How to Get Pregnant If You Have Endometriosis

Getting pregnant with endometriosis is possible, though it may not come easily. Up to half of the women with endometriosis will have trouble getting pregnant. The likelihood of having fertility problems depends on your age, your partner’s fertility, and how severe the endometriosis is. For those that do struggle to conceive, surgery or fertility treatments like IVF may help.

Perhaps you’ve been trying to conceive unsuccessfully for some time, and now, after a fertility evaluation and diagnostic laparoscopic surgery, your doctor has diagnosed you with endometriosis.

Or maybe you haven’t even started thinking about having children yet. However, after experiencing pelvic pain or severe menstrual cramps, your doctor has investigated and diagnosed you with endometriosis.

Either situation may lead you to wonder if you have any chance of conceiving. The answer is yes, you can conceive with endometriosis. It’s not a guarantee, but there is a real possibility.

Endometriosis and Infertility

The main concern many women have after being diagnosed with endometriosis is the impact it will have on current or future pregnancy plans. On an individual basis, there are no easy answers as to what the risk of infertility (the inability to conceive after one year) will be, and statistics vary on how many women with endometriosis are actually affected.

According to research published in the Journal of Assisted Reproduction and Genetics, an estimated 30 to 50 percent of women with endometriosis will experience infertility.

Women with infertility—who may not have an official diagnosis of endometriosis yet—are also more likely to have endometriosis. Some research has found that infertile women are six to eight times more likely to have endometriosis than those who don’t struggle to conceive.

Also, of the one in four couples who receive a diagnosis of unexplained infertility, it is suspected that many of them may actually be dealing with mild endometriosis. This is supported by research which concluded that anywhere from 20 percent to 25 percent of women with endometriosis will be entirely without symptoms.

However, because endometriosis can only be diagnosed with invasive diagnostic laparoscopic surgery, it appears that there is no "cause" for their infertility.

Chances of a Natural Pregnancy

If you have been diagnosed with endometriosis before you even thought about getting pregnant, you may wonder if it's worth trying to get pregnant on your own before seeking fertility treatment. The answer is simple: yes, absolutely.

Of course, you should always talk to your doctor about your specific situation. But endometriosis doesn’t automatically mean you will experience infertility.

If you have endometriosis, you will usually be advised to try conceiving naturally for six months (rather than the 12 months recommended for other women). If you don't conceive within this time frame, you should speak with a fertility specialist.

Some women with endometriosis may decide to go straight to a fertility specialist. This is also a reasonable option.

If you’re 35 years or older, you may not want to take the time to try to conceive on your own. Your natural fertility declines with age at a faster rate after age 35, and those extra six months—especially because you already know you have endometriosis—may not be wise.

Endometriosis Pain and Infertility

Pain can interfere with fertility simply by the fact that sexual intercourse may be too painful to perform. The pain itself does not interfere with your ability to ovulate or achieve fertilization; rather, it makes the act of sex difficult and sometimes unbearable.

With that being said, the amount of pain you experience isn’t necessarily related to the severity of the endometriosis. While severe endometriosis is associated with increased pain, it’s also possible for mild endometriosis to cause severe pain. It depends on where the endometrial deposits are located.

More pain doesn't mean that it will be harder for you to get pregnant compared to a woman without pain. It only impacts fertility in that you may be less able to have sexual intercourse.

Women with endometriosis who are not trying to get pregnant are usually given birth control drugs to lessen pain symptoms. The problem with this, of course, is that you can only get pregnant while the pills are stopped.

In cases of moderate to severe endometriosis, surgery may be required to remove endometrial lesions or cysts. Surgery can reduce pain, but repeated operations can cause the buildup of scar tissues (adhesions) that increases the risk of infertility.

In very severe cases of endometriosis, the uterus, ovaries, or part of the ovaries may be removed. This will impact your future fertility. You must also know that surgical removal of your reproductive organs isn't a cure for endometriosis. You may still experience pain.

Before you have surgery, talk to your reproductive surgeon about your future fertility plans. Make sure you’re fully informed about all the risks and benefits.

Underlying Causes of Infertility

We don’t fully understand how endometriosis impacts fertility. When endometriosis causes ovarian cysts (which may interfere with ovulation), or endometrial scar tissue blocks the fallopian tubes, the reason for infertility is clearer. However, women with endometriosis who don’t have endometrial ovarian cysts or blocked fallopian tubes may still experience reduced fertility.

There are several possible theories on why endometriosis makes it harder to get pregnant:

Distortion or Blockage of Reproductive Organs

Endometrial lesions can cause scar tissue—or adhesions—to form. These adhesions may pull on the reproductive organs, impeding their ability to function normally. Adhesions may also cause fallopian tube blockage, which can pretend the egg and sperm from meeting.

General Inflammation

The possible role of general body inflammation and infertility is the subject of ongoing research. Increased inflammation in the body does seem to be correlated with infertility. Women with endometriosis have biochemical signs of increased inflammation.

But does the endometriosis cause the inflammation? Or does inflammation increase endometriosis? And how does it all relate to infertility? That we don’t know.

Embryo Implantation Problems

While endometriosis is a condition that causes endometrial-like tissue to grow outside of the uterus, it may also affect the endometrium itself. Embryo implantation rates are lower in women with endometriosis. However, it’s possible lower embryo implantation rates are due to problems with the endometrium but are related to poor egg quality.

Some in-vitro fertilization research has found that women with endometriosis who use donor eggs have similar embryo implantation rates to women without endometriosis.

Decreased Egg Quality

Women with endometriosis may have poor egg quality. Moreover, embryos from women with endometriosis develop slower than average. When an egg donor has endometriosis, and those eggs are used in a woman without endometriosis, the resulting embryos tend to be of lower quality and implantation rates are negatively affected.

Endometriosis Stages and Infertility

Your doctor may have referred to your endometriosis in terms of stages. During surgery, your doctor takes into account the location, amount, and depth of endometrial deposits. Based on this, she scores the level of your endometriosis.

There is stage 1, stage 2, stage 3, and stage 4. These stages are used to help describe and evaluate the severity of endometriosis, with stage 1 being mild endometriosis and stage 4 being severe. But do these stages mean anything with regards to your odds of conception? Yes and no.

As a general rule, women with stage 1 or 2 endometriosis are less likely to experience infertility than women with stage 3 or 4 endometriosis.

The stage of endometriosis can also help your doctor come up with a treatment plan. For example, a woman with stage 2 endometriosis may want to try to conceive on her own for a while. A woman with stage 3 endometriosis may proceed directly to IVF treatment.

However, the stage of your endometriosis cannot predict whether fertility treatments will be more or less successful. It is possible to have stage 2 endometriosis and go through numerous failed IVF treatments. And it’s possible to have stage 4 endometriosis and conceive on your first cycle.

Bottom line: don’t put too much weight on the stage of your endometriosis.

Fertility Treatment Options

The most effective per cycle treatment for endometriosis-related infertility depends on your age, stage of disease, infertility risk factors, treatment costs, and personal choice. Your treatment plan will also depend on the stage of your endometriosis and whether endometriosis alone is the cause of your infertility. Your doctor will also take into account your age. 

Intrauterine Insemination (IUI)

Fertility drugs alone are not typically recommended for women with endometriosis. They don’t significantly improve pregnancy rates when compared to women with endometriosis who try to conceive naturally

For women with stage 1 or 2 endometriosis, intrauterine insemination (IUI) with fertility drugs is usually the recommended starting point.

The fertility drugs include Clomid (clomiphene) and gonadotropin. Clomid with IUI is usually attempted first because the risk of conceiving multiples and developing ovarian hyperstimulation syndrome (OHSS) is lower than it is with gonadotropins.

In a study of women with unexplained infertility or surgically corrected endometriosis, the pregnancy rate per cycle was 9.5 percent for those using Clomid with IUI, compared to 3.3 percent for those pursuing natural pregnancy.

A randomized trial of 49 women with stage 1 or 2 endometriosis compared pregnancy rates for women who received three cycles of gonadotropins with IUI with women who continued trying without fertility treatment help for six months.

The pregnancy rate per cycle for those who received gonadotropins with IUI was 15 percent. The untreated group had a pregnancy rate per cycle of 4.5 percent.

In Vitro Fertilization (IVF)

If fertility drugs with IUI are unsuccessful, then IVF is the next recommended step. In vitro fertilization (IVF) is considered the most effective overall and provides you the best odd for pregnancy. It is also expensive and invasive.

Depending on the circumstance, IVF may be the first treatment option for women whose likelihood of conceiving is significantly reduced. You would likely be advised to skip IUI and go straight to IVF would if you:

  • Have stage 3 or 4 endometriosis
  • Are over 35
  • Have multiple infertility risk factors (like male infertility or low ovarian reserves)
  • Prefer to go straight to IVF despite the costs and invasive nature of the procedure

According to research, the median IVF success rate for women with endometriosis was 22.2 percent. This is slightly less than the average IVF success rates for women with other causes of infertility.

Predicting IVF success rates on a case-by-case basis can be complicated. Most couples facing IVF treatment are dealing with additional fertility factors beyond just endometriosis. However, if endometriosis is the sole fertility factor, the live birth rate is similar or slightly higher than those with other infertility diagnoses.

Moreover, IVF treatment doesn't appear to increase endometriosis pain compared to women with endometriosis in general.

It’s important to recognize that IVF is not an option for all couples. Some prefer not to pursue this intense treatment, and others simply can’t afford it. For these couples, if multiple rounds of IUI with fertility drugs are unsuccessful, alternative options—like adoption or a child-free life—may be considered

Miscarriage Risks

Endometriosis can increase your risk of pregnancy loss, but more so in women experiencing endometriosis-related infertility. However, the risk of miscarriage appears to be conversely associated with the stage of the disease.

A 2017 study looked at 270 women with or without endometriosis and found that the miscarriage rate for women with endometriosis was around 35 percent, compared to 22 percent for those without the disease (a 60 percent difference).

Interestingly, the researchers found that women diagnosed with stage 1 or 2 endometriosis were more likely to experience miscarriage than those with stage 3 or 4 endometriosis (42 percent versus 31 percent). What this suggests is that mild endometriosis may be associated with greater inflammation than previously thought.

Surgery and Fertility Rates

The number one reason for surgical removal of endometrial deposits is to reduce pain symptoms. This is sometimes done at the time of diagnosis. Beyond pain reduction, surgery may also offer added benefits in terms of increased fertility.

For women with severe endometriosis, surgery does appear to improve fertility treatment success rates. On the other hand, repeated surgeries can reverse those gains by causing the extensive formation of adhesions.

Some studies have also found small but significantly improved live birth rates after surgery for women with stage 2 or 3 endometriosis.

However, if a woman isn’t experiencing endometrial pain, the risks of surgery outweigh the possible fertility benefits. Surgery to remove endometrial deposits has its risks, and you need to weight the pros and cons of surgery to make a fully informed choice.

If you’re still unsure after speaking with your doctor, don’t be afraid to seek a second opinion.

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