Endometriosis and Infertility: Symptoms and Treatment Options

What is endometriosis?

Endometriosis happens when tissue similar to the lining of the uterus (the endometrium) grows outside the uterus, commonly on the ovaries, fallopian tubes and the lining of the pelvis. Like the uterine lining, this tissue responds to hormones each cycle, which can cause inflammation, pain and scar tissue (adhesions).

Symptoms

• Painful periods that get worse over time
• Chronic pelvic pain, or pain during or after sex
• Pain with bowel movements or urination, especially during periods
• Heavy periods or bleeding between periods
• Fatigue, bloating or nausea
• Difficulty getting pregnant

Some people have severe disease with few symptoms, and others have significant pain with only mild disease.

How endometriosis affects fertility

Endometriosis may reduce fertility in several ways: scarring can distort the pelvis and block or damage the fallopian tubes, endometriomas (ovarian cysts) can reduce ovarian reserve, and inflammation may affect eggs, sperm and implantation. Even so, many people with mild disease conceive without treatment.

Diagnosis

Your clinician will take a history, perform a pelvic exam and often order a transvaginal ultrasound to look for endometriomas. MRI can map deep disease. Laparoscopic surgery can both diagnose and treat. Because endometriosis is often diagnosed late, advocate for yourself if pain is disrupting your life.

Treatment when you want to conceive

Pain treatments such as hormonal therapy do not help you conceive, because they work by suppressing ovulation. When pregnancy is the goal, options depend on severity, age and ovarian reserve:

• Trying naturally with timed intercourse, for mild disease and younger patients, often for a limited period.
• Laparoscopic surgery to remove or destroy lesions and adhesions in selected cases. See fertility surgery.
• Ovulation medication with IUI for mild disease with open tubes.
• IVF for moderate to severe disease, blocked tubes, older age, or when other treatments have not worked.

Questions to ask

Ask how surgery might affect your ovarian reserve, whether to test AMH and antral follicle count first, how long to try other options before moving to IVF, and what the clinic’s results are for patients with endometriosis. Use our appointment questions planner.

Stages and what they do and do not predict

Endometriosis is often described in stages from minimal to severe, based on the amount and location of disease found at surgery. These stages describe how much disease is present, but they correlate only loosely with pain and with fertility. Someone with minimal disease can have intense pain, and someone with severe disease can have few symptoms. Fertility is affected more by factors such as scarring around the tubes and ovaries, the presence of endometriomas, and age than by the stage label alone.

Why diagnosis is often delayed

Endometriosis takes years to be diagnosed for many people. Painful periods are often dismissed as normal, symptoms overlap with other conditions, and ultrasound can miss superficial disease. If you have pain that disrupts your life, it is reasonable to push for evaluation, ask for referral to a gynecologist experienced with endometriosis, and keep a symptom diary. Our cycle log lets you note pain and bleeding patterns to bring to appointments.

Endometriomas and ovarian reserve

Endometriomas, sometimes called “chocolate cysts,” are ovarian cysts filled with old blood. They can be a sign of more significant disease. Because surgery on the ovary can remove healthy ovarian tissue along with the cyst, and because the cysts themselves may affect the ovary, specialists weigh the benefits of removal carefully, particularly in people who want to conceive.

Testing AMH and antral follicle count before surgery gives a baseline. In some situations, going to IVF without surgery is preferred. In others, removing a large or painful cyst improves access to the follicles or relieves symptoms. This is a decision to make with a specialist who treats both endometriosis and infertility.

Timing when age matters

The decision of how long to try before moving to IVF depends heavily on age and ovarian reserve. A person in their late 20s with mild disease and open tubes may try for several months with ovulation medication and IUI. A person in their late 30s, or one with significant disease or reduced reserve, is often advised to move more quickly. Do not let a period of “wait and see” run on without a plan.

Managing pain while trying to conceive

Most hormonal pain treatments suppress ovulation, so they are stopped when you try to conceive. That can bring pain back. Talk with your clinician about options that are compatible with trying to conceive, which may include over-the-counter pain relievers, physical therapy for the pelvic floor, heat, and other non-hormonal approaches. Ask about what is safe in pregnancy before you start.

Endometriosis after pregnancy

Pregnancy does not cure endometriosis, although many people notice relief of symptoms during pregnancy and breastfeeding. Symptoms can return afterward, so it is worth planning follow-up care.

Questions to ask your care team

• What stage and type of disease do I have, and how does it affect fertility?
• Should I have surgery before trying, or go straight to treatment such as IUI or IVF?
• How could surgery affect my ovarian reserve?
• What pain management is compatible with trying to conceive?
• How long should we try before changing the plan?

Emotional health

Living with chronic pain while trying to conceive is hard. Seek support from your care team, patient communities and a counselor. See stress and emotional health.