Endometriosis affects many women during their reproductive years and can be associated with infertility.

However, a diagnosis of endometriosis does not automatically mean that natural pregnancy is impossible or that IVF is immediately required.

What Is Endometriosis?

Endometriosis occurs when tissue resembling the lining of the uterus is found outside the uterine cavity.

It may involve the ovaries, pelvic lining and other structures.

Ovarian endometriosis can form cysts known as endometriomas.

How Can Endometriosis Affect Fertility?

Potential mechanisms include:

• Pelvic inflammation
• Adhesions
• Distortion around the fallopian tubes or ovaries
• Endometriomas
• Altered tubo-ovarian anatomy
• Effects on ovarian reserve in some patients

The effect varies significantly between individuals.

Does Everyone With Endometriosis Need IVF?

No.

Age, duration of infertility, ovarian reserve, fallopian tube function, sperm quality and severity of disease all influence treatment.

A younger woman with mild disease and a short duration of infertility may face a very different decision from someone approaching 40 with reduced ovarian reserve.

Surgery Before IVF

Whether an endometrioma should be surgically removed before IVF requires careful consideration.

Surgery may sometimes be appropriate for symptoms, diagnostic uncertainty, accessibility or other clinical indications.

However, ovarian surgery can also reduce ovarian reserve.

Routine surgery solely to improve IVF outcomes is therefore not automatically appropriate for every patient.

When Might IVF Be Considered?

IVF may be appropriate where:

• The fallopian tubes are significantly affected
• Other fertility factors coexist
• Ovarian reserve is declining
• Age makes prolonged expectant management undesirable
• Previous treatment has been unsuccessful
• Fertility has not occurred after appropriate surgery or simpler treatment

Endometriosis and Ovarian Reserve

Women with ovarian endometriomas or previous ovarian surgery may have reduced AMH.

This makes early assessment particularly useful when future fertility is important.

Fertility Preservation

Some women with significant ovarian endometriosis may wish to discuss fertility preservation, particularly before ovarian surgery or when pregnancy will be delayed.

Egg freezing is not required for every woman with endometriosis, but discussing the option early may be appropriate in selected circumstances.

The Take-Home Message

Endometriosis and fertility require individualised management.

The decision between trying naturally, surgery, fertility preservation and IVF depends on much more than the diagnosis alone.

Age, ovarian reserve, symptoms, previous surgery, sperm factors and duration of infertility should all contribute to the plan.