Short answer
Yes, endometriosis commonly reduces fertility through multiple mechanisms (anatomical distortion, adhesions, local inflammation and impaired ovarian reserve), and its impact varies by disease type and severity; however, many people with endometriosis do conceive naturally or with treatment, and modern care is individualised to balance fertility preservation with symptom control.
Why this question matters
Endometriosis affects ~10% of reproductive-age people and is over-represented among people with infertility. Understanding how and when endometriosis impairs fertility, which treatments help (or harm), and when to refer for fertility care is crucial for patients and clinicians alike. Recent high-quality evidence and updated guidelines give clearer, more nuanced recommendations than older, blanket statements.
What is endometriosis — quick recap
Endometriosis is defined by the presence of endometrium-like tissue outside the uterus (ovaries, pelvic peritoneum, bowel, bladder, deep pelvic spaces). It presents heterogeneously: superficial peritoneal lesions, ovarian endometriomas (cysts), and deep-infiltrating disease. Each subtype can affect fertility through different pathways.
How endometriosis can impair fertility — the mechanisms
Contemporary research shows several overlapping mechanisms that explain the observed association between endometriosis and reduced fertility:
- Anatomical distortion and adhesions — Pelvic adhesions and distorted tubo-ovarian anatomy can block ovum pickup or interfere with gamete transport. This is a major mechanical pathway, especially in moderate to severe disease.
- Ovarian involvement and ovarian reserve loss — Endometriomas (ovarian “chocolate cysts”) themselves and surgical removal (cystectomy) can reduce ovarian reserve, measured by AMH and antral follicle count. Recent systematic reviews show a consistent post-surgical decline in AMH, so the risks and benefits of operating must be carefully weighed if fertility preservation is a priority.
- Hostile pelvic environment — inflammation & altered immune milieu — Endometriosis can create a pro-inflammatory peritoneal fluid (cytokines, oxidative stress) that may impair sperm function, fertilisation or early embryo development and implantation. Multi-omics and mechanistic studies over the last 3–5 years expand our understanding of these biochemical effects.
- Impaired implantation / endometrial receptivity — There is emerging evidence that in some people with endometriosis the endometrium itself is less receptive, contributing to lower implantation rates.
How big is the fertility impact in real terms?
Older figures (often quoted) suggested that 30–50% of people with endometriosis were infertile; modern data refine this: the degree of infertility risk depends on disease stage, lesion location (ovarian vs superficial vs deep), and patient factors (age, prior surgery). Some recent cohorts and IVF registry analyses show lower IVF implantation rates and slightly lower live-birth rates among people with endometriosis compared with other indications — but many still achieve pregnancy (natural or via ART). The exact absolute risk is therefore individualised.
Diagnosis & initial fertility assessment
- Non-invasive imaging first: Transvaginal ultrasound (skilled sonographer) and pelvic MRI can identify endometriomas and deep-infiltrating disease—recent guideline updates and living-guideline movements promote imaging to reduce diagnostic delay. Imaging is especially useful when fertility planning is underway.
- Early fertility assessment if appropriate: For people with suspected/confirmed endometriosis who are ≥35 or have other risk factors, earlier fertility workup (semen analysis for partner, ovarian reserve testing with AMH/AFC, evaluation of tubal patency when indicated) is reasonable rather than waiting the standard 12 months.
Prognosis — can people with endometriosis get pregnant?
Yes — many do. Natural conception is possible, particularly with minimal disease and younger age. Where natural conception is unlikely or delayed, ART (including IVF) offers substantial chances; recent data show that cumulative live-birth rates can be favourable when tailored treatment plans are used. Shared decision-making with a fertility team allows realistic, personalised counselling about timelines and likelihoods.
Practical, evidence-based checklist (what to do next)
- If you have pain or suspect endometriosis: seek assessment — start with a GP and arrange targeted imaging (specialist transvaginal ultrasound / pelvic MRI) and referral as needed. Early diagnosis reduces delays.
- If you’re trying to conceive now: get a fertility baseline — AMH/AFC, semen analysis for partner, and consider early referral if ≥35 or if trying >6 months without success.
- If you have an ovarian endometrioma and want fertility: discuss risks/benefits of surgery vs conservative management with a fertility specialist — consider fertility preservation (egg freezing/IVF).
FAQs
Q: Does removing endometriosis always improve fertility?
A: No — removal of superficial lesions can improve spontaneous conception in some patients, but removal of ovarian endometriomas often reduces ovarian reserve. Decisions must be personalised.
Q: Should I try to conceive before having surgery for endometriosis?
A: If fertility is a priority and you have ovarian cysts or reduced AMH, it may be reasonable to prioritise fertility evaluation/ART over elective cystectomy — discuss with your clinician.
Q: Is IVF successful for people with endometriosis?
A: Yes — IVF often bypasses mechanical problems and can achieve good cumulative live-birth rates, although some studies report slightly lower implantation/ per-cycle success compared with other indications; outcomes depend on age, ovarian reserve and disease severity.
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