How to Get Pregnant When You Have Endometriosis

Causes of Endometriosis Infertility, Best Treatments for Pregnancy Success

Parents playing with baby in bed at home, conceived after endometriosis infertility
Getting pregnant with endometriosis isn't guaranteed, but it is possible. Tara Moore / Getty Images

Can you get pregnant with endometriosis? 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. You may (or may not) require surgery or fertility treatments to make it happen. But it’s a real possibility.

Note: it is suspected that many couples with unexplained infertility are undiagnosed cases of mild endometriosis. While the below information is specific to those diagnosed with endometriosis, much of it may also apply to couples with unexplained infertility.

How Many Women With Endometriosis Are Infertile?

The answer varies depending on the research study.

It is estimated that 30 to 50 percent of women with endometriosis will experience infertility. (Infertility is defined as the inability to conceive with sexual intercourse after one year.)

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.

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

For couples with unexplained infertility and no pelvic pain, whether or not having surgery to diagnosis (and possibly surgical treat) endometriosis is a controversial topic.

Can I Get Pregnant Naturally With Endometriosis?

If you have been diagnosed with endometriosis before you even thought about getting pregnant, is it worth trying to get pregnant on your own first, before you seek fertility treatment? Yes.

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

However, following the usual advice of trying for a year before seeking fertility help is not recommended.

Instead, try for six months on your own. If you don’t conceive, then ask for help.

Some women with endometriosis may decide to go straight to a fertility specialist and not try to conceive naturally first. This is also an 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.

As always, discuss your particular situation with your doctor. 

How Might Treatment for Endometriosis-Related Pain Impact My Fertility?

Women with endometriosis, who are not trying to get pregnant, are usually given birth control drugs to lessen pain symptoms.

Obviously, if you’re taking birth control pills, you won’t be able to get pregnant. This is only temporary. Once you stop taking the birth control pills, your natural fertility will return.

Also, it’s important to know that the birth control pills don’t cure or “treat” endometriosis. They simply reduce uncomfortable symptoms by suppressing the hormones that feed into endometrial deposits.

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 scar tissue. The scar tissue may increase the risk of infertility and even increase pain.

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 in detail about your future fertility plans. Make sure you’re fully informed about all the risks and benefits.

What Makes Getting Pregnant With Endometriosis Difficult?

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.

Here are some possible theories on why endometriosis makes it harder to get pregnant.

Distortion or blockages of the 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.

Difficulty with embryo implantation: 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 research on IVF has found that women with endometriosis who use donor eggs have similar embryo implantation rates to women without endometriosis.

Decreased egg and embryo quality: Women with endometriosis may have lower egg quality. Embryos from women with endometriosis develop slower than average.

Also, 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.

Does Endometriosis Stages (Levels of Disease) Indicate Odds for 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 I, Stage II, Stage III, and Stage IV.

These stages are used to help describe and evaluate the severity of endometriosis, with Stage I being mild endometriosis, and Stage IV being severe.

But do these stages mean anything with regards to your fertility or your odds of conception?

Yes and no.

Women with Stage I and II endometriosis are less likely to experience infertility than women with Stage III and IV.

Also, the stage of endometriosis can help your doctor come up with a treatment plan.

For example, a woman with Stage II endometriosis may want to try to conceive on her own for a while. A woman with Stage IV endometriosis may proceed directly to IVF treatment.

However, the stage of your endometriosis cannot predict whether fertility treatments will be more or less successful for you.

It is possible to have Stage II endometriosis and go through numerous failed IVF treatments. And it’s possible to have Stage IV endometriosis and conceive on your first cycle.

Another reason endometriosis staging can’t predict your odds for pregnancy success is because there are frequently other fertility factors to consider. A woman with Stage IV endometriosis may also have ovulation dysfunction. Or there may be male factor infertility issues to consider.

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

Does How Much Pain I Experience Predict My Odds for Pregnancy Success?

No.

This is partially because the amount of pain you experience isn’t necessarily related to the severity of the endometriosis.

While severe endometriosis tends to come 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 it will be harder for you to get pregnant compared to a woman with less pain.

What Fertility Treatments Are Most Effective for Endometriosis?

The most effective per cycle treatment for endometriosis-related infertility is IVF treatment. That doesn’t mean you should or must start there.

IVF is expensive and invasive. Even if it has the best pregnancy odds, it may not be the best starting point for you.

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.  

Fertility drugs alone are not typically recommended for women with endometriosis. They don’t significantly improve the pregnancy rates when compared to expectant management. (Expectant management is continuing to try without treatment.)

For women with Stage I or II endometriosis, fertility drugs with intrauterine insemination (IUI) is usually the recommended starting point. This can be done with Clomid or with gonadotropins.

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.

If fertility drugs with IUI are unsuccessful, then IVF is the next recommended step.

However, IVF is sometimes the best first step in the treatment of endometriosis.

Women who go straight to IVF include...

  • Those with Stage III or IV endometriosis
  • Women over age 35
  • Couples with other complicating fertility factors (like male factor infertility or low ovarian reserves)
  • Women with Stage I or II endometriosis who prefer to go straight to IVF, despite the extra costs and invasive nature of the procedure

It’s important to recognize that IVF is not an option for all couples.

Some prefer not to pursue this intense treatment, and many couples can’t afford it.

For these couples, if multiple rounds of IUI with fertility drugs are unsuccessful, alternative options—like adoption or a childfree life—may be considered.

What Are the Odds for Fertility Treatment Success With Endometriosis?

In a study of women with unexplained infertility (which is often suspected mild endometriosis) or surgically corrected endometriosis, pregnancy rate per cycle was 9.5 percent for those using Clomid with IUI, compared to 3.3 percent for those using only timed intercourse.

A randomized trial of 49 women with Stage I or II 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.

What about the odds of IVF success?

According to one study, the average pregnancy rate per cycle for women with endometriosis was 22.2 percent.

This is slightly lower than the average IVF success rates for women with other causes of infertility.

Generally speaking, endometriosis is associated with lower egg retrieval numbers, lower implantation rates, and lower pregnancy rates, when compared to other causes of infertility.

Determining IVF success rates for women with endometriosis is complicated. Most couples facing IVF treatment are dealing with additional fertility factors, beyond the endometriosis.

One study attempted to investigate the odds, both for couples with only endometriosis as their infertility challenge and those with endometriosis in addition to other fertility factors.

They found that in the rare cases when endometriosis is the sole fertility factor, the live birth rate is similar or slightly higher than those with other infertility diagnoses.

However, when endometriosis presents with additional fertility problems, success rates are the lowest when compared to other infertile couples.

Your personal odds of IVF success will depend on your age and what other fertility factors you’re facing. Talk to your doctor about your particular situation.

Does Surgical Treatment for Endometriosis Improve Fertility?

The number one reason for surgical removal of endometrial deposits is to reduce pain symptoms. This may be done at the same time of diagnosis.

But does surgery improve fertility in women with endometriosis?

For those with severe endometriosis, surgery does seem to improve fertility and possibly improve the odds for fertility treatment success.

However, repeated surgical treatment does not further enhance fertility.

What about women with mild to moderate endometriosis? Some studies have found small but significantly improved live birth rates after surgical intervention for women with Stage I or II endometriosis.

It is suspected that many women with unexplained infertility have mild endometriosis. Is surgery warranted in these cases, to diagnose and possibly remove endometrial deposits (if found)?

This is questionable.

If the woman isn’t experiencing pain, the risks of surgery outweigh the possible fertility benefit.

(Keep in mind the benefit will only apply if the woman has endometriosis, and she may not. According to one study, for every 40 surgeries/cases, one pregnancy would possibly result. Those aren’t good odds.)

Surgery to diagnose and remove endometrial deposits has risks. It has also, in some cases, increased endometriosis symptoms or even caused further fertility damage. Surgery can lead to adhesions, which can harm fertility and cause pain. Removal of endometrial ovarian cysts may reduce ovarian reserves.

Talk to your doctor about whether surgical treatment is right for you. If you’re still unsure, don’t be afraid to seek a second opinion.

Sources:

Gibbons, William E.; Hornstein, Mark D. “Treatment of infertility in women with endometriosis.” UpToDate.

Practice Committee of the American Society for Reproductive Medicine. “Endometriosis and infertility: a committee opinion.Fertil Steril. 2012 Sep;98(3):591-8. Epub 2012 Jun 15.

Senapati S1, Sammel MD2, Morse C3, Barnhart KT4. “Impact of endometriosis on in vitro fertilization outcomes: an evaluation of the Society for Assisted Reproductive Technologies Database.” Fertil Steril. 2016 Jul;106(1):164-171.e1. doi: 10.1016/j.fertnstert.2016.03.037. Epub 2016 Apr 7.

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