeated surgical procedures—especially ovarian surgery—are not recommended. Multiple surgeries can significantly compromise ovarian reserve without consistently improving fertility outcomes. Therefore, surgery should not be routinely undertaken solely to enhance fertility.
When to Consider IVF With Endometriosis
In vitro fertilization (IVF) is a cornerstone of treatment for women with moderate to severe endometriosis, long-standing infertility, reduced ovarian reserve, or associated male factor infertility. IVF bypasses many of the peritoneal and tubal factors that impair natural conception.
Women with endometriosis may have implantation and live birth rates approximately 5–10% lower than women without the condition, largely due to effects on egg quality and endometrial receptivity. Despite this, good pregnancy rates can be achieved with individualized stimulation and transfer strategies.
Long GnRH agonist protocols or segmented IVF cycles, where embryos are frozen and transferred later in a hormonally down-regulated cycle, are commonly preferred to reduce inflammatory effects and optimize implantation.
Managing Pain While Trying to Conceive
Pain management must be balanced carefully in women attempting conception. Non-hormonal options such as analgesics, lifestyle modification, and supportive therapies may be used. Hormonal suppression can be considered for symptom control when pregnancy is not immediately planned, but treatment should be stopped when actively trying to conceive.
A coordinated approach between fertility specialists and endometriosis surgeons helps ensure both symptom relief and fertility preservation.
References
Giudice LC, Kao LC. Endometriosis. Lancet. 2020;395:1775–1788.
- Hamdan M, et al. Impact of endometriosis on assisted reproductive technology outcomes. Hum Reprod Update. 2021;27:441–456.
- Muzii L, et al. Repeated surgery for endometriosis and ovarian reserve. Fertil Steril. 2020;113:122–128.
- Ferrero S, et al. Surgical management of endometriosis and fertility outcomes. Curr Opin Obstet Gynecol. 2022;34:252–259.
- Sanchez AM, et al. Endometrial receptivity in women with endometriosis. Reprod Biomed Online. 2021;42:103–115.
- Alviggi C, et al. IVF outcomes in women with endometriosis. Reprod Sci. 2023;30:1530–1542.
- Surrey ES, et al. GnRH agonist pretreatment before IVF in endometriosis. Fertil Steril. 2021;116:132–139.
Mappa I, et al. Cumulative live birth rates after IVF in endometriosis. Healthcare (Basel). 2024;12:2435.
