Endometriosis affects an estimated 10% of women of reproductive age, and it's found in 25-50% of women with infertility. If you've been diagnosed with endo and want to have a baby, you're navigating a challenging situationâbut not a hopeless one.
Let's understand how endo affects fertility and what can be done about it.
What Is Endometriosis?
Endometriosis occurs when tissue similar to the uterine lining (endometrium) grows outside the uterusâon the ovaries, fallopian tubes, bowel, bladder, or other pelvic structures. This tissue responds to hormones, causing inflammation, pain, and scarring.
Common symptoms include:
- Painful periods (dysmenorrhea)
- Chronic pelvic pain
- Pain during sex
- Pain with bowel movements or urination
- Heavy periods
- Infertility
However, some women have no symptoms and discover endo only when investigating infertility.
How Endometriosis Affects Fertility
Endometriosis can impair fertility through multiple mechanisms:
Anatomical distortion: Adhesions (scar tissue) can distort the pelvis, blocking or displacing fallopian tubes and ovaries. Tubes may be unable to pick up eggs during ovulation.
Ovarian damage: Endometriomas (ovarian cysts filled with old blood, called "chocolate cysts") can damage ovarian tissue and reduce egg reserve. Surgery to remove them can further reduce ovarian reserve.
Inflammatory environment: The inflammatory response creates a hostile environment for sperm, eggs, and embryos. Inflammation may interfere with fertilization and implantation.
Egg quality: Some evidence suggests endo may negatively affect egg quality, possibly due to oxidative stress.
Implantation issues: Endometriosis may affect the uterine lining's receptivity to embryos, though this is still being studied.
Stages of Endometriosis
Endometriosis is classified into stages based on surgical findings:
| Stage | Severity | What It Means | Fertility Impact |
|---|---|---|---|
| Stage I | Minimal | Few small implants, no scarring | May still affect fertility; many conceive naturally |
| Stage II | Mild | More implants, deeper; minimal scarring | Similar to Stage I; may need treatment |
| Stage III | Moderate | Many implants, endometriomas, some adhesions | Often requires treatment; IVF may be recommended |
| Stage IV | Severe | Extensive disease, large endometriomas, dense adhesions | Usually requires IVF; surgery may help |
"The stage of endometriosis doesn't predict how hard it will be to get pregnant. Some women with minimal disease struggle, while others with severe disease conceive easily. Your fertility plan should be tailored to you."
Treatment Options for Fertility
The approach depends on your age, disease severity, other fertility factors, and how long you've been trying:
If you have minimal/mild endometriosis, are young, and have no other fertility issues, you may be advised to try naturally for 6-12 months. Timed intercourse with ovulation monitoring can optimize your chances.
Medications like Letrozole or Clomid stimulate ovulation, then washed sperm are placed directly in the uterus (IUI). Bypasses some barriers and increases the number of eggs available.
Surgery to remove endometriosis implants, cysts, and adhesions can improve fertility, especially in Stage I-II disease. Most beneficial for younger women planning to try naturally afterward. Benefits for severe disease are less clear.
IVF bypasses the tubes entirely, retrieving eggs directly from the ovaries and fertilizing them in the lab. Often the most efficient route for moderate-severe endometriosis, especially with tubal involvement or endometriomas.
Endometriosis is progressiveâit can worsen over time, and ovarian reserve can decline faster in women with endo. If you're over 35 or have been trying without success, don't wait too long to pursue more aggressive treatment. Many specialists recommend moving to IVF relatively quickly for endometriosis patients.
Should You Have Surgery Before IVF?
This is controversial and should be discussed with your doctor. Considerations:
Arguments for surgery before IVF:
- May improve uterine environment for implantation
- Removes endometriomas that could complicate retrieval
- Some studies show improved IVF outcomes post-surgery
Arguments against surgery before IVF:
- Surgery on ovaries reduces egg reserve (you'll have fewer eggs to retrieve)
- Delays treatment during recovery
- IVF success may be similar without surgery in some cases
Current thinking: Avoid surgery on endometriomas if your primary goal is IVF, unless they're very large, painful, or would interfere with egg retrieval. For deep infiltrating endometriosis or tubal disease, surgery may be more beneficial.
Supporting Your Fertility with Endo
While treating the underlying disease is important, supportive measures can help:
Anti-inflammatory diet: Some evidence suggests reducing inflammatory foods (processed foods, sugar, red meat) and emphasizing omega-3s, vegetables, and antioxidants may help manage symptoms and potentially improve fertility.
Supplements:
Pain management: Managing pain improves quality of life and may reduce stress that can affect fertility. Work with your doctor on appropriate optionsâavoid NSAIDs during the TWW and pregnancy.
Mental health support: Endometriosis combined with infertility is emotionally taxing. Therapy, support groups, and stress management are valuable parts of your fertility journey.
Where Are You in Your Journey?
Our quiz can help point you toward the right resources for your situation.
Take the Fertility Quiz âThe Bottom Line
Endometriosis does affect fertility, but it's not a sentence of infertility:
- Most women with endo can conceiveâ60-70% naturally or with treatment
- Stage doesn't predict outcomeâindividual factors matter more
- Treatment options existâfrom timed intercourse to IUI to IVF
- Time mattersâdon't wait too long, especially if you're over 35
- Expert care helpsâsee a reproductive endocrinologist experienced with endo
- Surgery is nuancedâbenefits depend on your specific situation
Work with a fertility specialist who understands endometriosis. Your treatment plan should be individualized based on your age, ovarian reserve, disease extent, and how long you've been trying. With the right approach, the majority of women with endometriosis become mothers.