Endometriosis is a disease that affects women of reproductive age and that may be
associated with both pelvic pain and infertility. Scientific advances have improved our
understanding of this benign (non-cancerous) but sometimes debilitating condition. And
modern medicine now offers women with endometriosis many treatment options for
relief of both pain and infertility.
But much remains unknown. Women who have been diagnosed with endometriosis
may wonder what this means for their future fertility. Similarly, women experiencing
infertility may wonder whether they have endometriosis and how that may affect their
prognosis. To quote a recent committee opinion from the American Society for
Reproductive Medicine (ASRM), “Treatment of endometriosis in the setting of infertility
raises a number of complex clinical questions that do not have simple answers.”
Here we aim to address the concerns of women facing endometriosis and/or infertility
and answer their most pressing questions. Armed with this fundamental knowledge,
women can take action to optimize both their own health and fertility.
What is Endometriosis?
Endometriosis is a disease involving growth of tissue resembling the endometrium
(uterine lining) in places outside the uterus. In the ovaries, cysts known as
endometriomas or “chocolate cysts” may form. Implants of endometriosis may grow on
the peritoneum (the lining of the abdomen and pelvis), sometimes causing scarring that
may involve the ovaries and block the tubes. In some women, endometriosis grows
deep beneath the peritoneal lining, such as in the area between the vagina and the
rectum. These cases are often associated with more severe pain, but not necessarily
more severe infertility. Although you or your physician may suspect endometriosis
based on signs, symptoms, and findings on physical exam, the only way to definitively
diagnose endometriosis is with a surgical procedure called a laparoscopy.
The cause of endometriosis is not known, although it often runs in families. Numerous
biochemical and immunological changes have been identified in association with
endometriosis, but it is unclear which may contribute to endometriosis and which simply
results from it.
What Treatments are Available for Endometriosis?
Birth control pills help relieve pelvic pain in many women, including those with
endometriosis. Women whose symptoms continue despite the pill should discuss with

their doctor undergoing a laparoscopy to see if they have endometriosis, which can
often be treated surgically at the time of the laparoscopy. Surgical treatment for
endometriosis has been shown to improve fertility, but women not ready to become
pregnant are encouraged to resume the pill to prevent endometriosis from recurring.
Stronger medications, such as leuprolide acetate, are effective to treat pain related to
endometriosis, but not infertility.
I Have Been Diagnosed with Endometriosis, But I am Not Yet Ready to Try to
Conceive. What Can I Do to Maximize My Future Fertility?
The birth control pill is commonly prescribed to reduce menstrual cramping and help
prevent endometriosis recurrence. Preventing endometriosis can help preserve fertility,
so the pill is an excellent treatment option following endometriosis surgery if you are not
yet ready to become pregnant.
Women with endometriosis should also strongly consider consulting with a fertility
specialist (a specialist in reproductive endocrinology/infertility), even if they are not yet
ready to try to conceive. This is particularly important if you are over 30 or if you have
“decreased ovarian reserve.” Fertility in women decreases with age. In addition to age,
“ovarian reserve” also helps predict your ability to conceive. Ovarian reserve is most
easily measured with a simple blood test called AMH (anti-mullerian hormone).
Surgery to remove or destroy endometriosis involving the ovaries may also reduce
ovarian reserve and thus lower a woman’s chances for pregnancy, even with fertility
treatment such as IVF. Women with moderate to severe endometriosis may have
scarring that can prevent the egg from entering the fallopian tube. Mild and minimal
endometriosis are also associated with infertility, so all women with endometriosis need
to consider the impact endometriosis may have on their fertility. A newer option is for
women to freeze eggs for possible future use in the event they experience infertility.
Unfortunately, egg freezing is costly and is usually not covered by insurance.
If I Have Infertility, Is It Important to Know Whether or Not I Also Have
Endometriosis?
No. In the 20th century, it was standard for all women with infertility to undergo
laparoscopy to see if they had endometriosis. Today, women with regular ovulatory
cycles, patent fallopian tubes, normal ovarian reserve, and a partner with a normal
semen analysis are said to have unexplained infertility, though some of these women
undoubtedly have endometriosis. Infertility treatments and success rates are generally
similar for women with endometriosis-related infertility and women with unexplained
infertility. Very few infertile women who undergo laparoscopic treatment of
endometriosis become pregnant as a result. But laparoscopy may be a good option for

women suffering from pelvic pain along with infertility, as well as for women who do not
consider IVF to be an option.
I Have Endometriosis and Now I am Also Experiencing Infertility. How Will This
Affect My Treatment?
It is helpful to bring the records from your surgery to your fertility specialist. Knowing the
severity of your endometriosis, whether it appears to have caused extensive scarring,
and whether it has affected your ovarian reserve will help you and your doctor plan the
most appropriate course of treatment. Although pregnancies do occur naturally in
women with endometriosis, pregnancy rates are superior with IVF. Women with low
ovarian reserve who do not conceive with IVF using their own eggs generally have an
excellent prognosis with donor egg IVF.
My Doctor Tells Me I May Need Another Operation for My Endometriosis. How Will
This Affect My Fertility?
Surgery to diagnose and destroy endometriosis can improve fertility, but repeat surgery
is generally not beneficial and may cause harm by reducing ovarian reserve. Large
endometriomas may need to be removed surgically prior to IVF, but smaller ones are
generally best left in place. Consider consultation with a fertility specialist before
undergoing another operation.