Does an Endometrioma Prevent Pregnancy?

One of the most frequently asked questions by women diagnosed with an endometrioma is:

“Does an endometrioma prevent pregnancy?”

There is no single answer to this question that applies to everyone. Many women with an endometrioma can become pregnant naturally. In some patients, however, diminished ovarian reserve, impaired fallopian tube function, pelvic adhesions, or the inflammatory environment associated with endometriosis may reduce the chance of pregnancy.

Therefore, it is not appropriate to make a definitive assessment of fertility based solely on the presence or size of the cyst. The patient’s age, AMH and AFC results, whether the cyst is present in one or both ovaries, the condition of the fallopian tubes, pain symptoms, sperm analysis, and pregnancy plans should be evaluated together.

Particularly in women who wish to have children, the primary aim is not merely to treat the cyst. It is necessary to determine the most appropriate timing and method for pregnancy while preserving healthy ovarian tissue and the existing ovarian reserve.

Brief Answer

No. Not every endometrioma prevents pregnancy.

Natural pregnancy may be possible in women who are young, ovulate regularly, have adequate ovarian reserve, open fallopian tubes, and a normal sperm analysis.

However, an endometrioma may:

1. Reduce ovarian reserve.
2. Affect ovarian tissue.
3. Cause adhesions within the pelvis.
4. Impair the fallopian tubes’ ability to pick up the egg.
5. Create an inflammatory environment that may affect fertilization and embryo development.

The degree of these effects is not the same in every patient. The treatment plan should be individualized.

Key Information

1. An endometrioma is the ovarian form of endometriosis.
2. Not every endometrioma causes infertility.
3. The size of the cyst alone is not sufficient to determine whether surgery is needed.
4. AMH and AFC are important in assessing ovarian reserve.
5. Both the endometrioma itself and ovarian surgery may affect ovarian reserve.
6. Unnecessary surgery should be avoided in women who wish to become pregnant.
7. Not every endometrioma is removed before IVF.
8. Surgery may be more appropriate first for some patients, while IVF may be more appropriate first for others.
9. Fertility-preservation options should also be considered in women with diminished ovarian reserve.

What Is an Endometrioma?

An endometrioma, commonly known as a chocolate cyst, is a cystic structure that develops when tissue resembling the lining of the uterus settles in the ovary.

Over time, old blood and cellular debris accumulate inside the cyst. Because this material has a dark brown appearance, the term “chocolate cyst” is commonly used.

An endometrioma may be found:

1. In one ovary
2. In both ovaries
3. In small or large sizes
4. With pain or without any symptoms

The size of the cyst does not always reflect the overall extent of the disease. A patient with a small endometrioma may have extensive pelvic adhesions, while another patient with a larger cyst may have more limited disease.

Are Endometriosis and an Endometrioma the Same Thing?

No. Although they are related, they are not the same concept.

Endometriosis is a chronic disease characterized by the presence of tissue resembling the uterine lining outside the uterus.

This tissue may be located:

1. In the ovaries
2. Around the fallopian tubes
3. On the peritoneum
4. Behind the uterus
5. Around the bowel or bladder

An endometrioma is the cystic structure formed by endometriosis in the ovary.

In other words, every endometrioma is associated with endometriosis, but not every patient with endometriosis has an ovarian endometrioma.

What Are the Symptoms of an Endometrioma?

In some women, an endometrioma may cause no symptoms and may be detected during a routine ultrasound examination.

When symptoms occur, the most common complaints include:

1. Severe menstrual pain
2. Chronic pelvic pain
3. Pain during or after sexual intercourse
4. Pain during bowel movements while menstruating
5. Lower back and lower abdominal pain
6. Abdominal bloating
7. Irregular menstrual cycles
8. Difficulty becoming pregnant
9. Diminished ovarian reserve

The severity of pain does not always correspond to the extent of the disease. A small endometrioma may cause severe pain, while a large cyst may remain asymptomatic for a long period.

How Does an Endometrioma Affect the Chance of Pregnancy?

An endometrioma does not affect fertility through a single mechanism. Several factors may be involved at the same time.

It May Reduce Ovarian Reserve

An endometrioma may affect the healthy ovarian tissue surrounding it. The number of healthy follicles in the ovary containing the cyst may decrease.

This should be evaluated particularly carefully when:

1. The cyst is present in both ovaries.
2. The cyst has been present for a long time.
3. The patient has previously undergone ovarian surgery.
4. The cyst has recurred.

It May Affect Ovarian Tissue and Egg Development

The inflammatory environment associated with endometriosis may affect ovarian function and follicular development.

This does not mean that egg quality will be impaired in every patient. However, particularly when advanced age and diminished ovarian reserve occur together, the likelihood of obtaining a healthy embryo may decrease.

It May Cause Adhesions Around the Fallopian Tubes and Within the Pelvis

Endometriosis may cause adhesions around the ovaries and fallopian tubes.

These adhesions may make it more difficult for:

1. The fallopian tube to reach the egg
2. The egg to enter the fallopian tube
3. The sperm and egg to meet

Even if the fallopian tubes appear open, adhesions around them may affect their natural movement.

It May Create an Inflammatory Environment That Affects Fertilization

Endometriosis may create a chronic inflammatory environment within the pelvis. This may negatively affect sperm movement, egg-sperm interaction, and embryo development.

It May Affect the Implantation Process

In some patients, endometriosis may affect the ability of the uterine lining to accept the embryo. However, endometriosis is not the only cause of implantation failure.

Intrauterine polyps, fibroids, adhesions, embryo genetics, and sperm factors should also be evaluated separately.

Does Every Endometrioma Cause Infertility?

No.

Not every woman with an endometrioma is infertile. Some women may become pregnant naturally before the condition is even diagnosed.

The likelihood of natural pregnancy may be higher particularly in the following circumstances:

1. The woman is young.
2. Menstrual cycles and ovulation are regular.
3. Ovarian reserve is adequate.
4. The cyst is present on only one side.
5. The fallopian tubes are open and functional.
6. There are no extensive pelvic adhesions.
7. The sperm analysis is normal.
8. Pregnancy has not been attempted for a long period.

In contrast, advanced age, bilateral endometriomas, low AMH, previous ovarian surgery, and fallopian tube problems may reduce the chance of pregnancy.

Does an Endometrioma Affect Ovarian Reserve?

Yes. An endometrioma may affect ovarian reserve.

The following criteria are commonly considered when evaluating ovarian reserve:

1. AMH level
2. AFC, or antral follicle count
3. The woman’s age
4. Whether the cyst is unilateral or bilateral
5. Previous ovarian surgeries
6. Response to previous ovarian stimulation

AMH provides important information about ovarian reserve. However, it does not by itself indicate the chance of pregnancy or egg quality.

AFC refers to the number of small follicles seen in both ovaries during ultrasound. When AMH and AFC are evaluated together, treatment planning can be performed more accurately.

Can Women With an Endometrioma Become Pregnant Naturally?

Yes.

Natural pregnancy is possible, particularly in young women who have adequate ovarian reserve, open fallopian tubes, and a normal sperm analysis.

However, the recommended duration of attempting natural pregnancy varies according to age and other findings.

For example:

1. In a 30-year-old patient with a small unilateral cyst and normal ovarian reserve, a period of natural-conception monitoring may be considered.
2. In a 38-year-old patient with bilateral endometriomas and low AMH, waiting for a long period may reduce the chance of pregnancy.
3. If there are fallopian tube adhesions or significant male-factor infertility, IVF may be considered earlier.

Therefore, the same period of attempting natural pregnancy is not recommended for every patient with an endometrioma.

Should Every Endometrioma Be Surgically Removed?

No. Not every endometrioma requires surgery.

In the past, surgery was more readily recommended to many patients diagnosed with an endometrioma. The current approach is more conservative, particularly in women who wish to become pregnant.

This is because healthy ovarian tissue may also be damaged while the cyst is being removed. AMH and AFC values may decrease after surgery.

Therefore, the decision to perform surgery should not be based solely on the size of the cyst.

The following factors should be evaluated together:

1. The patient’s age
2. Pain symptoms
3. The size and ultrasound appearance of the cyst
4. Whether it is present in one or both ovaries
5. AMH and AFC results
6. Pregnancy plans
7. Previous surgeries
8. The need for IVF
9. Suspicion of a malignant mass

In Which Patients May Monitoring Be Preferred?

Monitoring may be appropriate in the following situations:

1. The cyst is small and has a typical endometrioma appearance.
2. There is no significant pain or pressure.
3. There is no suspicion of malignancy.
4. The cyst is not growing rapidly.
5. Ovarian reserve is diminished.
6. Pregnancy is planned in the near future.
7. The expected benefit of surgery is limited.
8. IVF is planned and the cyst does not interfere with egg retrieval.

A decision to monitor does not mean that nothing will be done. Regular ultrasound examinations, assessment of symptoms, and review of pregnancy plans are required.

When May Endometrioma Surgery Be Considered?

Surgery may be considered in the following situations:

1. Severe pain affecting daily life
2. Persistent symptoms despite medical treatment
3. Rapid growth of the cyst
4. Suspicious features on ultrasound or MRI
5. Inability to rule out a malignant tumor
6. Risk of ovarian torsion or cyst rupture
7. The cyst making egg retrieval technically difficult
8. Suspicion of extensive pelvic adhesions or organ involvement
9. Severe symptoms unrelated to the patient’s pregnancy plans

When surgery is performed, the main goal is not merely to remove the cyst, but to preserve as much healthy ovarian tissue as possible.

Surgery First or IVF First?

This is one of the most important decisions for women with an endometrioma who wish to have children.

There is no single correct approach for everyone.

IVF May Be More Appropriate First

IVF may be prioritized instead of surgery in the following situations:

1. The woman is older.
2. AMH and AFC are low.
3. The cyst is present in both ovaries.
4. Previous ovarian surgery has been performed.
5. The cyst does not prevent egg retrieval.
6. There is no severe pain.
7. There is an additional cause of infertility, such as male-factor infertility or blocked fallopian tubes.
8. A loss of time could significantly reduce the chance of pregnancy.

Surgery May Be More Appropriate First

Surgery may be prioritized in the following situations:

1. There is suspicion of malignancy.
2. There is severe pain resistant to treatment.
3. The cyst is growing rapidly.
4. The cyst technically prevents access to the eggs.
5. Extensive organ involvement within the pelvis is suspected.
6. There is a risk of cyst rupture or ovarian torsion.

The decision should be based on the actual benefit expected from surgery, as well as the patient’s age and ovarian reserve.

Can Endometrioma Surgery Reduce Ovarian Reserve?

Yes. It may reduce ovarian reserve in some patients.

There may not always be a clear boundary between the cyst and healthy ovarian tissue. Healthy follicles may also be damaged while the cyst wall is removed. Some surgical techniques used to control bleeding may affect ovarian tissue.

The risk may be higher particularly in the following situations:

1. The cyst is present in both ovaries.
2. Surgery has previously been performed on the same ovary.
3. The cyst is large.
4. Ovarian reserve is already low.
5. Repeated surgery is required.

Therefore, AMH and AFC assessment before surgery is important in women of reproductive age.

Is Egg Freezing Necessary Before Surgery?

egg freezing is not necessary for every patient with an endometrioma. However, it may be considered for fertility preservation in selected patients.

Egg freezing may be considered in the following situations:

1. Bilateral endometriomas
2. Low AMH and AFC
3. Repeated ovarian surgery
4. Postponement of pregnancy until later years
5. A family history of early menopause
6. A high likelihood that surgery will reduce ovarian reserve
7. Diminished ovarian reserve combined with advanced age

Egg freezing before surgery may be more appropriate for some patients, while direct embryo freezing may be more appropriate for others. The plan is determined according to marital status, sperm availability, pregnancy goals, and applicable legal regulations.

Does an Endometrioma Affect IVF Success?

It may affect IVF success in some patients. However, many women with an endometrioma can become pregnant through IVF treatment.

An endometrioma may affect:

1. The ovaries’ response to medication
2. The number of eggs retrieved
3. The technical difficulty of reaching the eggs
4. Ovarian reserve
5. The number of embryos

Nevertheless, removing every endometrioma before IVF does not increase success.

Unnecessary surgery may reduce ovarian reserve and decrease the number of eggs obtained during IVF. Therefore, if the cyst does not interfere with egg retrieval, does not cause severe pain, and does not have a suspicious appearance, IVF may be planned directly.

Is PGT Necessary in Women With an Endometrioma?

An endometrioma alone does not require PGT.

The decision to perform PGT may be evaluated according to the following factors:

1. The woman’s age
2. The number of embryos
3. A history of recurrent miscarriage
4. Repeated IVF failure
5. A known genetic disease
6. A previous pregnancy affected by a chromosomal abnormality

PGT does not improve egg quality or create a healthy embryo. It may help genetically evaluate the embryos that have been obtained.

How Is an Endometrioma Treated?

Treatment is determined according to the patient’s symptoms and pregnancy plans.

The main options include:

1. Regular monitoring
2. Pain-relieving medications
3. Hormonal treatments
4. Laparoscopic surgery
5. Natural-conception monitoring
6. Intrauterine insemination
7. IVF treatment
8. Egg or embryo freezing in appropriate patients

It is not appropriate to apply the same treatment to every patient.

Do Hormonal Treatments Eliminate an Endometrioma?

Hormonal treatments may reduce pain associated with endometriosis and help suppress the disease. However, they do not always completely eliminate an existing large endometrioma.

Birth control pills, progesterone-containing treatments, or other hormonal options may be considered in patients who do not wish to become pregnant and who experience pain.

Natural pregnancy does not occur while hormonal treatment is being used. Therefore, the purpose and duration of treatment should be determined according to the pregnancy plan.

Can an Endometrioma Disappear on Its Own?

Unlike functional ovarian cysts, endometriomas generally do not disappear spontaneously.

Over time, their size may:

1. Remain unchanged
2. Increase slowly
3. Decrease under hormonal suppression
4. Recur after treatment

Therefore, ultrasound monitoring should not be neglected.

Can an Endometrioma Become Cancerous?

Endometriomas are usually benign. Malignant transformation is rare.

However, more detailed evaluation is required if the following findings are present:

1. A newly detected cyst after menopause
2. Rapid growth
3. Solid areas within the cyst
4. An irregular cyst wall
5. Suspicious blood flow
6. Atypical imaging features
7. A family history of ovarian or breast cancer

In suspicious cases, advanced imaging or surgical evaluation may be required instead of monitoring alone.

What Approach Does Assoc. Prof. Dr. Nurettin Türktekin Follow in This Situation?

During the evaluation of an endometrioma, the diameter of the cyst is not considered alone. In Assoc. Prof. Dr. Nurettin Türktekin’s clinical approach, the patient’s age, symptoms, pregnancy plans, and ovarian reserve are evaluated together.

During the examination, answers are sought to the following questions:

1. Is the cyst present in one ovary or both ovaries?
2. Does it have the typical appearance of an endometrioma on ultrasound?
3. Is the cyst growing?
4. Does the patient have severe pain?
5. What are the AMH and AFC values?
6. Has ovarian surgery been performed before?
7. Are the fallopian tubes open?
8. What are the results of the partner’s sperm analysis?
9. How long has pregnancy been attempted?
10. Is surgery, natural-conception monitoring, or IVF more appropriate first?
11. Is egg or embryo freezing necessary before surgery?

Natural-conception monitoring may be considered in a young patient who has good ovarian reserve, open fallopian tubes, and no severe pain.

In a patient who is older, has low AMH, has bilateral endometriomas, or has been unable to conceive for a long period, planning IVF without losing time may be more appropriate.

Surgery may be prioritized if there is severe pain, rapid growth, or suspicion of a malignant mass.

The primary aim is not merely to eliminate the cyst, but to determine the approach that provides the greatest benefit with the least harm by evaluating the patient’s pain, ovarian reserve, and pregnancy goals together.

When Should You Consult an Obstetrician and Gynecologist?

An evaluation should not be delayed in the following situations:

1. You have severe menstrual pain.
2. You experience chronic pelvic pain.
3. You have pain during sexual intercourse.
4. An endometrioma has been detected on ultrasound.
5. The cyst is increasing in size during follow-up.
6. Your AMH level is low.
7. The cyst is present in both ovaries.
8. You have previously undergone ovarian surgery.
9. You are under age 35 and pregnancy has not occurred within one year.
10. You are over age 35 and pregnancy has not occurred within six months.
11. IVF treatment is being planned.
12. You experience sudden severe pelvic pain, nausea, or vomiting.

Sudden and severe pain may indicate an emergency such as ovarian torsion or cyst rupture.

Common Misconceptions About Endometriomas

“Everyone with an endometrioma becomes infertile.”

Incorrect. Many women can become pregnant naturally.

“Every endometrioma must be surgically removed.”

Incorrect. The decision to perform surgery is based on age, ovarian reserve, pain, pregnancy plans, and ultrasound findings.

“The larger the cyst, the more severe the infertility.”

Not always. The extent of the disease and its effect on fertility cannot be measured solely by the size of the cyst.

“Pregnancy is guaranteed after surgery.”

Incorrect. The chance of pregnancy depends on age, the fallopian tubes, sperm characteristics, ovarian reserve, and other factors.

“The cyst must always be removed before IVF.”

Incorrect. In some patients, proceeding directly to IVF may be more protective.

“If AMH is low, pregnancy is no longer possible.”

Incorrect. Low AMH does not completely prevent natural pregnancy or pregnancy through IVF, but timing becomes more important in treatment planning.

“An endometrioma will definitely become cancerous.”

Incorrect. Malignant transformation is rare.

Assoc. Prof. Dr. Nurettin Türktekin’s Assessment

The most important point in the treatment of an endometrioma is to evaluate not only the cyst, but the patient’s overall reproductive health.

In a woman planning a pregnancy, age, AMH and AFC results, the condition of the fallopian tubes, sperm analysis, and previous surgeries are as important as the size of the cyst. Unnecessary surgery may damage healthy ovarian tissue and reduce the existing ovarian reserve.

Therefore, not every endometrioma should be surgically removed. Monitoring may be the most appropriate option for some patients, attempting natural pregnancy for others, IVF for some, and surgery for others.

A fertility-preserving approach becomes particularly important in the presence of bilateral endometriomas, diminished ovarian reserve, or repeated ovarian surgery. Egg or embryo freezing may also be added to the treatment plan when necessary.

The aim is not merely to eliminate the cyst seen on imaging, but to reduce the patient’s pain while preserving the chance of future pregnancy as much as possible.

Conclusion

An endometrioma does not prevent pregnancy in every patient.

Its effect on fertility varies according to the woman’s age, ovarian reserve, whether the cyst is unilateral or bilateral, the condition of the fallopian tubes, pelvic adhesions, and the partner’s sperm characteristics.

It is not appropriate to surgically remove every endometrioma in women who wish to become pregnant. Surgery may be necessary and beneficial in some patients, while in others it may make pregnancy planning more difficult by reducing ovarian reserve.

Therefore, an individualized assessment should be performed when deciding between natural-conception monitoring, surgery, IVF, and fertility-preservation options.

An obstetrician and gynecologist should be consulted in the presence of severe pain, a rapidly growing cyst, low AMH, bilateral endometriomas, a history of repeated surgery, or difficulty becoming pregnant.

Frequently Asked Questions

Does everyone with an endometrioma have difficulty becoming pregnant?

No. Many women with an endometrioma can become pregnant naturally.

Can an endometrioma disappear on its own?

Generally, no. Unlike functional cysts, it is not expected to disappear spontaneously within a short period.

Does an endometrioma require IVF?

Not always. The decision is based on age, ovarian reserve, the fallopian tubes, sperm analysis, and the duration of infertility.

Can endometrioma surgery reduce ovarian reserve?

It may reduce ovarian reserve in some patients. The risk should be evaluated particularly carefully in bilateral, large, or recurrent cysts.

Does an endometrioma cause pain?

Yes. Pain may occur particularly during menstruation, sexual intercourse, or bowel movements.

Is an endometrioma more significant when AMH is low?

Yes. If ovarian reserve is already diminished, the decision to perform surgery should be made more carefully.

Can an endometrioma recur?

Yes. It may recur after surgical or medical treatment.