Endometriosis and Fertility
Between pain and the desire for pregnancy
For many women diagnosed with endometriosis, the condition is not only about pain. It often represents a difficult balance between two fundamental needs: living without pain and the deep desire to become a mother.
In clinical practice, this internal conflict is common. Some patients seek medical help due to severe pain affecting their daily lives, while others present with difficulty conceiving. In most cases, however, both issues coexist.
When managing a patient with endometriosis, one of the most important questions is not just which treatment to choose, but what the priority is at that stage of life: pain control or achieving pregnancy.
Why does endometriosis affect fertility?
Endometriosis impacts fertility through more than just anatomical changes.
In advanced stages, the mechanisms are clear:
- pelvic adhesions
- damaged fallopian tubes
- ovarian cysts (endometriomas)
These can physically prevent the egg and sperm from meeting.
However, even in mild forms, fertility may be affected through more subtle mechanisms:
- chronic pelvic inflammation
- impaired egg quality
- altered immune environment
- reduced endometrial receptivity
- impaired tubal function
It is estimated that 30–50% of women with endometriosis experience infertility, while 25–50% of women evaluated for infertility are diagnosed with endometriosis, often discovered only during fertility investigations.
The role of the physician: identifying priorities
A key part of management is understanding:
- What is the dominant symptom?
- What is the patient’s main need at this moment?
- Is the priority pain control or achieving pregnancy?
The answers to these questions can completely change the treatment strategy.
When pain becomes the priority
For some patients, pain significantly impacts quality of life and becomes the main concern. In severe cases, such as intestinal endometriosis, symptoms may be underestimated but can lead to serious complications, including bowel obstruction. In these situations, surgery may be necessary. A critical aspect is preserving ovarian reserve during surgical intervention.
When pregnancy becomes the priority
For many women, achieving pregnancy becomes the primary goal. In these cases, time and age are critical factors.
Fertility evaluation should be systematic and include:
- detailed medical history
- partner evaluation (sperm analysis, DNA fragmentation test)
- fallopian tube assessment
- ovarian reserve and hormonal profile
- transvaginal ultrasound for endometriosis lesions
If additional factors reduce the chances of conception and cannot be quickly corrected, IVF may be the most effective option.
IVF in endometriosis patients
IVF requires specific considerations in these patients:
- sclerotherapy for large endometriomas
- tailored ovarian stimulation protocols
- use of letrozole for estradiol control
- diagnosis and management of adenomyosis
- evaluation and treatment of chronic endometritis
A personalized approach is essential to optimize outcomes.
Endometriosis and ovarian reserve
This is often underestimated.
Endometriosis may be associated with reduced ovarian reserve, even at younger ages. Ovarian cysts and repeated surgeries can further damage ovarian tissue.
Evaluation includes:
- AMH testing
- antral follicle count
- reproductive history
These findings can significantly influence treatment decisions.
When fertility should be prioritized
In some cases, patients are advised to consider pregnancy earlier than planned.
For women without a partner, egg freezing (oocyte cryopreservation) is an important option.
For young patients with endometriosis, fertility preservation can be extremely valuable—yet many women learn about this option too late.
An important message for patients
Endometriosis is a challenge, but it does not automatically mean infertility. Many women achieve pregnancy, either naturally or through assisted reproductive techniques. In most cases, the difference lies in: correct diagnosis, proper timing, personalized treatment strategy.
Bibliography:
2022 ESHRE Endometriosis Guideline Development Group
Bulletti C. Endometriosis and infertility.
Human Reproduction / Oxford Academic (revizuiri științifice). La Marca A. Fertility preservation in women with endometriosis. Human Reproduction Open.
American Society for Reproductive Medicine (ASRM). Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility
