Endometriosis and Infertility: Does It Prevent Pregnancy?

Endometriosis is one of the conditions frequently diagnosed in women who seek medical advice because of severe menstrual pain, chronic pelvic pain, pain during sexual intercourse, or a prolonged inability to become pregnant.

The first question asked by many women diagnosed with endometriosis is:

“Does endometriosis prevent pregnancy?”

Endometriosis does not cause infertility in every woman. Many women with mild disease can become pregnant naturally. In some patients, however, diminished ovarian reserve, impaired fallopian tube movement, pelvic adhesions, or a chronic inflammatory environment may reduce the chance of pregnancy.

Therefore, it is not appropriate to make a definitive assessment of fertility based solely on a diagnosis of endometriosis. The patient’s age, the location of the disease, AMH and AFC values, the condition of the fallopian tubes, sperm analysis, previous surgeries, and pregnancy plans should be evaluated together.

Brief Answer

Endometriosis does not prevent pregnancy in every woman.

However, the disease may:

1. Reduce ovarian reserve.
2. Cause adhesions between the ovaries and fallopian tubes.
3. Impair the fallopian tubes’ ability to pick up the egg.
4. Affect the interaction between the egg and sperm.
5. Make embryo development and implantation in the uterus more difficult.

The severity of these effects is not the same in every patient. Natural pregnancy may be possible in women who are young, have adequate ovarian reserve, open fallopian tubes, and a normal sperm analysis. In patients with advanced age, bilateral endometriomas, low AMH, or severe pelvic adhesions, assisted reproductive treatments may be considered earlier.

Key Information

1. Endometriosis is a chronic disease seen in women of reproductive age.
2. Infertility does not develop in every patient with endometriosis.
3. An endometrioma is the cystic structure formed by endometriosis in the ovary.
4. The disease may affect the ovaries, fallopian tubes, pelvis, and, in some patients, the intrauterine implantation environment.
5. The stage of endometriosis alone does not determine the chance of pregnancy.
6. Unnecessary ovarian surgery may reduce ovarian reserve.
7. Natural pregnancy, surgery, intrauterine insemination, and IVF should be evaluated according to the individual patient.
8. AMH and AFC help guide treatment decisions, particularly in women planning pregnancy.
9. Early evaluation may reduce loss of time and unnecessary interventions.

What Is Endometriosis?

Endometriosis is a chronic disease caused by cells resembling the endometrial tissue lining the inner surface of the uterus settling outside the uterus.

Endometriosis lesions are most commonly found in the following areas:

1. The ovaries
2. Around the fallopian tubes
3. Behind the uterus
4. The pelvic peritoneum
5. Around the bowel
6. Around the bladder
7. The connective tissues surrounding the uterus

These tissues may be affected by hormones. Over time, inflammation, fibrosis, and adhesions may develop in the surrounding tissues.

Endometriosis is not only a disease that causes pain during menstruation. In some women, it may progress without any symptoms and may be discovered during an infertility evaluation.

Are Endometriosis and an Endometrioma the Same Condition?

Not exactly.

Endometriosis is the general name of the disease.

An endometrioma, also known as a chocolate cyst, is the cystic structure formed by endometriosis inside the ovary.

Every endometrioma is associated with endometriosis. However, not every woman with endometriosis has an endometrioma.

In some patients, endometriosis may be present only as small lesions on the peritoneum. In others, ovarian cysts, deep endometriosis, and extensive pelvic adhesions may occur together.

What Are the Symptoms of Endometriosis?

The symptoms of endometriosis may vary depending on the location of the disease and the individual patient.

The most common symptoms include:

1. Severe menstrual pain
2. Pelvic pain beginning before menstruation
3. Chronic pelvic pain
4. Pain during or after sexual intercourse
5. Pain during bowel movements while menstruating
6. Pain during urination
7. Abdominal bloating
8. Lower back and back pain
9. Heavy or irregular bleeding
10. Difficulty becoming pregnant
11. Recurrent endometriomas

The severity of pain does not always correspond to the stage of the disease. Small endometriosis lesions may cause severe pain, while advanced-stage disease may cause no significant symptoms in some women.

Does Endometriosis Cause Infertility?

Endometriosis is one of the conditions associated with infertility. However, not every patient with endometriosis develops difficulty becoming pregnant.

The effect of the disease on fertility varies according to the following factors:

1. The woman’s age
2. The extent of the disease
3. Whether the ovaries are affected
4. Whether the endometrioma is unilateral or bilateral
5. The severity of pelvic adhesions
6. Whether the fallopian tubes are open and functional
7. Ovarian reserve
8. Previous surgical procedures
9. Sperm quality
10. How long pregnancy has been attempted

Therefore, a diagnosis of endometriosis alone does not mean “infertility.”

How Does Endometriosis Affect Pregnancy?

Endometriosis may affect fertility through several different mechanisms.

It May Reduce Ovarian Reserve

The presence of an endometrioma in the ovary may particularly affect healthy ovarian tissue.

Endometriosis tissue and the surrounding inflammatory process may cause changes in the ovarian tissue containing the follicles. Loss of ovarian reserve may be more pronounced if the cyst is bilateral or if ovarian surgery has previously been performed.

Ovarian reserve is evaluated using:

1. AMH testing
2. AFC, or antral follicle count
3. The woman’s age
4. Response to previous ovarian stimulation
5. A history of ovarian surgery

Low AMH does not mean that natural pregnancy is impossible. However, timing and treatment planning should be performed more carefully.

It May Affect Egg Development

The chronic inflammatory environment caused by endometriosis may affect follicular development within the ovaries.

In some patients, this may negatively affect:

1. The likelihood of obtaining mature eggs
2. The fertilization rate
3. Embryo development

However, it cannot be said that every woman with endometriosis has poor egg quality. The woman’s age remains one of the most important predictors of egg quality.

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

Over time, endometriosis may cause adhesions within the pelvis.

These adhesions may:

1. Impair the movement of the fallopian tube.
2. Alter the anatomical relationship between the ovary and the fallopian tube.
3. Make it more difficult for the tube to pick up the egg.
4. Prevent the sperm and egg from meeting.

Even if the fallopian tubes appear open on a hysterosalpingogram, dense adhesions around them may affect their natural function.

This is one of the reasons IVF may be considered in patients with advanced-stage disease.

It May Create an Inflammatory Pelvic Environment

Endometriosis may create a chronic inflammatory response within the pelvis.

This environment may affect:

1. Sperm movement
2. Egg-sperm interaction
3. The fertilization process
4. Embryo development

These biological changes do not occur to the same extent in every patient. They should be evaluated together with the extent of the disease, the patient’s age, and other infertility factors.

It May Affect Embryo Implantation

It is believed that endometriosis may affect the ability of the uterine lining to receive the embryo in some patients.

However, endometriosis is not the only cause of implantation failure.

In cases of repeated failure, the following factors should also be evaluated:

1. Embryo quality and genetic structure
2. Intrauterine polyps or fibroids
3. Intrauterine adhesions
4. Chronic endometritis
5. Transfer technique
6. Sperm-related factors
7. Age and ovarian reserve

It is not appropriate to consider endometriosis alone as the cause of every treatment failure.

It May Affect Pregnancy Through Pain and Sexual Function

Severe pain and tenderness during sexual intercourse may reduce the frequency of intercourse. This may indirectly affect the likelihood of natural pregnancy.

When planning treatment, not only the ovaries and fallopian tubes but also the patient’s pain and quality of life should be taken into consideration.

Does Every Woman With Endometriosis Have Difficulty Becoming Pregnant?

No.

Natural pregnancy may be possible particularly in women with the following characteristics:

1. Young age
2. Regular ovulation
3. Adequate ovarian reserve
4. Open fallopian tubes
5. No extensive pelvic adhesions
6. A normal sperm analysis
7. Mild or limited disease
8. Pregnancy has not been attempted for a long period

In contrast, pregnancy may be more difficult in the following circumstances:

1. Advanced maternal age
2. Bilateral endometriomas
3. Low AMH and AFC
4. Fallopian tube damage or adhesions
5. Multiple previous ovarian surgeries
6. Significant male-factor infertility
7. A prolonged duration of infertility
8. Advanced-stage endometriosis

Does the Stage of Endometriosis Determine the Chance of Pregnancy?

Endometriosis may be classified as mild, moderate, or advanced according to surgical findings. However, the stage of the disease alone does not indicate fertility potential.

A woman with mild endometriosis may be unable to become pregnant for a long period, while another woman with advanced-stage disease may conceive naturally.

In addition to the disease stage, the following criteria are important when assessing the chance of pregnancy:

1. The woman’s age
2. Ovarian reserve
3. Fallopian tube function
4. A history of ovarian surgery
5. Sperm analysis
6. The duration of attempting pregnancy

Therefore, treatment should not be planned based solely on the “stage” of the disease.

How Is Endometriosis Diagnosed?

The diagnostic process begins with a detailed medical history.

During the examination, the following symptoms are specifically reviewed:

1. The severity of menstrual pain
2. When the pain began
3. Pain during sexual intercourse
4. Bowel or bladder symptoms
5. The duration of attempting pregnancy
6. Previous surgeries
7. A family history of endometriosis

Methods that may be used in diagnosis include:

1. Gynecological examination
2. Transvaginal ultrasonography
3. Magnetic resonance imaging
4. AMH testing and ovarian reserve assessment
5. Evaluation of the fallopian tubes
6. laparoscopy when necessary

Ultrasound is particularly important in assessing endometriomas and certain deep endometriosis lesions.

Surgery is not required to diagnose every case of endometriosis. In many patients, clinical findings and imaging methods may be sufficient to create a treatment plan.

Is Laparoscopy Always Necessary to Diagnose Endometriosis?

No.

Laparoscopy is a surgical method that allows endometriosis lesions and adhesions to be directly evaluated by inserting a camera into the abdomen.

During the same procedure:

1. Endometriosis lesions may be removed.
2. Adhesions may be released.
3. Endometriomas may be treated.
4. The fallopian tubes and pelvis may be evaluated.

However, it is not appropriate to perform laparoscopy in every patient solely for diagnostic purposes. The potential benefits of surgery and the possible risks should be evaluated together.

Can Endometriosis Be Treated?

Endometriosis is a chronic disease. Treatment may control the symptoms and effects of the disease, but recurrence is possible.

The aims of treatment include:

1. Reducing pain
2. Improving quality of life
3. Controlling the progression of the disease
4. Preserving ovarian reserve
5. Increasing the chance of pregnancy
6. Avoiding unnecessary surgery

Treatment options vary according to whether the patient wishes to become pregnant.

Regular Monitoring

Regular monitoring may be preferred in patients who have no significant symptoms and whose cyst is small and does not have a suspicious appearance.

During follow-up, the following are reviewed:

1. Pain symptoms
2. Cyst size
3. Ultrasound appearance
4. AMH and AFC
5. Pregnancy plans

Pain Treatment

Pain-relieving medications may help reduce symptoms. However, they do not eliminate the disease itself.

If pain recurs frequently, a long-term treatment plan should be created separately.

Hormonal Treatments

In women who do not wish to become pregnant, hormonal treatments may reduce pain and help suppress the disease.

Possible options include:

1. Combined oral contraceptive pills
2. Progesterone-containing treatments
3. Hormonal intrauterine systems
4. Other hormonal suppression treatments in selected patients

Natural pregnancy cannot be pursued while hormonal treatments are being used. Therefore, the purpose and duration of treatment should be carefully planned in women who wish to have children.

Laparoscopic Surgery

Surgery may be considered in the following situations:

1. Severe pain resistant to treatment
2. Deep endometriosis affecting organ function
3. A rapidly growing or suspicious ovarian cyst
4. Risk of ovarian torsion or cyst rupture
5. Extensive adhesions disrupting fallopian tube and ovarian anatomy
6. A cyst making egg retrieval during IVF difficult
7. Suspicion of malignancy

The aim of surgery is not only to remove the visible lesions. Healthy ovarian tissue and the surrounding organs should be preserved as much as possible.

Should Every Woman With Endometriosis Undergo Surgery?

No.

Unnecessary surgery may reduce ovarian reserve, particularly in women who wish to become pregnant.

The following criteria are considered when deciding on surgery:

1. The patient’s age
2. Severity of pain
3. Characteristics of the cyst
4. Unilateral or bilateral involvement
5. AMH and AFC values
6. Previous surgeries
7. Pregnancy plans
8. The condition of the fallopian tubes
9. The need for IVF
10. Findings suspicious for a mass

If the cyst does not appear suspicious, does not cause severe pain, and does not prevent egg retrieval, it may not need to be removed before IVF.

Surgery First or IVF First?

This is one of the most important decisions in the evaluation of endometriosis and infertility.

There is no single correct approach for everyone.

IVF May Be Preferred First

Proceeding directly to IVF may be more appropriate in the following situations:

1. The woman is older.
2. AMH and AFC are low.
3. Bilateral endometriomas are present.
4. Previous ovarian surgery has been performed.
5. The fallopian tubes are severely damaged.
6. Significant male-factor infertility is present.
7. Pregnancy has not occurred for a prolonged period.
8. The cyst does not prevent egg retrieval.
9. Pain symptoms are limited.

Surgery May Be Considered First

Surgery may be prioritized in the following situations:

1. Severe and persistent pain is present.
2. There is suspicion of a malignant mass.
3. The cyst is growing rapidly.
4. Bowel, bladder, or ureter involvement is suspected.
5. Accessing the eggs appears technically impossible.
6. There is a risk of torsion or rupture.

The decision should balance the expected benefit of surgery against the risk it may pose to ovarian reserve.

Does Endometriosis Surgery Affect Ovarian Reserve?

Surgery for endometriomas in particular may affect ovarian reserve.

There may not be a clear boundary between the cyst tissue and healthy ovarian tissue. Healthy tissue containing follicles may be damaged while the cyst is removed.

The risk may be higher in the following situations:

1. Bilateral cysts
2. Large cysts
3. Repeated surgery
4. Pre-existing low AMH
5. Previous surgery on the same ovary

This is why AMH and AFC assessment before surgery is important in women planning pregnancy.

Is Egg Freezing Necessary Before Surgery?

egg freezing is not necessary for every patient with endometriosis. However, it may be considered in patients at high risk of diminished fertility.

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
5. A family history of early menopause
6. Extensive surgery that may reduce ovarian reserve
7. Rapid loss of ovarian reserve at a young age

For some patients, egg freezing before surgery may be more appropriate, while for others, embryo freezing or proceeding directly to IVF may be preferable.

How Long Should Women With Endometriosis Attempt Natural Pregnancy?

The recommended waiting period is determined according to the patient’s age and infertility risks.

Women who are young, have good ovarian reserve, open fallopian tubes, and a normal sperm analysis may attempt natural pregnancy for a certain period.

However, prolonged waiting may not be appropriate in the following situations:

1. Age over 35
2. Low AMH and AFC
3. Bilateral endometriomas
4. Fallopian tube damage
5. A prolonged duration of infertility
6. Significant male-factor infertility
7. Repeated ovarian surgery
8. Previous failed treatments

Although failure to achieve pregnancy after one year in women under age 35 and after six months in women over age 35 is generally used as a threshold for evaluation, earlier assessment may be necessary in the presence of endometriosis.

Can Intrauterine Insemination Be Performed in Women With Endometriosis?

Intrauterine insemination may be performed in selected patients.

It may be considered under the following conditions:

1. The woman is young.
2. The fallopian tubes are open.
3. Ovarian reserve is adequate.
4. Sperm parameters are suitable.
5. The disease is mild.
6. The duration of infertility is not long.

If advanced age, diminished ovarian reserve, fallopian tube damage, or advanced endometriosis is present, IVF may be more appropriate than intrauterine insemination.

When Is IVF Considered in Women With Endometriosis?

IVF may be considered earlier in the following situations:

1. The fallopian tubes are blocked or severely damaged.
2. Advanced maternal age
3. Low AMH and AFC
4. Long-term infertility
5. Bilateral endometriomas
6. Significant sperm problems
7. Failed intrauterine insemination treatments
8. Failure to achieve pregnancy after surgery
9. Recurrent disease
10. Pelvic anatomy making natural pregnancy difficult

IVF helps bypass the function of the fallopian tubes in the laboratory. However, it does not completely eliminate the biological effects of age and egg quality.

Does Endometriosis Affect IVF Success?

In some patients, ovarian response and the number of eggs obtained may be affected. Fewer eggs may be retrieved, particularly in the presence of an endometrioma, low AMH, or previous ovarian surgery.

Factors that may affect IVF success include:

1. The woman’s age
2. Ovarian reserve
3. The extent of the disease
4. Previous surgeries
5. The number of eggs obtained
6. Embryo quality
7. Sperm characteristics
8. The intrauterine environment

Despite this, many women with endometriosis can achieve a healthy pregnancy through IVF treatment.

Is PGT Necessary for Every Patient With Endometriosis?

No.

Endometriosis alone does not require PGT.

PGT may be considered in the following situations:

1. Advanced maternal age
2. Recurrent miscarriage
3. Repeated IVF failure
4. A known genetic disease
5. A previous pregnancy affected by a chromosomal abnormality
6. The availability of a sufficient number of embryos

PGT does not improve egg quality or create healthy embryos. It helps genetically assess the embryos that have been obtained.

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

In the evaluation of endometriosis and infertility, neither the presence nor the stage of the disease is considered alone.

In Assoc. Prof. Dr. Nurettin Türktekin’s clinical approach, the following criteria are evaluated together:

1. The patient’s age
2. How long pregnancy has been attempted
3. Menstrual and pain history
4. Whether an endometrioma is present
5. Whether the cyst is unilateral or bilateral
6. AMH and AFC results
7. Previous ovarian surgery
8. Whether the fallopian tubes are open and the condition of the pelvic anatomy
9. Sperm analysis
10. A history of previous pregnancy, miscarriage, or ectopic pregnancy
11. Results of previous intrauterine insemination or IVF treatments
12. The patient’s short-term and long-term pregnancy plans

Natural-conception monitoring or intrauterine insemination under suitable conditions may be considered in a young patient with good ovarian reserve, open fallopian tubes, and mild endometriosis.

If advanced age, diminished ovarian reserve, bilateral endometriomas, fallopian tube damage, or prolonged infertility is present, IVF may be planned earlier.

Surgery may become the priority in the presence of severe pain, organ involvement, or a suspicious mass. However, preserving ovarian reserve should be one of the main goals when deciding on surgery.

The aim is not merely to treat endometriosis lesions, but to manage the patient’s pain, quality of life, and pregnancy goals together.

Can Lifestyle Changes Be Beneficial?

Lifestyle changes do not completely eliminate endometriosis. However, they may support general health, pain management, and reproductive health.

Potentially beneficial habits include:

1. Avoiding smoking
2. Maintaining a healthy weight
3. Exercising regularly
4. Eating a balanced diet
5. Getting sufficient sleep
6. Keeping chronic diseases under control
7. Paying attention to stress management
8. Attending regular follow-up appointments

Herbal products or supplements should not be used without a doctor’s recommendation. It cannot be said that these products eliminate the disease or definitively increase the chance of pregnancy.

When Should You Consult an Obstetrician and Gynecologist?

An evaluation should not be delayed in the following situations:

1. Severe menstrual pain is present.
2. Persistent pelvic pain is experienced.
3. Pain occurs during sexual intercourse.
4. Bowel or bladder symptoms occur during menstruation.
5. An endometrioma has been detected on ultrasound.
6. AMH has been found to be low.
7. You are under age 35 and pregnancy has not occurred within one year.
8. You are over age 35 and pregnancy has not occurred within six months.
9. You have previously undergone ovarian surgery.
10. IVF treatments have failed.
11. There is a history of recurrent miscarriage.
12. Sudden and severe pelvic pain has developed.

Women who are suspected of having endometriosis and wish to become pregnant may require evaluation earlier than the general waiting periods.

Common Misconceptions About Endometriosis

“Everyone with endometriosis becomes infertile.”

Incorrect. Many women can become pregnant naturally.

“Endometriosis only means having an endometrioma.”

Incorrect. An endometrioma is the ovarian form of the disease. Endometriosis may also be present in different organs and tissues.

“Severe pain always means advanced-stage disease.”

Incorrect. Pain severity and disease stage do not always correspond.

“Natural pregnancy is impossible with endometriosis.”

Incorrect. Natural pregnancy may be possible if age, ovarian reserve, the fallopian tubes, and sperm parameters are suitable.

“Every patient with endometriosis should undergo surgery.”

Incorrect. The decision to perform surgery should be individualized.

“Surgery completely cures the disease.”

Incorrect. Endometriosis is a chronic disease and may recur.

“An endometrioma must always be removed before IVF.”

Incorrect. Proceeding directly to IVF may be more protective in some patients.

“Hormonal treatment immediately increases the chance of pregnancy.”

Hormonal treatments may suppress pain and disease activity. Natural pregnancy is not pursued while they are being used.

Assoc. Prof. Dr. Nurettin Türktekin’s Assessment

The most important goal in endometriosis treatment is not merely to control the disease lesions. The patient’s pain, quality of life, ovarian reserve, and plans to have children should be evaluated together.

Not every endometriosis lesion or endometrioma should be surgically removed in women planning pregnancy. Unnecessary surgery may damage healthy ovarian tissue and lead to a decrease in AMH.

Natural pregnancy or intrauterine insemination may be considered in young patients with adequate ovarian reserve and open fallopian tubes. If advanced age, diminished ovarian reserve, fallopian tube damage, bilateral endometriomas, or prolonged infertility is present, IVF may be considered earlier.

The correct treatment is determined according to the patient’s individual characteristics rather than solely according to the stage of the disease. The aim is to reduce pain while preserving existing fertility potential as much as possible.

Conclusion

Endometriosis may affect female fertility, but it does not cause infertility in every patient.

Its effect on pregnancy varies according to the woman’s age, ovarian reserve, the presence of an endometrioma, the condition of the fallopian tubes, pelvic adhesions, sperm characteristics, and previous treatments.

It is not appropriate for every woman with endometriosis to undergo surgery or proceed directly to IVF. Natural-conception monitoring may be suitable for some patients, intrauterine insemination for others, and surgery or IVF for others.

Evaluation should not be delayed particularly in the presence of low AMH, bilateral endometriomas, advanced age, fallopian tube damage, severe pain, or a prolonged inability to become pregnant.

With individualized treatment planning, both the symptoms of the disease and existing fertility potential can be managed and preserved as much as possible.

Frequently Asked Questions

Does endometriosis prevent pregnancy?

Not in every patient. The extent of the disease, the woman’s age, ovarian reserve, the condition of the fallopian tubes, and sperm parameters affect the chance of pregnancy.

Can endometriosis be completely cured?

Endometriosis is a chronic disease. Treatment may control the pain and effects of the disease, but it may recur.

Can endometriosis occur without an endometrioma?

Yes. Endometriosis may occur outside the ovaries, including on the peritoneum, behind the uterus, or around the bowel or bladder.

Can endometriosis block the fallopian tubes?

In advanced disease, adhesions may impair fallopian tube movement or cause tubal blockage.

Does endometriosis increase the risk of miscarriage?

An increased risk of miscarriage may be seen in some patients. However, miscarriage may have many different causes.