Endometriosis and Fertility: What Helps You Get Pregnant

Endometriosis is tissue similar to the lining of the uterus growing outside it, which causes inflammation and scar tissue.¹ It can cause painful periods and chronic pelvic pain, and it is one of the conditions most often found in people having trouble conceiving. It is also very variable: some people with endometriosis conceive easily, others need treatment. This guide explains how it affects fertility, what the European Society of Human Reproduction and Embryology (ESHRE) recommends, and when to get help.

How common is endometriosis?

The World Health Organization estimates endometriosis affects about 10% of women of reproductive age worldwide, around 190 million people.¹ Among women with infertility, as many as 25% to 50% have it.¹ Symptoms include severe period pain, heavy bleeding, chronic pelvic pain, bloating and nausea, and it can make sex, bowel movements or urination painful.¹ The WHO says the average time to diagnosis is between 4 and 12 years.¹ ASRM notes people with endometriosis typically present with pelvic pain, infertility or an ovarian mass.⁵

How does endometriosis affect fertility?

The WHO describes endometriosis as causing inflammation and scar tissue, and as associated with infertility worldwide.¹ How much it affects fertility depends on where the disease is and how extensive it is, including whether the fallopian tubes are involved and whether there are ovarian cysts (endometriomas).³ Doctors often describe it by stage (I to IV under the rASRM system), and ESHRE’s recommendations differ for milder (stage I/II) and more extensive disease.³

Surgery on the ovaries also matters for fertility. ESHRE says surgery for ovarian endometriomas is likely to have a negative impact on ovarian reserve, so decisions about surgery should take ovarian reserve and the expected fertility benefit into account.³

How is endometriosis diagnosed?

ESHRE’s 2022 guideline moved away from treating laparoscopy as the only gold standard. It recommends imaging, ultrasound or MRI, as part of the diagnostic workup, while noting that a negative scan does not rule out endometriosis, especially superficial disease.³ Laparoscopy is considered when imaging is negative and symptoms persist or treatment fails.³ The WHO notes many people cannot access surgical diagnosis, and long delays in diagnosis are common.¹

Can you get pregnant with endometriosis?

Yes, and there are several routes. ESHRE’s main recommendations for infertility linked to endometriosis:³

Summarized from the ESHRE 2022 guideline.³

The most counterintuitive point is the first one. Hormonal treatments help with pain, and many people with endometriosis have been on them for years. But ESHRE says they should not be used to improve fertility, and they prevent pregnancy while you take them.³ If you are stopping them to try, plan for pain management with your clinician before you stop, so you are not left choosing between pain control and trying.

For a comparison of treatments, see IUI vs IVF; for budgets, IVF cost.

Endometriosis and IVF

ESHRE supports assisted reproduction for infertility associated with endometriosis, especially when tubal function is compromised, when there is also male factor infertility, when the endometriosis fertility index (a score that estimates the chance of pregnancy after surgery) is low, or when other treatments have not worked.³ Its guidance on surgery before IVF is cautious: it does not recommend routine surgery for ovarian endometriomas before IVF to improve live birth rates, because surgery is likely to reduce ovarian reserve.³ Decisions about surgery should weigh ovarian reserve and the expected fertility benefit together.³

Questions to ask your specialist

• What stage is my endometriosis, and are my fallopian tubes affected?
• Would surgery improve my chances, or would it risk my ovarian reserve?
• Should we try stimulated IUI first, or go straight to IVF?
• How should I manage pain while I am off hormonal treatment and trying?
• Has my partner had a semen analysis?

ESHRE also found no evidence that symptom diaries or apps shorten the time to diagnosis, so don’t wait on an app to decide when to see someone.³

What about AMH with endometriosis?

AMH is often checked before decisions about surgery or IVF, because endometriomas and their surgery can affect ovarian reserve.³ Remember what AMH can and cannot tell you: ASRM says it predicts egg yield in IVF but is a poor predictor of natural fertility.⁶ See AMH explained.

When should you see a fertility specialist?

If you know or suspect you have endometriosis and are trying to conceive, ASRM says fertility testing should start without delay, not after the usual 6 or 12 months.⁴ A specialist will usually check ovulation and ovarian reserve, image the uterus and ovaries, test whether the fallopian tubes are open, and order a semen analysis for a male partner at the same time.⁴

If your workup is otherwise normal, ASRM does not recommend laparoscopy as a routine test for unexplained infertility, and ESHRE reserves diagnostic laparoscopy for people whose imaging is negative but symptoms persist or treatment fails.⁴³ In other words, surgery is a decision about treatment and symptoms, not a box to tick in every workup.

Severe pelvic pain that is new or worsening, very heavy bleeding, or pain with fever needs prompt medical attention whether or not you are trying to conceive.

Read when to see a fertility specialist for the full workup, and the Investigate hub for next steps.

Looking after yourself

Living with pain while trying to conceive is exhausting. The WHO notes that pain, fatigue, depression, anxiety and infertility can dramatically reduce quality of life, and lists multidisciplinary options such as physiotherapy and cognitive behavioral therapy alongside medical care.¹ The Support section and coping with the two-week wait have practical help.