Endometriosis and fertility: what research shows

Endometriosis and fertility are linked in many studies, but the link is more complicated than the common summary that endometriosis causes infertility. Endometriosis is found in a large share of people who have trouble conceiving, and some studies show that those with the condition conceive more slowly, especially at younger ages. Other studies find that many people with endometriosis conceive without help. Research on surgery, hormonal treatment, ovarian reserve, in vitro fertilization (IVF) and pregnancy outcomes gives a mixed picture, and several of the best-known findings are older, small or observational. This article describes what the main studies and guidelines report, who was studied, and where the evidence is thin.

What "fertility" and "infertility" mean in these studies

Researchers do not all use the same definitions. In the Nurses' Health Study II, infertility meant attempting to conceive for more than 12 months ^[5]. In the Canadian trials of surgery, the outcome was a pregnancy that continued for at least 20 weeks, counted over 36 weeks of follow-up ^[12]. Other studies count clinical pregnancy, a pregnancy seen on ultrasound, or a live birth ^[14][17]. These are different outcomes. A treatment can raise one and leave another unchanged, and the Cochrane review of laparoscopic surgery found data on ultrasound-confirmed pregnancy but none on live birth ^[14]. That gap matters when reading any single number.

Studies describe fertility as a rate or a probability, such as pregnancies per 100 person-months ^[12], not as a trait a person either has or lacks. The American Society for Reproductive Medicine (ASRM) describes fertility evaluation as a systematic process that starts with the least invasive methods for finding the most common causes ^[41]. Endometriosis is one of several possible factors in that process, and the studies below often include other factors that occur alongside it, such as tubal disease, male-factor infertility and diminished ovarian reserve ^[4][11]. ASRM notes that treating endometriosis in the setting of infertility raises complex clinical questions that do not have simple answers ^[2].

How often endometriosis is found among people who have trouble conceiving

The background section of a 2013 meta-analysis states that endometriosis is found in 0.5% to 5% of fertile women and in 25% to 40% of infertile women ^[3]. A critical review of epidemiology estimates that about 10% of women of reproductive age have endometriosis ^[40]. That review also stresses the need for a clear case definition and attention to diagnostic bias ^[40]. The authors of the Nurses' Health Study II analysis, described below, raise possible detection bias in earlier studies ^[5]. In plain terms, endometriosis may be looked for, and therefore found, more often in people being evaluated for infertility.

A study from Leuven, Belgium illustrates the figures. It was a retrospective case series of 221 infertile women treated at a tertiary academic fertility center. All had regular cycles and partners with normal semen analyses, and all had a diagnostic laparoscopy, with surgery if needed. Endometriosis was found in 47% (104 of 221). Among those 104, the stages were I in 39%, II in 24%, III in 14% and IV in 23%, using the revised American Fertility Society classification ^[4]. The rate was similar in those with pelvic pain (54%) and without it (40%) ^[4]. Another finding was that 29% of all the women had a tubal or uterine problem that could reduce fertility, including 40% of the women who did not have endometriosis ^[4].

Two cautions apply. The women were treated at one tertiary center and had surgery as part of their care, so the figure is not a general rate for infertile women. And finding endometriosis at laparoscopy does not show that it is the reason a couple has not conceived. The authors' model, which used pain, ultrasound findings, age, duration of infertility and type of infertility, was not reliable enough to predict which women had endometriosis ^[4].

Does endometriosis lower the chance of conceiving?

The most useful design for this question follows people over time, before infertility is known. The Nurses' Health Study II followed 58,427 married premenopausal nurses under age 40 from 1989 to 2005. Laparoscopically confirmed endometriosis was the exposure, and infertility was defined as more than 12 months of attempting conception ^[5]. Over 362,219 person-years the study identified 4,612 cases of infertility from any cause. Compared with women without endometriosis, those with it had an age-adjusted hazard ratio for infertility of 2.12 (95% confidence interval 1.76 to 2.56). The association was clear in women under 35 (multivariate hazard ratio 1.77) and weaker, with a confidence interval that included no effect, at ages 35 to 39 (1.20; 0.94 to 1.53) ^[5].

The same paper reports findings that are easy to miss. Among women with primary infertility, 50% became parous after the endometriosis diagnosis, and among all women with endometriosis, 83% were parous by age 40 ^[5]. The authors suggest the infertility risk from endometriosis may be about half the size seen in cross-sectional analyses ^[5]. They list two limits: they had no information on intentions to conceive, and women with undiagnosed endometriosis were counted as unexposed ^[5].

A second line of evidence compares women who have minimal or mild endometriosis with women whose infertility has no explanation. In a Canadian prospective cohort of 331 infertile women aged 20 to 39, 168 with minimal or mild endometriosis were compared with 263 with unexplained infertility, and both groups were managed without treatment. Fecundity over 36 weeks was 18.2% in the endometriosis group and 23.7% in the other group, and the adjusted fecundity rate ratio was 0.83 with a 95% confidence interval of 0.53 to 1.32. The authors concluded that fecundity in minimal or mild endometriosis was not significantly lower than in unexplained infertility ^[6]. The interval is wide enough that a modest difference in either direction cannot be excluded.

Taken together, these studies show that the answer depends on age and on the comparison group. A twofold rate against women without endometriosis was seen in one cohort ^[5], while a comparison with unexplained infertility found a smaller, statistically uncertain difference ^[6].

Proposed explanations for how endometriosis might affect fertility

Reviews describe several mechanisms, and none is settled. A review in Obstetrics and Gynecology Clinics of North America says the mechanisms are not fully understood. It proposes that endometriosis affects eggs and embryos, the fallopian tubes and embryo transport, and the lining of the uterus, and that these changes likely all contribute ^[7]. A Lancet review describes the association as clinical, notes that most evidence on surgery is uncontrolled, and sets out a framework that weighs surgery, medical treatment and assisted reproduction against age, ovarian reserve, and male and tubal status ^[8].

Effects on the tubes are one of the proposed routes ^[7]. Consistent with that, the Endometriosis Fertility Index described below found that a score for tubal, fimbrial and ovarian function at the end of surgery was the most important contributor to its prediction of later pregnancy ^[18][19]. For people with minimal disease, the explanations are more tentative, and the reviews do not claim otherwise ^[7].

One registry comparison tries to separate egg quality from the uterine lining. Researchers used UK Human Fertilisation and Embryology Authority data from 1996 to 2016 to compare 758 cycles in which women with endometriosis received donated eggs with 12,856 autologous IVF cycles in women whose only infertility diagnosis was endometriosis. Live birth rates after fresh embryo transfer were 31.6% and 31.0% (adjusted odds ratio 1.05, 99.5% confidence interval 0.79 to 1.41), and the frozen transfer comparison also showed no significant difference ^[9]. The authors read this as suggesting little or no effect of oocyte quality on IVF outcomes in endometriosis. Limits include no data on disease extent or classification, no data on oocyte number, and no information on adenomyosis, which often coexists with endometriosis ^[9]. This is a registry analysis, and it does not exclude effects on eggs in individual cases.

Surgery and natural conception

Surgery for endometriosis-associated infertility has been studied for decades, and the findings are less consistent than the common summary suggests.

The Canadian trial randomized 341 infertile women aged 20 to 39 with minimal or mild endometriosis, during diagnostic laparoscopy, to resection or ablation of visible disease or to diagnostic laparoscopy only. Pregnancies that lasted at least 20 weeks occurred in 50 of 172 women in the surgery group and 29 of 169 in the control group, with cumulative probabilities of 30.7% and 17.7% (log-rank P = 0.006). The fecundity rate ratio was 1.9 (95% confidence interval 1.2 to 3.1). Fetal losses were similar in the two groups ^[12].

An Italian randomized trial of 101 women aged 36 or younger with minimal or mild disease and otherwise unexplained infertility of at least two years found no significant difference. After one year of attempting to conceive, 12 of 51 (24%) in the resection or ablation group and 13 of 45 (29%) in the no-treatment group had conceived, and the one-year birth rate was 19.6% and 22.2%. The authors concluded that the study did not support a marked improvement from ablation ^[13]. The trial was small, so it could not exclude a modest benefit.

The Cochrane review of laparoscopic surgery for endometriosis included 14 randomized trials with 1,563 women. It reported moderate-quality evidence that laparoscopic treatment raised the rate of viable intrauterine pregnancy confirmed by ultrasound compared with diagnostic laparoscopy only (odds ratio 1.89, 95% confidence interval 1.25 to 2.86, three trials, 528 participants). It found no studies that reported live birth. It also notes common limitations in the underlying trials, including unclear blinding and randomization methods, and insufficient data on adverse events ^[14].

A narrower analysis tried to estimate the real size of the benefit. It concluded that the increase in postoperative likelihood of conception over the background rate was probably between 10% and 25%, with a limited effect from surgery on peritoneal lesions. It described the benefit of removing endometriomas as hard to define, and it judged excision of rectovaginal disease to be of questionable benefit with a concerning rate of complications. It concluded that the absolute benefit appears smaller than previously believed ^[15]. This 2009 analysis was not a formal meta-analysis.

A network meta-analysis of 26 randomized trials covering 2,245 women with laparoscopically confirmed endometriosis and infertility reported that, compared with placebo, laparoscopic surgery alone (odds ratio 1.63, 95% confidence interval 1.13 to 2.35) and GnRH agonist alone (odds ratio 1.68, 1.07 to 2.46) were each associated with higher odds of pregnancy. Evidence on other interventions and on live birth, miscarriage and adverse events was insufficient ^[17].

The ESHRE guideline reflects this uncertainty. As summarized from its text, the guideline offers operative laparoscopy as an option for stage I or II disease with infertility and says the decision should be guided by the presence or absence of pain ^[1]. For endometriomas and deep disease the recommendations are labeled weak, and surgery is described as something that may be considered ^[1]. The guideline group also states that, based on existing evidence, no firm recommendations could be made on the most appropriate treatments ^[1].

Hormonal treatment and fertility

Endometriosis appears to depend on estrogen, and that is why ovulation-suppressing drugs were tried as a way to improve later fertility ^[16]. Medical treatments for endometriosis are themselves contraceptive during use ^[8]. A Cochrane review of ovulation suppression included 24 trials. For pregnancy after suppression versus placebo or no treatment, the odds ratio was 0.79 (95% confidence interval 0.54 to 1.14) for all women randomized and 0.80 (0.51 to 1.24) for subfertile couples only. The authors found no evidence of benefit from ovulation suppression in subfertile women with endometriosis who wish to conceive ^[16]. The review was last published in 2007.

The ESHRE guideline, as summarized from its text, advises against ovarian suppression to improve fertility and against postoperative hormone suppression whose only purpose is to increase future pregnancy rates ^[1]. It adds that women who cannot or choose not to conceive right after surgery may be offered hormone therapy ^[1]. Whether hormonal treatment helps pain is a separate question outside this article.

Estimating chances after surgery: the Endometriosis Fertility Index

The Endometriosis Fertility Index (EFI) is a scoring tool for people with surgically documented endometriosis who then try to conceive without IVF. It combines history (age, years of infertility, prior pregnancy) with surgical findings, including a least function score that describes how well the tubes, fimbriae and ovaries work at the end of surgery. The developers built it on 579 patients from a private reproductive endocrinology practice and tested it prospectively on 222 more ^[18].

An external validation in 233 women at a Belgian university center found a significant relationship between EFI score and time to non-IVF pregnancy. The Kaplan-Meier estimate of cumulative pregnancy at 12 months after surgery was 45.5% overall, ranging from 16.7% for scores of 0 to 3 up to 62.6% for scores of 9 and 10. The authors noted that the score performed only moderately for prediction and that the decrease in prediction error was small ^[19]. A retrospective cohort of 279 women with stage III or IV disease reported that 63% had a live birth after surgery, 64% of those without IVF, and that estimated five-year non-IVF live birth rates rose from 0% with an EFI of 0 to 2 up to 91% with an EFI of 9 or 10. That study is retrospective, and its authors acknowledge that the EFI is somewhat subjective ^[20]. A meta-analysis of 17 studies and 4,598 women reported cumulative non-IVF pregnancy rates at 36 months of 10% for an EFI of 0 to 2 and 69% for 9 to 10, and called the score's prognostic performance good while noting substantial heterogeneity between studies ^[21].

The EFI works only after surgery, because it needs operative findings. It is a group-level estimate, and individual outcomes within any score band vary. As summarized from its text, the ESHRE guideline describes the EFI as validated, reproducible and cost-effective for counseling about chances after surgery ^[1].

Ovarian endometriomas and ovarian reserve

Ovarian endometriomas are estimated to affect 17% to 44% of women with endometriosis ^[25]. Researchers have studied two separate questions: whether an endometrioma itself reduces ovarian reserve, and whether removing it does.

Ovarian reserve is the number of eggs remaining in the ovaries. ASRM states that markers of ovarian reserve, such as hormone levels and ultrasound counts, can predict how many eggs are retrieved after stimulation, but are poor predictors of reproductive potential independent of age ^[34]. This caveat applies to everything below: a lower marker value does not by itself mean a lower chance of pregnancy.

On the first question the evidence conflicts. A meta-analysis of 17 studies, with 968 patients with unoperated endometriomas and 1,874 without, found lower AMH in the endometrioma group (mean difference -0.84 ng/mL, 95% confidence interval -1.16 to -0.52) ^[23]. A separate meta-analysis found lower antral follicle count and AMH, and higher follicle-stimulating hormone, in people with endometriosis, particularly those with endometriomas and advanced stage disease ^[24]. A more recent meta-analysis took another approach. It compared the ovary with an unoperated endometrioma to the other ovary in the same women with unilateral disease. Across 13 observational studies, the number of oocytes retrieved was comparable (mean difference -0.72, 95% confidence interval -1.45 to 0.02), though the number of embryos formed was lower in the affected ovary. Eight of the studies were retrospective, none was preregistered, and the effect of larger endometriomas stayed uncertain ^[25].

On the second question, the evidence is more consistent. A systematic review of 11 studies found that nine reported a statistically significant fall in serum AMH after excision of endometriomas, with larger declines after surgery for bilateral cysts. The authors did not pool data because the studies were too different ^[27]. A meta-analysis of eight prospective studies and 237 patients found a significant fall in AMH after cystectomy (weighted mean difference -1.13 ng/mL) with high heterogeneity ^[26]. A later meta-analysis of 12 prospective controlled studies and 783 women found that AMH fell by 39.5% after unilateral and 57.0% after bilateral cystectomy, and the authors argued that surgery, more than the cyst itself, harms ovarian reserve ^[28].

These studies measure a blood marker, not pregnancy, and the clinical meaning of a lower AMH after surgery is uncertain, as the ASRM caution above suggests ^[34]. As summarized from its text, the ESHRE guideline comments that surgery is likely to have a negative effect on ovarian reserve ^[1].

IVF and other assisted reproduction

ESHRE states that assisted reproductive technology (ART) can be performed for endometriosis-associated infertility, especially if tubal function is compromised ^[1]. Outcomes in women with endometriosis have been compared with those of other women many times, with mixed results.

A BJOG meta-analysis of 27 observational studies covering 8,984 women found reduced fertilization rates in stage I or II disease (relative risk 0.93, 95% confidence interval 0.87 to 0.99), and reduced implantation (relative risk 0.79) and clinical pregnancy (relative risk 0.79) in stage III or IV disease ^[3]. A larger meta-analysis in Obstetrics and Gynecology reported that, compared with women without endometriosis, women with endometriosis had a similar live birth rate per woman (odds ratio 0.94, 95% confidence interval 0.84 to 1.06, 13 studies, 12,682 patients), a lower clinical pregnancy rate (0.78), and fewer oocytes retrieved per cycle (a mean difference of about two). Women with stage III or IV disease had lower live birth and pregnancy rates ^[10].

A U.S. registry analysis of 347,185 autologous cycles from 2008 to 2010 added a distinction. Endometriosis made up 11% of cycles, and 64% of those cycles reported another infertility diagnosis, most often male factor (42%), tubal factor (29%) or diminished ovarian reserve (22%). Isolated endometriosis was associated with similar or higher live birth rates than other diagnostic groups. Endometriosis combined with other diagnoses was associated with lower implantation and live birth rates ^[11]. The authors concluded that the link between endometriosis and IVF outcome is confounded by other infertility diagnoses ^[11]. This was a retrospective analysis of reported cycles, and the diagnoses came from clinic reporting.

Two reviews address whether endometriomas, or surgery for them, change IVF results. A Human Reproduction Update meta-analysis of 33 studies, 30 of them retrospective, found that women with endometrioma had a similar live birth rate (odds ratio 0.98) and clinical pregnancy rate, fewer oocytes retrieved, and a higher cycle cancellation rate (odds ratio 2.83). Women who had endometrioma surgery before IVF had a similar live birth rate (odds ratio 0.90) to those who did not ^[22]. A 2026 meta-analysis of 22 studies and 3,590 participants compared surgery followed by IVF with direct IVF. Surgery did not significantly improve live birth in women with ovarian endometriomas (odds ratio 0.89) or deep endometriosis (odds ratio 1.82, with a wide interval of 0.70 to 4.77) and, in the endometrioma subgroup, lowered AMH and the number of oocytes retrieved. The authors rated the certainty of evidence as very low ^[29].

As summarized from its text, the ESHRE guideline recommends against routine surgery before ART for stage I or II disease and for endometrioma to improve live birth, and says excision of deep disease before ART should be guided mainly by pain symptoms and patient preference ^[1]. It also states that women with endometriosis can be reassured about the safety of ART, and that no specific ART protocol can be recommended for them ^[1].

Pretreatment with a GnRH agonist for at least three months before IVF was reviewed in eight randomized trials with 640 participants. The Cochrane authors graded the evidence very low to low and said they were uncertain about effects on live birth or complications compared with no pretreatment. One trial of 147 women reported a lower live birth rate with pretreatment (relative risk 0.48, 95% confidence interval 0.26 to 0.87) ^[30]. The ESHRE guideline does not recommend extended GnRH agonist use before ART to improve live birth ^[1].

A frequent question is whether stimulation for IVF makes endometriosis worse. In an Italian observational study of 189 women with endometriosis who had IVF, 22% reported recurrence, and the cumulative recurrence rate over 36 months was 20%. Neither the number of IVF cycles nor the response to stimulation was associated with recurrence ^[31]. The study was single-center, relied on contacting patients, and did not include a comparison group that avoided IVF, so it cannot show that IVF has no effect.

Egg freezing for people with endometriosis

A group of studies looks at fertility preservation, in which eggs are vitrified (frozen) for possible later use. A retrospective study at a university-affiliated private IVF center followed 485 women with endometriosis who froze eggs between 2007 and 2018. Mean age at freezing was 35.7 years. Oocyte survival was 83.2% and the cumulative live birth rate was 46.4%. Women with prior ovarian surgery had fewer oocytes frozen per cycle than those without surgery, and younger women who had not had surgery had the highest cumulative live birth rate (72.5% versus 52.8% in younger women who had surgery) ^[32]. A follow-up analysis of the same cohort reported that the estimated cumulative live birth rate rose with the number of oocytes used, reaching 89.5% (95% confidence interval 80.0% to 99.1%) with 22 oocytes, and was higher in women 35 or younger than in older women ^[33].

These are retrospective results from one center. The higher figures come from survival-curve modeling (Kaplan-Meier) of the number of eggs used, so they are projections and not observed outcomes for every woman who froze eggs ^[33]. The comparison group of elective freezing patients differed in age ^[33]. As summarized from its text, the ESHRE guideline says clinicians should discuss the pros and cons of fertility preservation with women who have endometriosis, and it rates the supporting evidence as very low certainty ^[1].

Age, ovarian reserve and why timing appears in so many studies

Age appears in almost every analysis above. In the Nurses' Health Study II, the infertility association was seen under 35 and not clearly at 35 to 39 ^[5]. In the egg-freezing cohort, younger age was associated with better outcomes ^[32][33]. In the EFI, age is one of the inputs ^[18][19]. The American College of Obstetricians and Gynecologists notes that fertility declines with age as ovarian follicle count falls, that patients tend to overestimate their chance of pregnancy at all ages, and that factors unrelated to age may speed ovarian decline ^[35].

The Nurses' Health Study II authors reported a statistical interaction with age (P = 0.008) ^[5]. The abstract does not explain why the association was weaker at ages 35 to 39, and a weaker association there does not show that endometriosis is harmless for older women.

Endometriosis and pregnancy outcomes

For people who conceive, a separate set of studies asks about pregnancy complications. These are observational and cannot show that endometriosis causes a complication, because other factors, including the use of assisted reproduction, may differ between groups ^[36].

A Human Reproduction systematic review and meta-analysis of 33 observational studies and 3,280,488 participants reported higher odds in women with endometriosis for several outcomes, including placenta previa (odds ratio 3.31, 95% confidence interval 2.37 to 4.63), preterm birth (1.70), cesarean section (1.86), pre-eclampsia (1.18), stillbirth (1.29) and neonatal death (1.78). Among women who conceived spontaneously, endometriosis was associated with placenta previa, cesarean section, preterm birth and low birth weight, and among those who conceived with ART, with placenta previa and preterm birth. Diagnosis and comparison groups varied across studies ^[36].

A second meta-analysis of 24 studies and 1,924,114 women reported higher risks of preterm birth (odds ratio 1.63), miscarriage (1.75), placenta previa (3.03), small-for-gestational-age infants (1.27) and cesarean delivery (1.57), and no difference in gestational hypertension or preeclampsia ^[37]. The two reviews therefore agree on several outcomes and differ on others, including preeclampsia. A Danish national cohort of deliveries from 1997 to 2014 reported higher risks of severe preeclampsia, hemorrhage in pregnancy, placental abruption, placenta previa and preterm birth before 28 weeks (odds ratio 3.1), and described a further increase in risk among women who had gynecological surgery for endometriosis before pregnancy ^[38].

These reviews report relative measures such as odds ratios, and the abstracts cited here do not give absolute risks ^[36][37]. The authors of the largest review said that outcomes such as stillbirth and neonatal death warrant further study to find the mechanisms ^[36].

The weight of the topic for people living with it

Studies that ask about daily life describe infertility concerns as one part of a larger picture. A critical narrative review of 42 papers on the social and psychological effects of endometriosis identified several categories of impact, including diagnostic delay and uncertainty, quality of life, intimate relationships, planning for and having children, education and work, and mental health ^[39]. The authors noted that many studies had methodological limitations, and that most came from just four countries ^[39]. The review does not say that every person with endometriosis is affected in each domain.

Why the evidence is hard to interpret

Several features of this research recur and explain why numbers differ between studies.

Detection bias. Endometriosis was confirmed at laparoscopy in many of the studies above ^[4][5]. The nurses' cohort authors suggest that the infertility risk may be about half the size seen in cross-sectional analyses ^[5], and a critical review calls for attention to diagnostic bias ^[40].

Stage and phenotype. Minimal and mild disease, endometriomas and deep disease may relate to fertility in different ways. Many studies combine them. The EFI uses surgical findings on tubal and ovarian function plus age and history instead of stage alone ^[18][19].

Confounding by other infertility factors. In the U.S. registry, most women with endometriosis had another infertility diagnosis, and the combination predicted worse results than endometriosis alone ^[11].

Different outcomes and time frames. Ongoing pregnancy at 20 weeks, ultrasound-confirmed pregnancy and live birth are not interchangeable ^[12][14].

Small or older trials. The two randomized trials of surgery for minimal or mild disease enrolled 341 and 101 women, and the Cochrane review of ovulation suppression was last published in 2007 ^[12][13][16].

Retrospective design. Much of the work on IVF, egg freezing, endometriomas and the EFI is retrospective ^{[20][22][25][32]}.

What this does not tell you

This article describes research on groups of people. It does not tell any individual whether she has endometriosis, whether endometriosis is affecting her fertility, how long it may take her to conceive, or what her own chance of a live birth is. Averages from a study population do not apply directly to one person, and individual results vary around them.

It does not tell anyone which test, treatment or timing is right. The guidelines and trials cited describe options and their evidence, and the choice involves age, ovarian reserve, partner factors, symptoms, the extent of disease, preferences and costs that no study can weigh in advance. Pain symptoms and fertility goals can point in different directions, and the ESHRE guideline says decisions about surgery should take pain into account ^[1].

It does not mean that people without symptoms or without a surgical diagnosis can be assumed to be free of or affected by endometriosis. Several studies depended on surgical confirmation, and the findings may not apply to people diagnosed by imaging or symptoms, or to those never evaluated.

It does not cover other causes of infertility, such as adenomyosis, fibroids, polycystic ovary syndrome, male-factor infertility or tubal disease, in detail. It does not review newer drugs, devices or procedures that have limited published evidence, and it does not assess the cost, availability or insurance coverage of any option.

Finally, some of the findings come from observational data and cannot show cause. Where this article says "associated with," it means only that the two things occurred together in the studied groups.

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