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

Written by Dr Mei Cheah, Co-Founder of Create Health and Create Fertility, Obstetrician-Gynaecologist and Fertility Specialist, Melbourne. Reviewed July 2026.

There is a conversation I have on a near-weekly basis. A woman sits down in my consulting room and tells me she has endometriosis. She was diagnosed years ago, probably after a long wait, and is now ready to have a baby. She has been trying for a few months, maybe longer, and she has come to me because she is starting to worry.

The first thing I tell her is that I'm glad she came now.

The second thing is that I wish we'd had this conversation sooner.

Not to frighten her. Not to imply that it's too late. But because endometriosis and fertility is one of those areas in medicine where the information people need most often comes too late, or not at all. The internet is full of contradictions and medical misinformation, and the decisions that genuinely matter, about staging, surgery and timing, are rarely explained in plain terms until someone is already in the middle of a difficult situation. These are the kinds of conversations we have every day in our fertility and women's health clinic in Melbourne.

So let me try to change that. I'm Dr Mei Cheah, a fertility specialist and an obstetrician, gynaecologist and fertility specialist in Melbourne, co-founder of both Create Health and Create Fertility, and this is the conversation I wish more of my patients had access to earlier.

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. That is not a small number, and yet 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 management at that particular stage in their lives, but without any conversation about what the disease might mean for their reproductive future.

That gap is not acceptable, and it is something I think about every day in my practice. I live it daily as a patient myself.

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 the severity of the disease.

How Does Endometriosis Cause Inflammation That Affects Fertility?

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.

Can Endometriosis Distort Pelvic Anatomy?

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.

How Do Endometriomas Damage Ovarian Reserve?

It can damage the ovarian reserve directly. This is the one that concerns me most from a fertility perspective, because it is the least reversible. Endometriomas, the cysts that form when endometriosis affects the ovary, sit inside the ovarian tissue itself, and the longer they are there, the more of the surrounding tissue they can damage. Endometriomas affect both egg quantity and quality. Women with bilateral endometriomas (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 Are the Stages of Endometriosis, and Do They Predict 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 considered moderately severe, often called deep infiltrating endometriosis. Stage IV is severe, typically involving large endometriomas and significant adhesions to surrounding organs like bowel and bladder.

Here is the part that catches people out: pain does not reliably predict severity, neither does it 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 Does Dr Cheah Actually Look at Instead of Stage?

What I actually look at when thinking about fertility is more nuanced than just the staging of the disease itself. I look at the location and type of disease, whether it is superficial, ovarian, or deep infiltrating (DIE). I look at the AMH. I look at the antral follicle count on ultrasound. I look at whether the tubes are affected. And I look at how long she has been trying, whether she is able to comfortably try, or whether we're unable to achieve intercourse secondary to severe pain (vaginismus). I evaluate how old she is, because all of those factors together tell a much more useful story than a stage number alone.

What Does Endometriosis and Fertility Look Like in Real Patients?

Because I think patient stories make this real in a way that clinical descriptions cannot, let me share some anonymised scenarios from my practice.

Can Mild Endometriosis Still Affect Your Fertility Years Later?

"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 initially, and her period pain had returned with force. Her AMH when we tested it was low for her age.

The issue here was time. The endometriosis had been quietly progressing for over a decade, not dramatically, but enough to affect her ovarian reserve and egg quality. It had not been monitored. Nobody had checked her disease progression nor provided comprehensive long-term education. Nobody had told her back then, that going back for 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.

Can You Have Endometriosis With a Normal Ultrasound?

"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 some years ago meant there was nothing wrong. She had painful periods and pain with intercourse, both of which she had normalised over years. They just kept trying on their own as they were told some months ago.

On specialist ultrasound review, using the kind of targeted technique that is 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 would have explained her painful intercourse, and an AMH that had dropped significantly.

This is a scenario I see more than it should happen. A standard pelvic ultrasound is not sensitive enough to detect deep endometriosis, pelvic organ mobility or early endometriomas. If your symptoms are there, the pain, the dyspareunia, the painful bowel movements around your period, you need a specialist gynaecological ultrasound performed by someone with specific training in endometriosis imaging. If you do not ask the right questions, it is unlikely you will get the right answer.

Does Surgery for Endometriosis Permanently Fix Fertility?

"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 at the time of her surgery was her ovarian reserve going forward, or the likelihood of disease recurrence, or what her path to parenthood might look like now that she had had 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, neither is it a good predictor of disease progression or future fertility. Unfortunately, endometriosis can be relentless and we do not yet have a cure for this cruel condition. We had a frank conversation about what pursuing another surgery may look like, detailing risks versus benefit, versus proceeding directly to IVF given the length of time they had been trying to conceive, and they chose IVF. She is currently pregnant with her first child.

Does Surgery Help or Harm Fertility With Endometriosis?

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

When Does Surgery Help Fertility in Endometriosis?

Surgery before trying naturally can absolutely make a difference in the right circumstances. If you have deep infiltrating endometriosis affecting the tubes, if you have large endometriomas causing symptoms or distorting anatomy, or if there is a strong case that your pelvic environment is significantly hostile to conception, then surgery by a skilled excision surgeon, performed once, thoroughly, can be genuinely helpful.

A patient whose surgery I did eighteen months ago had Stage IV disease with the rectovaginal space involved, and bilateral endometriomas distorting her pelvic anatomy. Fortunately, 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. I was not surprised, but she was.

Does Surgery on the Ovaries Reduce Egg Count?

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

Should You Have Surgery Before IVF for an Endometrioma?

If you have a small endometrioma and your AMH is already low, I will often recommend going directly to IVF rather than operating first. Removing the cyst before IVF may not improve your IVF success rates, and it risks reducing the reserve we have to work with. There are situations where surgery before IVF makes clinical sense, particularly if the endometrioma is large, causing pain, or making egg collection technically difficult, or potentially dangerous due to bowel adhesions. The real answer is that there is no default answer to this question, as every patient and their disease is nuanced, hence an individualised plan is always the way forward.

Is Repeat Surgery Worth It for Fertility?

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 could even possibly do harm. This is a conversation I have very directly with patients who come to me asking about further surgery before IVF.

Does Surgery Still Make Sense for Pain, Even Without Fertility Goals?

The exception is pain. If you are in pain that is significantly affecting your quality of life, surgery has a role independent of fertility goals. But if your primary goal is conception, the risk-benefit calculation looks very different.

What Should You Do If You Have Endometriosis and Want to Get Pregnant?

If you have an endometriosis diagnosis and you are thinking about having a family, whether that is in six months or six years, there are a few things I would urge you to do today.

Should I Get My AMH Tested If I Have Endometriosis?

Get an AMH. This is not routinely done at diagnosis, but it should be. Your ovarian reserve can be declining without any symptoms, and knowing your number gives you genuinely useful information about how much time you have and what your options look like. It is important not to treat this as a marker of fertility or infertility, rather a helpful decision-making tool, in helping you form your fertility timeline.

What Type of Ultrasound Do I Need for Endometriosis?

Have a specialist gynaecological ultrasound. Not just a standard pelvic ultrasound. Ask specifically for an ultrasound performed by a sonographer or radiologist with expertise in endometriosis imaging. This is a different and more targeted examination. There is often some minor preparation involved in this scan.

When Should I See a Fertility Specialist If I Have Endometriosis?

See a specialist before you start trying, not after months of disappointment. If you have an endometriosis diagnosis, the standard "try for 12 months" advice does not apply to you. Come and talk to me, or to any fertility specialist with specific experience in endometriosis, before you start trying, or as soon as you decide you are ready to think about it.

Is It Normal to Have Painful Periods?

Do not normalise your symptoms. In Australia, the average time between endometriosis symptoms starting and receiving a diagnosis is around 6 to 8 years. That figure has been improving, but it is still far too long, and it still 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. If you have these things and nobody has investigated why, please push for answers.

Should You Freeze Your Eggs If You Have Endometriosis?

One more thing I want to address, because it comes up often and is not well understood.

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 decline over time. There is reasonable evidence that freezing eggs before that decline advances gives you more options in the future. Waiting until you are "ready" to start trying may mean waiting until your reserve has declined further. For more on the process itself, see Putting Your Eggs On Ice.

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 know that you want children but not for several years, it is a conversation worth having now.

The thing I most want people reading this to take away is simple: 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, with honest conversation, and with a plan that is specific to your situation rather than a generic protocol that was designed for someone without your history.

Come and talk. The earlier, the better. I'm always here to listen. Together, we plan for a better fertility future.

Dr Cheah answers your questions about endometriosis and fertility

Further Reading From the moode Journal

• Endometriosis Diet: Anti-Inflammatory Foods That Help
  
• A Starters Guide to IVF: Everything You Need to Know Before You Begin
  
• When Should I Start Taking a Prenatal Vitamin?
  
• What Is Ovulation Tracking? A Naturopath's Guide to Your Fertile Window
  
• Putting Your Eggs On Ice