Endometriosis and Fertility: What I Tell My Patients Before They Start Trying

Written by Dr Mei Cheah, Obstetrician, Gynaecologist and Fertility Specialist, Co-Founder of Create Health and Create Fertility | Last reviewed July 2026

I have had a version of the same conversation nearly every week for years. A woman sits down in my consulting room and tells me she has endometriosis. She was diagnosed some time ago, managed her symptoms, and is now ready to have a baby. She has been trying for a few months. And she has come to me because she is starting to worry.

The first thing I tell her is that I am glad she came now. The second is that I wish we had had this conversation sooner.

I say this not to frighten her, and not to imply it is too late. I say it because endometriosis and fertility is one of those areas in medicine where the information that matters most arrives too late, or not at all. The decisions about staging, surgery, and timing are rarely explained in plain terms until someone is already in the middle of a difficult situation. I live this daily as a patient myself. That gap is not acceptable. So let me try to close it here.

For more on when to see a specialist if you are trying to conceive, see When Should I See a Fertility Specialist?

How does endometriosis affect fertility?

Endometriosis affects roughly one in seven people assigned female at birth in Australia. About 30% of those women will experience fertility challenges. Many of my patients tell me they were never told this when they were first diagnosed. They were given a pill to manage their pain, which is not an unreasonable response at that particular stage in their lives, but without any conversation about what the disease might mean for their reproductive future.

The link between endometriosis and reduced fertility is real, but it is not straightforward. The disease affects fertility through several different mechanisms depending on where it is, what type it is, and its severity.

Endometriosis causes inflammation in the pelvic environment. That inflammation can affect egg quality, sperm function, and the delicate process of fertilisation even when tubes are open and cycles appear regular.

It can distort anatomy. Adhesions can pull the tubes and ovaries out of position, interfering with egg collection even when IVF is a proposed option. Severe disease can fuse structures together in ways that can only be properly assessed and addressed with expert surgery.

It can damage the ovarian reserve directly. This concerns me most from a fertility perspective, because it is the least reversible. Endometriosis, the cysts that form when endometriosis affects the ovary, sit inside the ovarian tissue itself. The longer they are there, the more surrounding tissue they can damage. Women with bilateral endometriosas, cysts on both ovaries, are at particularly high risk of reduced ovarian reserve, and this can happen silently, with no symptoms that would prompt anyone to check.

What does endometriosis staging actually mean for fertility?

Endometriosis is classified in stages I through to IV, based on the extent and location of disease seen at laparoscopy. Stage I and II are considered minimal to mild. Stage III is moderately severe, often called deep infiltrating endometriosis. Stage IV is severe, typically involving large endometriosis and significant adhesions to surrounding organs including bowel and bladder.

Here is the part that catches people out: pain does not reliably predict severity, and staging does not reliably predict fertility impact.

I have patients with Stage I disease who have taken years to conceive due to widespread inflammation. I have patients with Stage IV disease who conceived naturally within a few months after surgical treatment. The staging system was designed to describe anatomy at the time of surgery, not to predict biological outcomes.

What I actually look at when thinking about fertility is more nuanced than a stage number. I look at the location and type of disease, whether it is superficial, ovarian, or deep infiltrating. I look at the AMH, the antral follicle count on ultrasound, whether the tubes are affected, and how long she has been trying. I look at age. All of those factors together tell a more useful story than staging alone.

Real patient stories: what endometriosis and fertility actually looks like

Because patient stories make this real in a way that clinical descriptions cannot, here are three anonymised scenarios from my practice.

"I've had endo since I was a teenager, but it's never been that bad."

Sarah came to see me at 32, having been diagnosed with Stage II endometriosis at 19. She had managed her symptoms well with the pill and had largely put the diagnosis to the back of her mind. When she came off contraception to start trying at 31, her cycles were irregular and her period pain had returned with force. Her AMH was low for her age.

The issue was time. The endometriosis had been quietly progressing for over a decade, not dramatically, but enough to affect her ovarian reserve and egg quality. Nobody had monitored it. Nobody had told her that a review when she started thinking about a family might be worthwhile. We ended up proceeding to IVF. She has a beautiful daughter now. But we had less time and fewer eggs to work with than we might have had if we had started the conversation earlier.

"My ultrasound was normal, so my GP said I was fine."

Priya came to me after 14 months of trying, having been reassured more than once that a normal pelvic ultrasound meant there was nothing wrong. She had painful periods and pain with intercourse, both of which she had normalised over years.

On specialist ultrasound review, using targeted technique not standard in general radiology, she was found to have evidence of deep infiltrating endometriosis nodules including a nodule behind the uterus close to the cervix, which explained her painful intercourse, and an AMH that had dropped significantly.

A standard pelvic ultrasound is not sensitive enough to detect deep endometriosis, pelvic organ mobility or early endometriosis. If you have the symptoms, including pain, dyspareunia, or painful bowel movements around your period, you need a specialist gynaecological ultrasound performed by someone with specific training in endometriosis imaging.

"I had surgery last year so I thought I was in the clear."

Jasmine had a laparoscopy twelve months before she came to see me, performed to manage pain. Her surgeon had removed superficial lesions and she felt much better. When she started trying and nothing happened, she assumed the surgery had fixed everything.

What had not been discussed was her ovarian reserve going forward, the likelihood of disease recurrence, or what her path to parenthood might look like after one procedure. Her AMH post-surgery was lower than it had been prior, something that can happen even with careful surgery on the ovaries, and there was already evidence of early recurrence.

This is why the post-surgery conversation about fertility is as important as the pre-surgery one. One procedure does not provide indefinite protection. We had a frank discussion about whether another surgery or proceeding directly to IVF made more sense. She chose IVF. She is currently pregnant with her first child.

Should you have surgery for endometriosis before trying to conceive?

This is probably the most misunderstood area of endometriosis and fertility management, and I want to be direct about it.

Surgery before trying naturally can make a difference in the right circumstances. If you have deep infiltrating endometriosis affecting the tubes, large endometriomas causing symptoms or distorting anatomy, or significant pelvic hostility to conception, then surgery by a skilled excision surgeon performed once and thoroughly can be genuinely helpful.

A patient I operated on eighteen months ago had Stage IV disease with the recto-vaginal space involved and bilateral endometriosis distorting her pelvic anatomy. Her tubes were patent when we flushed them during surgery. We excised everything completely. She came back three months later having conceived naturally without any further treatment.

But surgery on the ovaries carries a real cost. The evidence is now clear and consistent: excision of ovarian endometriosis reduces ovarian reserve. For bilateral endometriomas, the impact on AMH can be substantial. Removing a cyst from the ovary is not like removing one from anywhere else in the body. The ovarian tissue is intimately involved, and even careful surgery affects the surrounding follicles.

If you have a small endometrioma and your AMH is already low, I will often recommend going directly to IVF rather than operating first. The real answer is that there is no default answer. Every patient and their disease is nuanced. An individualised plan is always the right approach.

Repeat surgery is rarely the answer for fertility. I have seen patients who have had two, three, even four laparoscopies for endometriosis, each one reducing their ovarian reserve further. If the first surgery did not achieve pregnancy and your reserve is declining, another operation is very unlikely to help and may cause harm. This is a conversation I have very directly with patients who come to me asking about further surgery before IVF.

What to do right now if you have endometriosis and want to have a family

Get an AMH.

This is not routinely done at diagnosis, but it should be. Your ovarian reserve can be declining without symptoms. Knowing your number gives you genuinely useful information about how much time you have and what your options look like. Treat it as a decision-making tool rather than a verdict.

Have a specialist gynaecological ultrasound.

Not a standard pelvic ultrasound. Ask specifically for one performed by a sonographer or radiologist with expertise in endometriosis imaging. This is a different and more targeted examination.

See a specialist before you start trying.

If you have an endometriosis diagnosis, the standard "try for 12 months" advice does not apply to you. See a fertility specialist with specific experience in endometriosis before you start trying, or as soon as you decide you are ready to think about it. Book a consultation at Create Fertility to discuss your specific situation.

Do not normalise your symptoms.

In Australia, the average time between endometriosis symptoms starting and receiving a diagnosis is around six to eight years. That reflects a culture where painful periods are dismissed as normal. Pain that stops you functioning is not normal. Pain with intercourse is not normal. Bowel symptoms around your period are not normal. Push for answers.

Should women with endometriosis consider egg freezing?

If you are not ready to have children yet but you have an endometriosis diagnosis, particularly if you have endometriomas or a low AMH, egg freezing is worth a serious conversation now rather than later. The ovarian reserve in endometriosis patients tends to be lower to start and also declines over time. Waiting until you are ready to start trying may mean waiting until your reserve has declined further.

I am not suggesting that every woman with endometriosis needs to rush to freeze her eggs. But if your AMH is already on the lower end, or if you want children but not for several years, this is a conversation worth having now. See Egg Freezing and Endometriosis: Hayley's Story.

Your endometriosis diagnosis is not a footnote. It is a relevant, ongoing part of your reproductive health story, and it deserves to be treated as such, with monitoring, honest conversation, and a plan specific to your situation.

Supporting your body nutritionally with endometriosis

Nutrition does not treat endometriosis, but it can meaningfully support the inflammatory environment that endometriosis creates. Anti-inflammatory eating, broadly Mediterranean in pattern, fresh vegetables, fruit, oily fish, olive oil, and limited red meat and processed foods, is the most consistently evidence-supported dietary approach for women with endometriosis.

Active folate, choline and zinc are particularly important in the preconception period. The Prenatal by moode contains calcium folinate, 300mg of choline and zinc, and is Australian made and iron-free. Always read the label and follow directions for use. For more on preconception nutrition, see A Fertility Nutritionist's Guide to Preconception Preparation.

moode answers your questions about endometriosis and fertility

Can I get pregnant naturally with endometriosis?

Yes, many women with endometriosis conceive naturally. The likelihood depends on the type, location and severity of your disease, your ovarian reserve, your partner's sperm health, and how long you have been trying. A specialist assessment gives you a much more accurate picture of your individual situation than a general statistic.

How does endometriosis affect IVF success rates?

Endometriosis can affect IVF outcomes, though the impact varies significantly. Endometriomas and reduced AMH can mean fewer eggs at retrieval. The inflammatory pelvic environment can affect egg quality and implantation. However, with appropriate management and experienced care, many women with endometriosis achieve successful pregnancies through IVF.

Should I have surgery before IVF for endometriosis?

Not necessarily. The decision depends on the size and type of your endometriosis, your current AMH, whether surgery would improve your IVF success rates, and the risks of surgery to your ovarian reserve. This is a highly individualised decision. Discuss it specifically with a fertility specialist who has expertise in endometriosis before proceeding either way.

What is an AMH test and why does it matter for endometriosis?

AMH (Anti-Müllerian Hormone) is a blood test that provides an estimate of your ovarian reserve, the quantity of eggs remaining. For women with endometriosis it is particularly important because the disease can reduce ovarian reserve, sometimes silently. AMH is not routinely tested at endometriosis diagnosis but is one of the most useful pieces of information for fertility planning.

Why does it take so long to get an endometriosis diagnosis in Australia?

The average time between endometriosis symptoms starting and receiving a diagnosis in Australia is six to eight years. This reflects a combination of factors: symptoms being dismissed as normal, standard ultrasounds missing the disease, limited specialist availability, and a historical under-prioritisation of women's pain in medical culture. If you have symptoms and have been told your tests are normal, push for a specialist gynaecological ultrasound performed by someone with endometriosis imaging expertise.

Does endometriosis get worse over time?

It can. Endometriosis is a progressive disease in many, though not all, cases. Endometriomas can grow over time, and ovarian reserve can continue to decline. This is one of the strongest arguments for early specialist review and monitoring, particularly if you plan to have children in the future.

About Dr Mei Cheah

Dr Mei Cheah is co-founder and director of Create Health and Create Fertility, specialist women's health and fertility clinics in Melbourne offering integrated gynaecology, fertility, obstetrics and IVF services across three locations. She is an advanced laparoscopic surgeon with subspecialty expertise in endometriosis-related fertility challenges, and holds a public appointment at Monash Health. Book a consultation with Dr Cheah.