How Does Endometriosis Impact Fertility?

If you’re reading this, the first thing you need to know is: getting pregnant with endometriosis is possible. But it’s not always an easy journey. The condition — which means tissue that’s similar to that of the inner lining of your uterus is growing outside the uterus — can make it harder to get conceive. In fact, as many as 30 to 50 percent of folks with endometriosis “may experience infertility,” per the International Journal of Molecular Sciences.

You may notice that’s a pretty big range — and that “may” doesn’t sound very certain. Well, unfortunately, there’s still a lot that scientists don’t know about endometriosis, says Louise Perkins King, MD, JD, an ob-gyn and surgeon in the division of minimally invasive gynecology at Brigham and Women’s Hospital.

Every individual has a different experience with endo, and some women have no trouble getting pregnant while others struggle for years. So, what exactly do we know and not know about how much endo will impact your fertility journey? We asked the experts what to know about fertility if you’ve been diagnosed with endometriosis (or suspected endo — if you’re presenting with symptoms but haven’t had a laparoscopy yet). Here’s what they said.

Experts Featured in This Article:

Louise Perkins King, MD, JD, is an ob-gyn and surgeon in the division of minimally invasive gynecology at Brigham and Women’s Hospital.

Tia Jackson-Bey, MD, MPH, is a reproductive endocrinologist and fertility specialist at RMA New York.

Banafsheh Kashani, MD, ob-gyn, is a reproductive endocrinologist and infertility specialist.

Can Endometriosis Cause Infertility?

It’s possible that endometriosis may impact your fertility, but just because you have the condition doesn’t mean you’re guaranteed to have fertility troubles. While some folks with endo struggle to get pregnant, others have no trouble conceiving at all. Frustratingly, the science on the inconsistency — and on how and why endo even impacts your reproductive health — is a little murky, Dr. King says.

“We don’t fully understand how endometriosis causes infertility nor do we really understand if it always causes infertility,” she says. “We only know about endometriosis-related infertility when patients present as infertile. Many endometriosis patients have no pain and many never present as infertile — these cases of endometriosis without infertility are thus not captured by studies.”

However, there are a few theories as to why the condition might impact fertility. “Our best guess is that endometriosis causes infertility because it’s a disease of chronic inflammation,” Dr. King notes.

When endometrial tissue is growing outside of its usual home in the uterus, it creates an issue because the cells that make up that tissue are responding to your normal hormonal cues as though they’re in the uterus. The endometrial tissue grows and proliferates through a certain portion of your cycle and then begins to die when your period starts, explains Tia Jackson-Bey, MD, MPH, a reproductive endocrinologist and fertility specialist at RMA New York. Normally, this tissue would be expelled through the vagina during the menstrual process, but in this case there’s nowhere for it to go. “As the cell death-like process happens in other places in the body, it creates inflammation because your body’s like: ‘hey, um, what are you doing here?'”

Your body doesn’t like it so it may start to “wall the endo cells off,” sometimes causing cysts or scarring to appear, Dr. Jackson-Bey explains. “You have the creation of new tissue, which almost looks like cobwebs or connections between organs that shouldn’t be there, and the main ways that it impacts your fertility is by, one, creating blockages in the fallopian tubes.”

In order for an egg and sperm to come together and grow an embryo, the fallopian tubes have to open “like a highway or a tunnel,” Dr. Bey explains. The scar tissue and cobweb-like blockage can get in the way of this making it hard for the egg and sperm to come together and grow an embryo that makes its way to the uterus. Scarring can prove problematic if it’s impacting the ovaries or the ovarian egg quality or reserve, which can happen if endometriosis remains unchecked or treated Dr. Jackson-Bey says.

Finally, she explains, endo is often associated with chronic pain. When you don’t feel good — whether you’re having pain with intercourse, trouble moving your bowels, or just general, no-good, very bad pain — it can cause stress and potentially impact your chances of getting pregnant in ways doctors don’t fully understand.

Again, there’s a lot we don’t know about endometriosis — partially because the research is underfunded (though the Biden Administration has recently set aside more money for research into endo and fertility) and partially because this research is incredibly hard to do well. “The way that you get to a scientific answer is to have two individuals in front of you and subject one to an intervention that you don’t give the other person — and you see which one does better. In the setting of infertility, it’s hard — and you could argue, unethical — to ask people to delay their childbearing. So we may never have those really good randomized controlled trials to get to these answers,” Dr. King says.

Is It Possible to Get Pregnant With Endometriosis?

Yes, it is definitely possible to get pregnant with endometriosis. The outcome varies on a case-by-case basis, and where the endometrial tissue has spread makes a difference. But Dr. King notes that age is actually a statistically bigger issue when it comes to fertility than endo is.

In general, the chance of getting pregnant each month for folks with no endometriosis is about 10 to 20 percent, while people who have surgically documented endo have a chance of about one to 10 percent, per Mass General (again, this isn’t everyone — some folks have no trouble getting pregnant). But when it comes to age, your chance of successfully getting pregnant without intervention each month drops to about 5%, per Extend Fertility.

“Whether you have endometriosis or not, the primary driver of any infertility in your life will still be your age,” Dr. King adds, so don’t let the condition scare you out of trying if you’d like to.

How to Potentially Improve Fertility With Endometriosis

The number one thing both Dr. King and Dr. Jackson-Bey recommended for managing endometriosis to preserve fertility is getting on a hormonal medication that helps control your cycle. Again, from what we know, the endometrial tissue is responding to hormonal changes in your body that can lead to inflammation, so if you can head those off, you can reduce inflammation and pain. Although birth control isn’t always right for everyone — some folks will experience side effects or have personal reasons for not wanting to be on it — it can help manage things. If you take hormonal birth control and skip the placebo week, Dr. King says, it may help preserve fertility because you’re reducing the inflammation because your body won’t be bleeding and effectively having a period. She says the Mirena IUD also allows you not to have a period because you’re thinning the endometrial lining of your uterus, although it doesn’t have the same systemic effects on fertility because it still allows for ovulation that can cause hormonal changes that cause pain and potential issues.

“Anything you do to decrease inflammation, including using hormonal treatment to stop menses, should help preserve fertility,” Dr. King says. “Studies support this.”

If birth control isn’t your thing or you want to take other steps, generally, you can reduce inflammation by eating a balanced diet, getting regular exercise, and generally doing what you can to reduce stress. “Meditation and psychological therapy is actually proven to be anti-inflammatory,” Dr. King says. One JAMA review notes that psychosocial interventions may improve your immune system function and help in general with immune-related health. “That’s not to say your pain is in your head at all,” Dr. King adds.

She adds that acupuncture (from a well-trained specialist) may also help. All of this can help reduce pain, which may in turn help with fertility.

Again, these things aren’t foolproof, and, not to be a broken record, there’s a lot we don’t know. But these strategies can’t hurt. And, if you’ve already tried to get pregnant for six months to a year with no success, it’s probably time to speak to your doctor (more on that below!).

When to Speak to Your Doctor Regarding Fertility and Endo

It’s never too soon to talk to your doctor about endometriosis or fertility — whether you suspect you have endo symptoms or you have a confirmed diagnosis. Dr. King recommends seeking out a specialist with experience treating endo.

“The biggest thing for women with endometriosis is being diagnosed because the vast majority of women go undiagnosed for an average of 10 years before someone connects the dots and their symptoms,” Dr. Jackson-Bey says. “If you are having painful intercourse, pain with periods that makes you change your social schedule, or painful bowel movements, it’s not just ‘normal.’ You deserve to be provided an answer for why it’s happening. Proactively ask your physician: Could I be someone who has endometriosis? Make sure that they explain to you the reasons why or why not, and how they’re going to screen for endometriosis.”

When it comes to endo and fertility, you don’t have to wait until you’re “ready” for kids (or have to even know you want them) to discuss the possibility. “Be proactive,” Dr. Jackson-Bey says.

If you want to get pregnant or are considering freezing your eggs, ask questions about that too. Dr. King notes that the only way to truly know if your fertility will be affected by endo is to start trying. If you’ve already tried to get pregnant for six months to a year with no success, that’s a sign to speak to your doctor or a fertility specialist. “Infertility” is typically defined as not being able to get pregnant after trying for one year, but Dr. King notes: ” If we suspect infertility from a specific cause like endometriosis, we suggest shortening the time frame to try on your own,” she notes. “Insurance will accept endometriosis as a diagnosis that supports payment for IVF in states in which it’s mandated.”

Best Fertility Treatment For Endometriosis

If your endometriosis is impacting your fertility, there are options. For starters, you can consult a fertility doctor, who will likely do some testing to assess your condition, says EndoFound medical director Dan Martin, MD. A hysterosalpingogram is common, which involves inserting dye into your fallopian tubes to confirm they’re not blocked by endometrial tissue and scarring.

Your doctor will also look at your partner’s fertility abilities if sperm is involved, and may suggest a few routes. Your doctor may suggest first trying a procedure known as intrauterine insemination (IUI), which involves placing the sperm directly into the uterus to achieve pregnancy. This procedure is cheaper than In vitro fertilization (IVF).

With IVF, sperm and eggs are combined in a lab outside of the body and they’re later implanted into the uterus to grow. This process “gives the highest success rates in terms of treatment options for women with endometriosis,” says Banafsheh Kashani, MD, ob-gyn, a reproductive endocrinologist and infertility specialist. “Alternatively, some women may take medications (pills or injections) to help them ovulate more than one egg and combine that with an IUI and this can help increase the success of getting pregnant in women with endometriosis.” If you’re going through insurance, many insurers require you to have multiple failed IUIs before they’ll pay for IVF. However, Dr. Jackson-Bey says, if you have an endometriosis diagnosis and can show that the fallopian tubes are impacted, your doctor may be able to help you override starting with IUIs, so your insurance will let you proceed right to IVF, to increase your chance of pregnancy.

Meanwhile, the more you try, you may also end up getting pregnant on your own, Dr. King adds, so don’t rule that out. “Don’t assume you are infertile simply because you have painful periods or even documented endometriosis,” she says.

Pregnancy is possible for many people with endometriosis — remember that stat we mentioned that about 30 to 50 percent of people with endo potentially having fertility issues — that means 50 to 70 percent don’t struggle with fertility. And, with any luck, as the science catches up, we’ll learn more about how to best treat the condition help those with endo live with less pain and have an easier fertility journey.

Molly Longman is a freelance journalist who loves to tell stories at the intersection of health and politics.