Endometriosis and fertility

Endometriosis and fertility

Endometriosis and fertility problems are closely linked - approximately 40% of women with endometriosis experience fertility difficulties. At the same time, an important message: endometriosis does not mean infertility.

An Australian study following nearly 4,000 women with endometriosis found that while 54% were unable to conceive naturally within the first 12 months, 70% of them eventually had at least one child - either naturally or with treatment. A diagnosis of endometriosis is not a reason to give up hope.

How does endometriosis affect fertility?

• Adhesions and fallopian tube damage - adhesions caused by inflammation can block the fallopian tubes or disrupt egg transport to the uterus
• Ovarian endometriomas - cysts filled with old blood damage healthy ovarian tissue and reduce egg reserve
• Inflammatory environment in the pelvis - inflammatory substances produced by lesions can damage eggs and sperm and disrupt fertilisation
• Disrupted uterine environment - endometriosis may affect uterine lining receptivity for embryo implantation
• Adenomyosis - if present simultaneously, it further disrupts uterine contractions and conditions for embryo implantation

Natural conception

Many women with endometriosis - particularly at lower stages - conceive naturally without any fertility treatment. If you have been unable to conceive for more than 6 months (or 12 months if over 35), it is appropriate to seek specialist advice.

Surgical removal of lesions, endometriomas and adhesions can significantly improve conditions for natural conception.

What doesn't work - an important warning

Hormonal treatment of endometriosis does not treat infertility. Preparations such as GnRH analogues, progestins or contraception suppress ovulation - they cannot improve the chances of conceiving. If your main goal is pregnancy, hormonal treatment of endometriosis is not the right path.

Equally, there is no evidence that endometriosis causes recurrent miscarriage, nor that treating endometriosis reduces miscarriage risk.

Surgical treatment and fertility

Laparoscopic removal of lesions and adhesions improves chances of natural conception - results depend on disease extent and severity:

• Minimal-mild endometriosis - surgical treatment is effective and achieves better pregnancy rates than diagnostic examination alone without treatment
• Moderate-severe endometriosis - results vary; some surgeons report that the proportional fertility benefit of surgery is greatest in more severe cases

For ovarian endometriomas: excision (surgical removal) of endometriomas larger than 4 cm improves pregnancy chances and reduces recurrence risk compared to simple drainage and coagulation.

IUI - intrauterine insemination

IUI is an assisted reproduction method in which sperm is placed directly into the uterus, combined with hormonal ovarian stimulation (Clomid, Gonal-F, Puregon).

In women with minimal-mild endometriosis, IUI with ovarian stimulation is more effective than attempting natural conception. An important guideline: if pregnancy has not occurred after 3-4 IUI cycles, further cycles are unlikely to help - it is appropriate to move on to IVF.

IVF - in vitro fertilisation

IVF is recommended particularly when the fallopian tubes are not functioning properly, the partner has reduced fertility, or other treatments have failed.

Key finding for IVF: One well-designed study showed that 3-6 months of GnRH analogue treatment before starting IVF increases the chances of pregnancy fourfold. Researchers note that more evidence is needed, but the result is significant enough that many centres take it into account.

IVF success rates in women with endometriosis: study results vary. One systematic review found results approximately one-third lower than in women with tubal infertility. Other large IVF databases found no significant difference. Results depend on age, egg reserve, endometriosis stage and centre experience.

Endometriomas and IVF - what to do?

• Leaving endometriomas in place - studies show that the presence of endometriomas alone does not significantly affect IVF outcomes
• Removal of endometriomas >4 cm before IVF is recommended - confirms diagnosis, may reduce pain, improves access to the ovary during egg collection and reduces infection risk
• Risk of surgery - removal of endometriomas may damage surrounding ovarian tissue and reduce egg reserve, particularly with repeated operations

This decision is highly individual and should be discussed with an experienced specialist who knows your specific situation.

Egg freezing - protecting future fertility

If you have been diagnosed with endometriosis and do not plan pregnancy in the near future, egg freezing (cryopreservation) may be a way to protect your fertility. Endometriomas progressively damage egg reserve - the sooner eggs are frozen, the better their quality will be.

Pregnancy and endometriosis

Pregnancy temporarily improves endometriosis symptoms - absence of menstruation and elevated progesterone levels settle the lesions. However, symptoms typically return after delivery and the end of breastfeeding. Pregnancy does not cure endometriosis.

Women with endometriosis have a slightly higher risk of some pregnancy complications - premature birth and ectopic pregnancy. It is important that your obstetrician also knows about your diagnosis.

Our collaboration with IVF centres

Our centre works closely with assisted reproduction centres. We coordinate care so that surgical treatment of endometriosis and any IVF follow each other in the optimal sequence and timing.

If you have endometriosis and are planning pregnancy - or are having difficulty conceiving - do not delay a consultation. Time matters, particularly if endometriosis is progressively reducing egg reserve. Book an appointment with us and we will find the best path together.

Further information: endometriosis.org - Infertility treatments.