A common symptom of endometriosis is fertility issues. Up to 50% of people with endometriosis will struggle to conceive, with the causes still relatively unknown. Here take a deep dive into what you need to know about your fertility if you have diagnosed or suspected endometriosis.

Quick facts:

• Although common, having endo does not mean you will have fertility problems. 
• Possible causes of fertility issues could be structural issues, endometriomas, immune reactions and painful sex.
• There are treatments available to improve fertility with endo, including surgery.

What is endometriosis?

Endometriosis is a reproductive health condition where tissue similar to the lining of the womb grows in other places. This is called endometrial tissue. This tissue can grow in the ovaries and fallopian tubes and can cause painful symptoms. 

It’s one of the most common reproductive health conditions. 1 in 10 women and those assigned female-at-birth (AFAB) will develop endometriosis, yet its definitive cause is still unknown. 

As a long-term condition, endometriosis can significantly impact some people’s lives. One of the most common concerns is how does endometriosis affect fertility?

Will endometriosis affect my fertility?

In short, it might. Fertility problems are common in those with endometriosis, with 30-50% experiencing fertility problems (1).

But having endometriosis does not automatically mean you will have fertility problems—every case is different. It will depend on the severity of your symptoms and any structural or hormonal issues you may have. 

Is it possible to get pregnant with endometriosis?

Yes, it’s possible to get pregnant with endometriosis. However, you may experience difficulty getting pregnant. Those with endometriosis have a lower chance of getting pregnant with each monthly cycle (2). This can result in it taking longer for people with endometriosis to conceive (3). 

Infertility is also common in those with endometriosis, and in subfertile (failure to conceive after one year of trying) women the prevalence seems to be considerably higher, ranging from 20% to 50%, but it varies with time and age (1).

How does endometriosis affect fertility?

Again, not necessarily. But those with endometriosis are at an increased risk of miscarriage, ectopic pregnancy and other obstetric complications compared to those without (4).

How does endometriosis affect fertility?

Exactly why and how endometriosis affects fertility is still unknown. But here are the latest theories of possible links and causes. 

Structural issues

One of the ways endometriosis is likely to affect fertility is by distorting the position of reproductive organs. Growth of endometrial tissue and adhesions around the uterus and Fallopian tubes can cause this distortion. In turn, this may block mature eggs from reaching the uterus to be fertilised. The risk of blocked Fallopian tubes, in particular, increases in the more advanced stages of endometriosis. 

Endometriomas

The presence of cysts on your ovaries, called endometriomas, could also affect fertility and ovulation. Endometriomas can damage ovarian tissue and the precious ovarian follicles which house immature eggs. 

Immune reaction

Another theory is an immune reaction to endometrial tissue growing outside the uterus. This is because this tissue is recognised as ‘foreign’ to these parts of the body. The immune system responds by attacking it, causing inflammation. Inflammation leads to harmful toxins which may affect Fallopian tube function, sperm function and egg quality (5).

Womb reciprocity

There is also debate about whether endometriosis affects the receptivity of the womb to a fertilised egg. However, there is currently no conclusive evidence to prove this theory. 

Painful sex

Painful sex is one of the symptoms associated with endometriosis. Pain during or after intercourse can negatively impact your sex life and make the trying-to-conceive process difficult.

Can treating endometriosis improve fertility?

Various treatments for endometriosis that aim to improve fertility. The right ones for you will depend on the location and severity of your endometriosis and what your symptoms are. 

One treatment that aims to improve fertility is laparoscopic surgery. This is surgery to remove the endometrial tissue deposits and adhesions. It aims to free the pelvic organs of any structural issues or blockages and reduce inflammation. 

For people with endometrioma, laparoscopic ovarian cystectomy can remove the endometriosis-related cysts on the ovaries (6). This has been shown to lower the recurrence rate of both cysts and pain symptoms. 

However, there are risks associated with any surgery. For example, ovarian cystectomy can also negatively affect ovarian reserve by the removal of healthy tissue. 

It’s important to discuss the potential for surgery with a specialist. And to explore the individual risks.

How can I improve my chances of conceiving with endometriosis?

If you’re trying to conceive with endometriosis, there are options to improve your chances. These include expectant management and assisted reproductive techniques (ARTs). 

Expectant management 

This is for heterosexual people who are trying to conceive naturally and: 

• Have suspected endometriosis
• Have a normal ovarian reserve
• Have normal Fallopian tube function
• Are not experiencing pelvic pain
• Have no evidence of any hormone imbalances
• Have no issues with their partners’ fertility

To improve your chances of conceiving with every menstrual cycle, it is recommended to have sex every 2-3 days so there is a good chance of catching your fertile window.  

Assisted reproductive techniques (ARTs)

ART options include ovarian stimulation (COS), intrauterine insemination (IUI), and in-vitro fertilisation (IVF). 

Depending on your age, ART is recommended if:

• You’ve not conceived after 6-12 months of trying.
• Youre in a same-sex relationship.

IUI is usually offered to couples with minimal or mild endometriosis if their partner has normal semen quality and is typically not offered to those with moderate/severe endometriosis, because of a probable effect on the Fallopian tubes.

IVF can be offered to those with moderate or severe endometriosis. It can also help those with a very low egg reserve.

IVF has been found to be less successful in people with endometriosis compared to those without endometriosis. However, lots of factors influence IVF success, like age, whether you’ve been pregnant before, if you’ve had treatment before body mass index, underlying health conditions, lifestyle and your partner’s sperm quality. 

Resources:

1. (ASRM, 2016; Zondervan et al., 2018)
2. (The Practice Committee of the American Society for Reproductive Medicine, 2012). 
3. (Zondervan et al., 2018).
4. (Saraswat et al., 2017)
5. (Sanchez et al., 2017).
6. (European Society of Human Reproduction and Embryology, 2022).
7. (ETIC Endometriosis Treatment Italian Club, 2019).
8. (Tan et al., 2018).