By Zaira Salvador BSc, MSc (embryologist), Blanca Paraíso MD, PhD, MSc (gynecologist), Manuel Aparicio Caballero MD, MSc (gynecologist) and Mark P. Trolice MD, FACOG, FACS, FACE (reproductive endocrinologist).
Last Update: 09/20/2018

Endometriosis is a common disorder among women of childbearing age which is directly linked to female infertility.

About 30 to 50% of patients who are diagnosed with endometriosis have infertility issues or problems to get pregnant.

Assisted Reproductive Technology (ART) can definitely help these women get pregnant in spite of endometriosis, especially with techniques like in vitro fertilization (IVF) with donor eggs.

The different sections of this article have been assembled into the following table of contents.

Causes of infertility

Even though the causes of endometriosis are still being evaluated, many studies have been published to date showing how endometriosis affects female fertility. The following are the main causes:

Anatomical causes

The ovaries and the Fallopian tubes are damaged mainly by the growth of endometrial implants in places other than the uterus.

In the ovary, adhesions destroy the healthy tissue, which affects the ovarian reserve directly, complicates the normal development of follicles, and prevents the maturation of eggs. Moreover, endometrial cysts can prevent ovulation as well.

When endometriosis is located on the Fallopian tubes, it can compromise tubal patency. This is a barrier for the journey of the egg through the tube after being released from the ovary. As a consequence, fertilization and therefore pregnancy never take place.

Diminished endometrial receptivity

Infertility can be a consequence of immunological alterations. The levels of IgG and IgA antibodies, as it happens with lymphocytes, appear increased on blood, which may affect endometrial receptivity and embryo implantation.

The embryo’s ability to implant to the uterus can be compromised because endometriosis causes patients trouble to synthesize endometrial tissue. Moreover, the levels of integrins (cell adhesion molecules that take part in the implantation process) are too low.

Finally, lesions of the endometrium or endometriomas can produce toxic substances that can affect both the egg and the sperm.

Getting pregnant naturally

The most advisable option for women with endometriosis to recover their fertility and have the possibility of having children naturally is to undergo medical or surgical treatment. Choosing one option or the other depends on the severity of endometriosis and the history of each patient.

We can classify endometriosis into four stages or grades depending on the location, quantity, profundity, and size of the endometrial implants:

  • Stage 1 or minimal disease
  • Stage 2 or mild disease
  • Stage 3 or moderate disease
  • Stage 4 or severe disease

Painkillers and hormonal treatments are effective to relief the pain and regulate the menstrual cycles. However, laparoscopic surgery is likely to be required in order to improve the woman’s fertility and increase her chances of conceiving.

So, in short, these treatments are effective in achieving a natural pregnancy in cases of mild-to-moderate endometriosis.

Laparoscopic surgery, also known as minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, involves inserting a laparoscope through a small incision to observe the abdominal cavity.

Stage IV or severe endometriosis, especially when endometriomas or ovarian cysts (also called chocolate cysts) are found, can be treated with a technique known as laparoscopic cystectomy to remove this type of cysts. This helps increase the pregnancy success rates.

Endometriosis & fertility treatments

If you have undergone surgery and have been trying to conceive for one year without luck, the good news is that fertility treatments can be the best option for you to start a family.

Depending on the severity of endometriosis and the progress of other treatments, the most adequate options may be, from the simplest to the most challenging:

Intrauterine Insemination (IUI)

IUI is the option of choice in younger patients with mild-to-moderate endometriosis (stages I and II).

The hormones used to induce ovulation improve the prognosis of these patients. However, for IUI to be effective in achieving pregnancy, tubal patency is required so that the sperm is able to hit the egg.

To learn more, click here: Artificial Insemination (AI): Process, Cost & Types.

In Vitro Fertilization (IVF)

IVF is an option for patients affected with stage III or IV endometriosis. It is also recommended when IUI has failed in women with stage I-II endometriosis.

The pregnancy rates of IVF are higher than those of IUI in women with endometriosis. Specialists recommend, however, that these women give IUI a try on the first attempt as long as they meet the requirements to be referred to IUI.

Assisted procreation, as any other medical treatment, requires that you rely on the professionalism of the doctors and staff of the clinic you choose. Obviously, each clinic is different. Get now your Fertility Report, which will select several clinics for you out of the pool of clinics that meet our strict quality criteria. Moreover, it will offer you a comparison between the fees and conditions each clinic offers in order for you to make a well informed choice.

Get more info about this common fertility treatment here: What Is In Vitro Fertilization (IVF)? – Process, Cost & Success Rates.

Egg Donation

It has been proved after several analyses at IVF lab that the morphology of eggs and embryos from women with endometriosis is poorer. Moreover, the fertilization rates and subsequent embryo development rates are lower.

For this reason, women with severe endometriosis, or those who have been through various failed IVF cycles, have no alternative but to use donor eggs to have a baby. In fact, 10% of donor egg recipients are endometriosis patients.

Eggs from young, healthy women have an excellent morphology. For this reason, we can only expect high success rates, irrespective of whether the recipient is a woman with endometriosis or not.

Does egg donation improve success rates in patients with endometriosis?

According to Dr. Blanca Paraíso, specialized in Gynecology & Obstetrics, several studies have confirmed that a limiting factor when it comes to achieving pregnancy in these patients is the egg cell.

This has been a concerning issue for a long time, and this is the reason why so many studies have been conducted so far, which have showed that many of these patients have their endometrial receptivity affected, that is to say, they may have alterations that make the embryo implantation process more complicated. However, they have also confirmed that the egg cell plays a major role on this.

As a matter of fact, one study was conducted by donating eggs from women without endometriosis to patients affected by endometriosis and others not affected, and the results showed that the results were the same in both cases. So, broadly speaking, using donor eggs in patients with endometriosis leads to the same success rates than in the general population,
which are considerably high—between 60% and 70%.

Using donor eggs is also indicated when ovarian endometriomas make it difficult for the specialist to retrieve the eggs from the ovary through follicle puncture. See also: What’s Being an Egg Donor Recipient Like?

Surrogacy

Surrogacy may be an option to have a baby when IVF or even IVF with donor eggs are unsuccessful.

In the most severe cases of endometriosis (stage IV) the hormones used to trigger the production of multiple eggs can promote the growth of endometrial implants, thereby making it impossible for the woman to bear a full-term pregnancy.

In such cases, surrogacy may be the only option to have baby. Learn more: What Is Surrogacy & How Does It Work? – Everything You Should Know.

Fertility Preservation

Given that endometriosis is a progressive disease and, what’s more, the biological clock is ticking non-stop, women diagnosed with endometriosis are strongly recommended to preserve their fertility by means of egg vitrification in order not to miss their chance of having children in the future.

It allows egg quality to be retained, thereby reaching better IVF success rates. Moreover, it should be taken into account that endometriosis affects the ovarian reserve as well.

Read: Fertility Preservation – Cost & Options for Retaining Your Fertility.

FAQs from users

What are your reproductive options if you have stage IV endometriosis?

By Mark P. Trolice MD, FACOG, FACS, FACE (reproductive endocrinologist).

Endometriosis affects 10-15% of all women. Of women with endometriosis, 30-50% are estimated to have infertility; of women with infertility, 25-50% are estimated to have severe endometriosis. A hallmark of endometriosis is inflammation and subsequent formation of adhesions in the pelvis. These adhesions distort the pelvic anatomy and impacts the woman in a variety of ways. The most direct consequence of adhesions can be a disruption of the anatomical relationship between the ovaries and fallopian tubes. In advanced cases of endometriosis, tubal blockage may occur to the point of a hydrosalpinx which may require removal before any fertility treatment.

The most appropriate treatment for each couple will depend on a number of factors including the woman’s age, the duration of infertility, her ovarian reserve, the sperm analysis, a history of past surgery for endometriosis and its severity.
For women younger 35 years of age with low stage disease, a trial of Fertility treatment with intrauterine insemination (IUI) is recommended. However, for women greater than or equal to 35 years of age with advanced stages of endometriosis (stages III and IV), IVF is recommended due to the higher pregnancy rate. Of note, advanced endometriosis, compared to other diagnoses, may reduce the pregnancy rate with in vitro fertilization.

Which is more effective with mild endometriosis, IUI or IVF?

By Manuel Aparicio Caballero MD, MSc (gynecologist).

Intrauterine Insemination (IUI) is the treatment of choice for young patients with mild-to-moderate endometriosis (stages I and II). For this treatment to be possible, no blockage in the Fallopian tubes must exist. However, recent studies suggest that IUI may be ineffective in these cases. The latest European review on the average success rates during years 2016-2017 with AIH (artificial insemination by husband) are below 15% per cycle. So, in conclusion, opting for IUI in cases of mild-to-moderate endometriosis is possible in very particular cases where there is evidence that it might work.

In general, In Vitro Fertilization (IVF) is the first option for patients with a moderate or severe type of endometriosis (stages III and IV), as well as for women with previous failed cycles in spite of having a good prognosis initially.

Can you get pregnant with endometriosis without surgery?

By Zaira Salvador BSc, MSc (embryologist).

Unfortunately, the chances are very low. While painkillers or hormonal treatments can help relieve the symptoms of endometriosis, laparoscopic surgery is necessary to achieve pregnancy with endometriosis, even in mild-to-moderate cases.

Can you get pregnant with untreated endometriosis?

By Zaira Salvador BSc, MSc (embryologist).

As explained earlier, it is highly unlikely. Endometriosis should be properly managed by means of laparoscopic surgery.

What are the chances of getting pregnant with one tube and endometriosis?

By Zaira Salvador BSc, MSc (embryologist).

The odds of falling pregnant with one Fallopian tube should not be different than any other woman as long as the remaining tube is working normally. Depending on the stage of endometriosis, you may need IVF to get pregnant.

What are the dangers of being pregnant with endometriosis?

By Zaira Salvador BSc, MSc (embryologist).

Several studies have indicated that endometriosis is a risk factor for complications during pregnancy. Your doctor should advise you on the potential risks associated according to the severity of your endometriosis.

The risks associated with pregnancy in women with endometriosis include increased risk of miscarriage, ectopic pregnancy, placenta displacement, spontaneous rupture of the uterus, obstructed labor, postpartum hemorrhage, and preterm birth.

How does pregnancy help endometriosis?

By Zaira Salvador BSc, MSc (embryologist).

No, pregnancy does not cure endometriosis. Although it is a widespread myth, it is actually true that pregnancy may temporarily suppress the symptoms of endometriosis. However, this does not mean that it eradicates the disease itself.

Suggested for you

In addition to female infertility, endometriosis may cause other symptoms such as pain. To learn more, we recommend that you visit this post: What Are the Symptoms of Endometriosis?

The ovarian reserve is the egg supply of women, and unfortunately it can be severely affected by endometriosis. Find out more about the capacity of the ovary to provide egg cells here: What Is the Ovarian Reserve? – Assessment, Test Results & Meaning.

To get an overall idea of Assisted Reproductive Technology (ART), we recommend that you visit this complete guide: What is Assisted Reproductive Technology (ART)? – Techniques & Costs.

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Authors and contributors

BSc, MSc
Embryologist
Bachelor's Degree in Biotechnology from the Polytechnic University of Valencia (UPV). Embryologist specializing in Assisted Procreation, with a Master's Degree in Biotechnology of Human Assisted Reproduction from the University of Valencia (UV) and the Valencian Infertility Institute (IVI). More information
License: 3185-CV
 Blanca Paraíso
MD, PhD, MSc
Gynecologist
Bachelor's Degree in Medicine and Ph.D from the Complutense University of Madrid (UCM). Postgraduate Course in Statistics of Health Sciences. Doctor specialized in Obstetrics & Gynecology, and Assisted Procreation. More information
License: 454505579
 Manuel Aparicio Caballero
MD, MSc
Gynecologist
Bachelor's Degree in Medicine from the University of Murcia. Specialist in Obstetrics & Gynecology. Master's Degree in Human Reproduction from the King Juan Carlos University and the IVI. Currently, he is part of the team of Tahe Fertilidad (Murcia, Spain). More information
License: 303008030
 Mark P. Trolice
MD, FACOG, FACS, FACE
Reproductive Endocrinologist
Mark P. Trolice is the Director of Fertility CARE – The IVF Center and Clinical Associate Professor in the Department of Obstetrics & Gynecology (OB/GYN) at the University of Central Florida College of Medicine. He is Board-certified in REI and OB/GYN, and maintains annual recertification. His colleagues select him as Top Doctor in America® annually, one among the top 5% of doctors in the U.S. More information
License: ME 78893
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