Introduction

Endometriosis — when tissue similar to the uterine lining grows outside the uterus — is common and can cause pain, heavy periods, and fertility challenges. Many people with endometriosis will conceive naturally, but for some the condition interferes with ovulation, egg quality, fallopian tube function or implantation.

This guide explains how endometriosis can affect fertility, the investigations I commonly use, the role (and limits) of surgery, medical and assisted reproduction options, and practical advice to help you plan and optimise outcomes.

💡 Note: This blog is general educational information only and does not constitute personalised medical advice. Please consult with a fertility specialist to discuss your individual situation.

 

How endometriosis can affect fertility

Endometriosis impacts fertility through several mechanisms:

• Anatomical distortion and adhesions — Endometriosis can cause scarring that distorts pelvic anatomy and interferes with the fallopian tube’s ability to capture an egg.
• Ovarian endometriomas — Endometriotic cysts on the ovary (endometriomas, sometimes known as “chocolate cysts”) can damage ovarian tissue and reduce ovarian reserve, especially after cyst surgery.
• Inflammation and altered pelvic environment — Chronic inflammation can impair sperm function once it is inside the pelvic cavity, egg quality or embryo development.
• Reduced endometrial receptivity — In some cases, the uterine lining may be less receptive to implantation.
• Pain and sexual dysfunction — Painful intercourse (dyspareunia) may reduce the frequency of intercourse at fertile times.

Severity varies — many people with minimal disease conceive easily, while others with severe disease may need targeted interventions.

 

Symptoms and when to seek assessment

Common symptoms of endometriosis include:

• Painful periods (dysmenorrhoea) that progressively worsen
• Pelvic pain outside of menstruation
• Pain during sex (dyspareunia)
• Infertility or difficulty conceiving
• Bowel or bladder symptoms that vary with the cycle

 

If you have persistent pelvic pain, difficult periods, or unexplained infertility, an evaluation sooner rather than later is sensible. Early assessment helps preserve options and avoids unnecessary delay.

 

How we diagnose and assess endometriosis

• Clinical history and examination — A detailed symptom history often gives the first clues.
• Transvaginal ultrasound — Good for detecting ovarian endometriomas and some pelvic lesions. Experienced ultrasonographers can pick up deep infiltrating disease.
• MRI — Useful for complex or deep disease or when ultrasound findings are inconclusive.
• Diagnostic laparoscopy — The gold standard for confirming endometriosis and can be therapeutic (excision of lesions).

 

For fertility planning I also assess ovarian reserve (AMH, antral follicle count), partner semen analysis, and uterine cavity as needed (hysteroscopy or ultrasound) to get the full picture.

 

The role of surgery — benefits and trade-offs

Surgery can help in specific situations:

When surgery is often beneficial

• Symptomatic relief for pain when medical therapy has failed.
• Removal of endometriomas >3–4 cm that cause pain or obstruct access to follicles during IVF treatment.
• Correction of tubal disease or adhesions that impair tubal function.

 

When surgery may not improve fertility

• Routine surgical excision for minimal/mild disease solely to improve fertility is controversial. Some studies show limited benefit for conception. Benefits on improved natural fertility is more pronounced in younger women.
• Ovarian cystectomy for endometriomas can reduce ovarian reserve (AMH), so surgery must be weighed carefully — performed by an experienced endometriosis surgeon to minimise ovarian damage.

 

Key principle: individualised decision-making. If you have a large painful endometrioma and poor access to follicles, surgery by a specialist may be recommended. If your main issue is reduced ovarian reserve, proceeding directly to IVF might be preferable.

 

Medical treatments — what they do and don’t do for fertility

Hormonal therapies (oral contraceptives, progestogens, GnRH analogues are excellent for controlling pain symptoms but do not restore fertility while suppressing ovulation. They are useful for symptom control before conception is attempted but are not fertility-enhancing per se.

Sometimes a short course of GnRH agonist therapy before IVF can be considered in select cases, but routine prolonged suppression before fertility treatment is not universally recommended.

 

Assisted reproduction (IUI, IVF) and endometriosis

The fertility pathway often depends on disease severity and other fertility factors:

• IUI (intrauterine insemination) may be suitable for younger patients with minimal to mild disease, good ovarian reserve, and no tubal or severe male factor issues.
• IVF is generally the most effective option when there is moderate to severe disease, impaired tubal function, reduced ovarian reserve, or after failed IUI attempts. IVF bypasses peritoneal factors and tubal problems and allows control over timing and embryo selection.
• Egg freezing (fertility preservation) may be appropriate for patients who must delay pregnancy or who have reduced reserve; ovarian stimulation and vitrification offer the chance to preserve options.

 

Discuss with your specialist whether to prioritise surgery vs IVF — often the answer is nuanced and depends on age, reserve, symptoms and prior treatments.

 

Strategies to preserve ovarian reserve

• If you have endometriomas and are planning pregnancy soon, discuss options promptly.
• If surgery is necessary, seek an experienced endometriosis surgeon who uses ovarian-sparing techniques.
• Consider fertility preservation (egg freezing) before surgery if your ovarian reserve is already low or if multiple surgeries are likely.

 

 

Lifestyle, pain management and adjunctive care

• Pain management: pelvic physiotherapy, pain medicine specialists, and multidisciplinary approaches often help.
• Exercise & diet: gentle exercise and anti-inflammatory dietary approaches can reduce symptoms for some people.
• Mental health: chronic pain and fertility concerns are emotionally challenging — counselling is an important part of care.

 

A realistic patient example

Sarah (35) had painful periods and a 2cm ovarian endometrioma. Her AMH was borderline. After multidisciplinary counselling, she elected to freeze eggs prior to laparoscopic excision of the endometrioma performed by a specialist endometriosis surgeon. Later she proceeded to IVF and achieved a successful pregnancy. The sequence preserved her ovarian reserve while treating symptoms.

 

FAQs

Will endometriosis always cause infertility?
No — many people with endometriosis conceive naturally. The impact depends on disease severity, location, and individual factors.

Should I have my endometrioma removed before IVF?
Not always. If the endometrioma interferes with access to follicles, causes pain, or is large, surgery may be advised. But cystectomy can reduce ovarian reserve, so the decision is individualised.

Does surgery cure endometriosis?
Surgery can remove lesions and relieve pain, but endometriosis can recur. Long-term management often combines surgery, medical therapy and lifestyle care.

 

Final thoughts

Endometriosis and fertility care require thoughtful, personalised planning. Early assessment, collaboration between specialist surgeons and fertility teams, and clear counselling are essential. With the right approach many people with endometriosis go on to have successful pregnancies—sometimes with assistance, sometimes naturally.

If you’re concerned about endometriosis or fertility, book a consultation and we can discuss your situation.

 

📍Dr Alice Huang – Fertility Specialist Melbourne
Book a consultation today and let’s take the first step together.

Disclaimer: This information is general in nature and does not replace medical advice. Please consult with your treating specialist for individualised guidance.