Key takeaways

• Endometriosis can affect fertility through both inflammation and structural changes involving the ovaries, fallopian tubes, and surrounding tissue.
• Having endometriosis does not mean you cannot become pregnant.
• Symptoms vary widely, and pain severity does not necessarily reflect disease extent.
• Endometriosis may affect ovarian reserve, particularly when endometriomas involve the ovaries or surgery is required.
• Treatment before trying to conceive or beginning IVF should be individualized based on symptoms, fertility history, age, and reproductive goals.
• An earlier fertility evaluation can help clarify your options if you have endometriosis and are trying to build your family.

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When you’re trying to build your family, being diagnosed with endometriosis can immediately raise a bigger question: what does this mean for my fertility?

The answer is not always straightforward. Endometriosis can affect conception and fertility treatment differently depending on the location and extent of the disease, the level of inflammation, symptoms, ovarian involvement, and your individual reproductive goals.

To better understand how endometriosis can affect fertility, we spoke with Dr. Deepti Nahar, a highly esteemed OB-GYN in the Bay Area with expertise in complex gynecologic conditions and minimally invasive surgery, along with Collab Fertility founder and reproductive endocrinologist Dr. Thalia Segal.

How does endometriosis affect fertility?

“Endometriosis is when the lining of the uterus grows outside of the uterus, and therefore it can increase inflammation, which can directly impact fertility and pregnancy.

It can also cause scar tissue and shift the tubes and ovaries out of their normal position, which can affect the egg's ability to reach the tube and then the uterus.

So it can be both an anatomical or structural thing, along with also an inflammatory thing.”

Dr. Nahar’s explanation highlights why endometriosis can affect fertility in more than one way. Inflammation may affect the reproductive environment, while scarring and changes in pelvic anatomy can interfere with the normal interaction between the ovaries, fallopian tubes, and uterus.

Can you get pregnant with endometriosis?

“Yes. You can definitely get pregnant with endometriosis, and a lot of patients will.

They may notice that their symptoms actually improve during pregnancy. However, if they’re having difficulty getting pregnant, especially if it’s more than six months, potentially 12 months depending on age and everything, then I always tell people to go check with their fertility specialist.

It’s worthwhile taking a look because if there is something that we can do to help, and that’s what the patient wants in terms of actively trying to get pregnant, then it doesn’t make sense to wait three years.”

Having endometriosis does not automatically mean IVF will be necessary. Some patients conceive naturally, while others may benefit from fertility treatment depending on age, ovarian reserve, anatomy, how long they have been trying, and other fertility factors.

Can treating endometriosis improve the chances of pregnancy?

“Yes. Often, for sure. A lot of the treatments for endometriosis are hormonal management, which inherently will then prevent pregnancy, whether it’s by primary mechanism because of something like birth control or IUDs, or it’s through competing hormonal factors like GnRH agonists or antagonists.

A lot of times, for patients who are actively wanting to get pregnant or trying to get pregnant, surgery is one of the best options that they may have.

Surgery can remove some of the endometriosis lesions, try to restore normal anatomy, reduce scar tissue, and it can significantly increase the ability of that patient to get pregnant, both naturally and potentially make reproductive procedures more successful as well.”

The right treatment depends on the individual patient. For someone who is actively trying to conceive, the approach may be very different from the treatment used primarily to control pain or other endometriosis symptoms.

Does endometriosis affect ovarian reserve?

Endometriosis can affect the ovaries, particularly when a patient develops endometriomas, sometimes called chocolate cysts.

“Endometriosis can definitely decrease egg quantity for sure, especially because a lot of times endometriosis can lead to endometriomas, which is where we get chocolate cysts or endometrial cells that start growing within the ovary and taking up space in the ovary.

That directly affects fertility, but then also a lot of times those patients often end up having pain and/or needing surgery, and then a portion of their ovary is removed as well, or it’s been replaced by this chocolate cyst.

So in that sense, it can definitely affect their fertility or egg reserve.”

Importantly, ovarian reserve should be evaluated in the context of the entire fertility picture rather than relying on a single test such as AMH. Age, antral follicle count, ovarian history, previous surgery, and reproductive goals all matter.

Can endometriosis contribute to implantation failure?

Endometriosis is associated with an inflammatory reproductive environment, which may be one factor considered when evaluating implantation difficulties.

Dr. Nahar explains:

“All of it causes this inflammatory state. Often, we want to do endometrial biopsies not just to check for cancer or precancer, but also to look at the white cell count and for inflammation.

A lot of times that was then correlated with higher inflammatory markers, higher white cells, potentially leading to more risk of rejection or implantation failure.”

Implantation failure can have many possible causes, so endometriosis should be considered as one part of a broader fertility evaluation rather than assumed to be the explanation for an unsuccessful embryo transfer.

Can endometriosis be “silent”?

Yes.

Dr. Nahar explains that the severity of someone’s symptoms does not necessarily reflect how extensive the disease may be.

“There’s no rhyme or reason. Sometimes patients have crippling pain, and I go in, and I either barely see endometriosis, or maybe it’s barely stage one, or sometimes not even anything.

And then sometimes I go in, and I’m like, ‘How in the world was she walking? Was she doing anything?’ And we just go in for some other reason.”

For some patients, difficulty conceiving or recurrent pregnancy loss may be one of the reasons an underlying reproductive condition is investigated, even when significant pelvic pain is not present.

Should endometriosis be treated before IVF?

“I think it depends.”

Dr. Nahar explains that treatment decisions should take into account the extent of a patient’s symptoms, how long they have been trying to conceive, and whether delaying fertility treatment for surgery makes sense.

“I don’t think it always needs to be treated. A lot of times, endometriosis can be treated with hormonal suppression as well.

I think it comes down to: what symptoms is the patient having? Are the symptoms tolerable, or are they so bad that they can’t even go through a week or two right now, much less a few months of fertility treatment?

I’ve had patients that are like, ‘I really want to get pregnant. I don’t want to try to delay things right now.’ Then usually I’ll say, ‘Go for it. If you haven’t tried, go for it. Give it six months. Let’s see how things go. And if you get pregnant, great, amazing.’

However, if you’ve been trying and it’s not happening, you’re having miscarriages, or your symptoms are so bad that you can’t even fathom having sex, much less trying to get pregnant, then we may want to treat those symptoms first, whether it’s medically and/or surgically.”

There is no universal rule that every patient with endometriosis needs surgery before IVF. The decision should balance symptom management with age, ovarian reserve, fertility history, and the potential impact of delaying treatment.

How is endometriosis diagnosed?

“Endometriosis actually is a clinical diagnosis. Typically it relates to women having cyclical pain correlated with their menstrual cycle that is more than the typical pain for periods.”

One challenge is that severe period pain is often normalized.

Dr. Nahar explains:

“Sometimes it’s, ‘Oh, that’s your period. You’ve got to deal with it. This is how it works. This is how mine was. This is how your grandma’s was. So don’t complain. Work with it.’

And so you’re like, ‘Okay, I guess this is how it’s supposed to be,’ until they come in and they’re like, ‘Oh yeah, for two days a month, I don’t get out of bed because I’m in a fetal position.’

That’s not normal.”

When evaluating pelvic pain, she also looks closely at whether symptoms change with the menstrual cycle, diet, activity, or other factors because pelvic pain can have gastrointestinal, musculoskeletal, and other causes.

Surgery can provide confirmation of endometriosis, but the disease does not always have one obvious appearance. Dr. Nahar may see lesions, scarring, puckering or pulling of tissue, or deeper disease involving surrounding structures.

MRI may also be helpful in certain cases, particularly when interpreted by a radiologist experienced in identifying endometriosis.

When should you see a fertility specialist for endometriosis?

Consider speaking with a fertility specialist if:

• Your periods are significantly painful
• You have known or suspected endometriosis
• Your cycles are irregular
• You have been trying to conceive without success
• You have experienced recurrent pregnancy loss
• You are concerned about your ovarian reserve
• You are considering delaying pregnancy or preserving fertility

Dr. Nahar notes that even an initial evaluation can be helpful:

“Sometimes we don’t do a full workup right then and there, but if we can start doing some basic workups and figure out what’s going on, it might be worthwhile.”

Collab Fertility’s in-house nutritionist, Shannon Keefe, shares that emerging research suggests targeted nutrition interventions may improve symptoms and quality of life for people with endometriosis. Because symptoms, gastrointestinal involvement, nutrient needs, and fertility goals vary so much between individuals, nutrition care is most useful when it’s personalized rather than built around a one-size-fits-all endometriosis diet.

Historically, nutrition received little attention in endometriosis care. Today, individualized nutrition strategies are playing a growing role alongside standard treatment. A well-tailored approach can help ease patients' symptoms, support their fertility goals, improve their nutrient status, and make some hormone-related side effects easier to manage. These are things that are a large focus at Collab Fertility as part of the Collab Way. 

Understanding the Full Fertility Picture

Endometriosis does not affect every patient in the same way.

The extent of the disease, symptoms, ovarian involvement, age, ovarian reserve, fertility history, and reproductive goals can all influence whether treatment is recommended and when.

At Collab Fertility, we take an individualized approach to understanding how endometriosis may be affecting your fertility and determining the next steps that make sense for your goals.

If you have been diagnosed with endometriosis, are experiencing painful periods, or have questions about how endometriosis may affect conception or fertility treatment, schedule a consultation with Collab Fertility to learn more about your options.

This version removes the fibroid-specific sections entirely, including fibroid infertility, fibroid removal, pregnancy with fibroids, hysteroscopy for fibroids, and the fibroid embryo-transfer case example. I also removed the adenomyosis section and references so the article stays completely focused on endometriosis.

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