IVF for Endometriosis: When May It Be Considered?

Endometriosis can sometimes make it harder to conceive naturally. Depending on factors such as age, ovarian reserve, the extent of endometriosis, previous treatment, how long you have been trying to conceive, and whether there are other fertility factors, in vitro fertilisation (IVF) may become part of the fertility treatment plan.

IVF is not automatically recommended simply because you have endometriosis. The decision is usually individualised and may involve trying to conceive naturally, surgery, intrauterine insemination (IUI), IVF, or a combination of approaches depending on your circumstances. You can learn more about the condition and its broader treatment approaches on the Endometriosis Treatment page.

How Can Endometriosis Affect Fertility?

Endometriosis may affect fertility in several ways. In some people, inflammation and changes around the reproductive organs may interfere with the normal movement of the egg, sperm, or embryo. Scar tissue and adhesions can also alter the anatomy of the pelvis or affect the fallopian tubes and ovaries.

Endometriosis may also be associated with ovarian endometriomas, which can affect ovarian tissue and, in some cases, ovarian reserve. 

However, the severity of symptoms or the stage of endometriosis does not always directly predict how easily someone will conceive. Because fertility is influenced by several factors, the presence of endometriosis alone does not determine whether IVF is needed.

When May IVF Be Considered for Endometriosis?

There is no single point at which everyone with endometriosis should move to IVF. A fertility specialist may consider IVF when spontaneous conception is less likely or when other approaches have not resulted in pregnancy.

1. When pregnancy has not occurred after trying naturally

If you have been trying to conceive for an appropriate period without success, fertility treatment may be discussed. Current guidance recommends considering factors such as how long you have been trying, your age, the severity and symptoms of endometriosis, ovarian reserve, and other fertility factors when deciding the next step.

For some people with endometriosis, expectant management may be reasonable for a period of time. For others, particularly when there are additional fertility concerns, moving more quickly toward assisted reproduction may be appropriate.

2. When endometriosis is more extensive

More extensive endometriosis, particularly when it involves the ovaries, fallopian tubes or other pelvic structures, may affect the chances of natural conception. 

In these situations, IVF may be discussed as an alternative to waiting for spontaneous pregnancy or as an option after other treatment.

However, the decision should not be based solely on the stage of endometriosis. The overall fertility picture is more important than a stage number alone.

3. When ovarian reserve is a concern

Ovarian reserve refers to the remaining supply of eggs and is one of the factors considered when planning fertility treatment. 

Endometriosis involving the ovaries, particularly ovarian endometriomas, may be associated with reduced ovarian reserve. Previous ovarian surgery can also affect the number of eggs that may be retrieved during IVF.

If ovarian reserve is reduced, delaying fertility treatment may not always be appropriate. Age and the results of ovarian reserve testing are therefore important when discussing whether IVF should be considered.

4. After unsuccessful surgery or when surgery is not appropriate

Surgery can improve the chance of natural pregnancy in selected people with endometriosis. However, surgery is not always the best next step for everyone.

For deep endometriosis or ovarian endometriomas, surgery may involve considerations about ovarian reserve, possible complications and future fertility. If surgery has already been performed without resulting in pregnancy, or if surgery is unlikely to provide enough benefit, assisted reproductive treatment such as IVF may be considered.

5. When there are additional fertility factors

Endometriosis may not be the only factor affecting fertility. Reduced sperm quality, blocked or damaged fallopian tubes, diminished ovarian reserve, or other reproductive factors can influence the treatment plan.

When more than one fertility factor is present, IVF may be considered because it can bypass some problems associated with the fallopian tubes and allows fertilisation to take place outside the body.

6. When age makes delaying treatment less desirable

Age is an important factor in fertility, including for people with endometriosis. As fertility naturally changes with age, a fertility specialist may recommend moving toward assisted reproduction sooner rather than spending a long period on treatments that have a lower likelihood of success.

This does not mean that everyone with endometriosis needs IVF at a particular age. Instead, age is considered alongside ovarian reserve, fertility history, endometriosis severity and other factors.

Is IVF Always the First Fertility Treatment for Endometriosis?

No. IVF is one of several possible approaches. Depending on the individual situation, a fertility specialist may discuss:

• Trying to conceive naturally for a period of time
• Surgical treatment of endometriosis when appropriate
• Intrauterine insemination (IUI), sometimes combined with ovarian stimulation
• IVF or IVF with intracytoplasmic sperm injection (ICSI) when indicated

What Fertility Tests May Be Done Before IVF?

Before deciding on IVF, the fertility team generally evaluates the factors that could affect treatment and pregnancy. Depending on the situation, this may include:

• Ovarian reserve assessment: Tests such as anti-Müllerian hormone (AMH) and antral follicle count may help estimate ovarian response to stimulation.
• Ovulation assessment: The menstrual cycle and evidence of ovulation may be reviewed when relevant.
• Ultrasound: Pelvic ultrasound can assess the ovaries, endometriomas and other pelvic findings.
• Tubal assessment: The fallopian tubes may be assessed when the result would influence the choice of fertility treatment.
• Semen analysis: Assessment of the male partner or sperm source is important because male-factor fertility problems can coexist with endometriosis.
• Medical and fertility history: Previous pregnancies, fertility treatments, endometriosis surgery and the duration of attempts to conceive are considered.

Does Endometriosis Surgery Need to Be Done Before IVF?

Not necessarily. Surgery may be appropriate in some people with endometriosis, but removing endometriosis before IVF does not automatically improve IVF outcomes. 

This is particularly important when an ovarian endometrioma is present because ovarian surgery can affect ovarian reserve.

Surgery may instead be considered for specific reasons, such as significant symptoms, particular anatomical problems, suspicion of another condition, or when the findings interfere with fertility treatment. 

The potential benefits and risks need to be weighed carefully. For this reason, the decision to have surgery before IVF is usually made on an individual basis rather than as a routine step.

Does Endometriosis Reduce the Chances of IVF Success?

IVF can help people with endometriosis achieve pregnancy, but outcomes can vary between individuals. Research has found that some people with endometriosis may have differences in measures such as the number of eggs retrieved or pregnancy rates compared with people undergoing IVF for other reasons. 

However, the effect varies according to factors including age, ovarian reserve, the extent of disease and other fertility factors. Importantly, having endometriosis does not mean that IVF will not work. The fertility team considers the complete clinical picture when estimating the likely response to treatment.

What Happens During IVF for Endometriosis?

The IVF process is broadly similar whether or not a person has endometriosis. The treatment may involve:

1. Ovarian stimulation: Medication is used to encourage several follicles to develop.
2. Monitoring: Ultrasound scans and, when appropriate, blood tests are used to monitor follicular development.
3. Egg retrieval: Mature eggs are collected from the ovaries using a procedure guided by ultrasound.
4. Fertilisation: The eggs are fertilised with sperm in the laboratory. ICSI may be used when there is a specific indication.
5. Embryo development: Fertilised eggs are monitored as they develop into embryos.
6. Embryo transfer: An embryo may be transferred into the uterus.
7. Pregnancy testing: A pregnancy test is performed at the appropriate time after embryo transfer.

What About IVF If There Is an Ovarian Endometrioma?

An ovarian endometrioma does not automatically mean that IVF cannot be performed. However, its size, location, symptoms, effect on the ovary and potential impact on egg retrieval may need to be considered.

Surgery to remove an endometrioma can itself affect ovarian reserve. Therefore, removing an endometrioma simply to improve IVF success is not routinely appropriate in every case.

The fertility team may instead assess whether the endometrioma is likely to interfere with egg collection or whether there are other reasons that surgery should be considered.

Can IVF Be Considered Without Treating the Endometriosis First?

In some situations, yes. There are circumstances in which proceeding directly to assisted reproduction may make more sense than delaying fertility treatment for additional endometriosis treatment. 

This may be particularly relevant when age, ovarian reserve, previous treatment, duration of infertility or other fertility factors make time important.

In other situations, treating endometriosis or addressing an anatomical problem first may be considered. The decision is therefore based on the balance between the potential benefits of treatment and the potential cost of delaying fertility treatment.

How Is the Decision About IVF Made?

A fertility specialist may consider several factors together rather than relying on a single test or the stage of endometriosis.

What If IVF Does Not Work?

An unsuccessful IVF cycle does not necessarily mean that pregnancy is impossible. Depending on the circumstances, the fertility team may review the ovarian response, number and quality of embryos, the uterine environment, sperm factors and other relevant information before deciding what to do next.

Further IVF treatment, a change in treatment strategy, treatment for another identified fertility factor, or other reproductive options may be considered depending on the individual situation.

The Bottom Line

IVF may be considered when endometriosis is affecting fertility and the likelihood of natural conception is reduced, particularly when other fertility factors are present or pregnancy has not occurred after an appropriate period of trying or previous treatment.

However, having endometriosis does not automatically mean that IVF is necessary. The decision is based on the complete fertility picture, including age, ovarian reserve, endometriosis characteristics, previous surgery, duration of trying to conceive and other fertility factors.

For some people, trying naturally or treating endometriosis may be appropriate first. For others, moving toward assisted reproduction sooner may help avoid unnecessary delays. A personalised fertility assessment can help determine which approach is appropriate for the individual situation.