If you have endometriosis and are trying for a baby, you have probably read some frightening things. So let us start with the most important fact: most women with endometriosis do conceive. This page is about what actually helps, and what does not.

A short recap

Endometriosis is a condition in which tissue similar to the lining of the womb grows outside it, causing inflammation, scarring and pain. If you want the full picture of symptoms, diagnosis and treatment of the pain, read our main article: endometriosis — symptoms, diagnosis and treatment.

This page deals only with fertility.

How endometriosis affects fertility

There is no single mechanism. Several things can contribute:

  • Scarring and adhesions that distort the anatomy, so the tube cannot pick up the egg properly
  • Blocked or damaged fallopian tubes
  • Endometriomas — endometriosis cysts on the ovary — which can affect the surrounding ovarian tissue
  • Inflammation in the pelvis, which may affect the egg, the sperm and the early embryo

Importantly, the stage of endometriosis does not reliably predict how hard it will be to conceive. Some women with extensive disease conceive quickly; some with mild disease take much longer.

Care should be shared with a fertility specialist

Endometriosis-related subfertility is best managed with input from both a gynaecologist and a fertility specialist, with access to fertility services.1 It is not a decision to be made by one person in isolation, because the surgical questions and the fertility questions pull in different directions.

Tests before decisions

Before any plan is made, we need the full picture — treating the endometriosis alone is not enough if something else is also contributing.

  • Ovarian reserve testing, which estimates the number of eggs remaining. This carries particular weight in endometriosis, because surgery on the ovary can reduce it.1,2
  • Checking the fallopian tubes are open
  • Confirming that you are ovulating
  • A semen analysis for your partner — a male factor is common and changes the plan entirely
  • Imaging to map where the endometriosis actually is, particularly whether it involves the bowel, bladder or ureter

The point that surprises most people: hormonal treatment does not help you conceive

If you are trying to conceive, hormonal treatment should not be used — either on its own or alongside surgery. It does not improve the chance of natural pregnancy.1

This confuses many women, and understandably so, because hormonal treatment is the mainstay for endometriosis pain. It works by suppressing ovulation — which is precisely why it cannot help you conceive. It is a pain treatment, not a fertility treatment.

There is a genuine tension here if you have severe pain and want to conceive. That is exactly the conversation to have in clinic rather than resolving it from a website.

What surgery can do

For endometriosis that does not involve the bowel, bladder or ureter

Removing or destroying the endometriosis, along with dividing adhesions, improves the chance of conceiving naturally, and should be offered.1

For endometriomas (cysts on the ovary)

This is the decision that needs the most care.

Surgery for an endometrioma improves the chance of natural conception. But there is a real trade-off: operating on the ovary can reduce your ovarian reserve — the number of eggs you have left.1

There are two surgical approaches, and they differ in this respect:

  • Cystectomy — removing the cyst wall completely
  • Drainage and ablation — draining the cyst and destroying its lining

Guidance notes that drainage and ablation may preserve ovarian reserve better than cystectomy.1 The right choice depends on the size of the cyst, whether it has been operated on before, your age, and your ovarian reserve.

This is why the old, simple message — "surgery improves fertility" — is not the whole truth. It does, and it can also cost you eggs. Both need to be on the table when you decide.

For deep endometriosis involving the bowel, bladder or ureter

Here the picture is less clear-cut, and the guidance is explicitly a discussion rather than a recommendation.1 Things to weigh up:

  • Whether deep endometriosis is affecting the pregnancy outcome in your case
  • Whether surgery would actually improve your chance of pregnancy
  • What happens to your fertility if a complication occurs — this is major surgery
  • What the alternatives are, including going straight to IVF
  • Everything else affecting your fertility: your age, your reserve, your partner's results

Surgery or IVF?

There is no single right answer, and anyone who gives you one without knowing your details is guessing.

The decision weighs up:

  • Your age, which matters more than almost anything else
  • Your ovarian reserve — if it is already low, ovarian surgery becomes a harder decision
  • How long you have been trying
  • Whether your tubes are open
  • Your partner's semen analysis
  • Whether you also have pain that needs treating — surgery may address both
  • Whether you have already had surgery — repeat ovarian surgery carries more cost to the reserve

Sometimes surgery first is clearly right. Sometimes going straight to IVF is clearly right — particularly where age or ovarian reserve means time is not on your side.2 Often it is a genuine judgement call, and you should expect to be part of it.

What you can do yourself

  • Do not wait too long before being assessed. If you have endometriosis, come after six months of trying rather than a year.
  • Stop smoking. It reduces fertility and worsens outcomes at every stage.
  • Start folic acid before conceiving — see preconception care.
  • Keep to a healthy weight, which improves both natural conception and IVF outcomes.
  • Ask about your ovarian reserve before agreeing to ovarian surgery. It is a reasonable question and you are entitled to the answer.

When to come and see us

Please make an appointment if:

  • You have endometriosis and have been trying for six months without success
  • You have severe period pain or pain during sex and are planning a pregnancy
  • You have been told you have an endometrioma and want children
  • You are over 35 and have any of the above — do not wait

The takeaway

Endometriosis makes conception harder for some women, but most do conceive. Hormonal treatment helps pain, not fertility. Surgery genuinely improves the chance of natural conception, but ovarian surgery has a cost to your egg reserve that must be weighed openly. The right path depends on your age, your reserve and your partner's results as much as on the endometriosis itself — so get assessed early, and expect a discussion rather than a formula.

References

  1. National Institute for Health and Care Excellence. Endometriosis: diagnosis and management (NG73) — Recommendations, section 1.10: Management if fertility is a priority [Internet]. London: NICE; updated 2024 [cited 2026 Jul 22]. Available from: https://www.nice.org.uk/guidance/ng73/chapter/recommendations
  2. National Institute for Health and Care Excellence. Fertility problems: assessment and treatment (NG257) [Internet]. London: NICE; 2026 [cited 2026 Jul 22]. Available from: https://www.nice.org.uk/guidance/ng257
  3. NHS. Endometriosis [Internet]. London: NHS; [cited 2026 Jul 22]. Available from: https://www.nhs.uk/conditions/endometriosis/