What are the chances of pregnancy for a patient with endometriosis?

Pregnancy Chances in Endometriosis

Women with endometriosis face reduced fertility, with infertility rates ranging from 20-68%, though many can still conceive naturally or with treatment—the Endometriosis Fertility Index (EFI) provides the most validated prognostic tool for predicting pregnancy success after surgical staging. 1, 2

Baseline Fertility Impact

• Endometriosis affects at least one-third of women with infertility, representing a substantial proportion of reproductive-age women seeking conception 3
• The disease causes infertility through multiple mechanisms: pelvic adhesions disrupting tubal transport, chronic inflammation producing reactive oxygen species, immune dysregulation affecting implantation, and progressive ovarian damage reducing ovarian reserve 2, 4
• Approximately 26% of women with endometriosis present specifically with infertility as their primary complaint 5

Prognostic Assessment Using EFI

The Endometriosis Fertility Index is the only classification system with validated prognostic value for predicting pregnancy likelihood, as it incorporates clinical variables affecting fertility independent of endometriosis severity alone. 1

• The EFI combines surgical findings with clinical factors (age, duration of infertility, prior pregnancy history) to generate a score predicting natural conception rates post-surgery 1, 2
• This tool has undergone external validation and demonstrates superior predictive accuracy compared to the revised American Society for Reproductive Medicine (r-ASRM) staging system, which correlates poorly with fertility outcomes 1
• The EFI should be calculated at the time of diagnostic laparoscopy to guide subsequent fertility management decisions 2

Disease Severity and Ovarian Reserve Considerations

• Women with endometriomas demonstrate reduced ovarian reserve markers, including decreased antral follicle counts and ovarian volume, which directly impact IVF success rates 3
• The severity of endometriosis correlates with degree of ovarian reserve compromise, with deep infiltrating endometriosis (lesions >5mm below peritoneal surface) causing more extensive damage 6, 4
• Up to 44% of women experience symptom recurrence within one year after surgery, potentially leading to progressive ovarian damage that further reduces fertility potential 3, 7

Treatment Impact on Conception Rates

Surgical Management

• Surgical treatment at any stage of endometriosis enhances chances of natural conception based on available data, though much of this evidence is uncontrolled 8
• Surgery should be considered immediately when age, ovarian reserve, and male/tubal factors permit, dedicating time afterward for natural conception attempts 8
• Critical caveat: Surgical resection of endometriomas can cause iatrogenic ovarian injury during tissue removal, further deteriorating ovarian reserve—this must be weighed against potential fertility benefits 4

Medical Management Limitations

• All medical treatments for endometriosis (combined oral contraceptives, progestins, GnRH agonists) are contraceptive and provide no fertility benefit during active use 8, 5
• Medical therapy as neoadjuvant or adjuvant to surgical treatment has no definite beneficial effect on fertility outcomes 4
• However, 3-6 months of GnRH analogues before assisted reproductive technology (ART) improves IVF outcomes in women with endometriosis 8

Assisted Reproductive Technology Considerations

• IVF should not be delayed in favor of prolonged medical management in women with documented endometriosis and infertility, as progressive ovarian damage may occur during treatment delays 3
• The biological basis for reduced IVF success involves impaired oocyte quality, reduced fertilization potential, and compromised endometrial receptivity 3
• For mild-to-moderate stage endometriosis, intrauterine insemination with ovarian stimulation after surgical treatment may increase pregnancy likelihood 4
• For severe endometriosis, treatment prioritization should consider patient age, ovarian reserve status, and disease extent when choosing between surgery and immediate IVF 4

Critical Pitfalls to Avoid

• Do not assume normal imaging excludes endometriosis—superficial peritoneal disease is poorly detected by all imaging modalities yet may still significantly impact fertility 3, 7
• Do not overlook ovarian reserve assessment (antral follicle count, AMH levels) in women with endometriosis, as diminished reserve further compromises conception chances 3
• Do not perform repeat surgeries for endometriomas without considering cumulative ovarian damage—criteria for non-removal include bilateral cysts, history of past surgery, and already altered ovarian reserve 8
• Do not delay fertility treatment in older women or those with compromised ovarian reserve—time is the most critical factor in these populations 8

Coexisting Conditions

• Adenomyosis frequently coexists with endometriosis and may further compromise fertility outcomes, requiring specific diagnostic attention with transvaginal ultrasound or MRI 7, 2
• Women with endometriosis have increased risk for pregnancy complications including placenta previa, preterm labor, and postpartum hemorrhage, which should inform prenatal counseling 9