Endometriosis and Fertility

endometriosis patient holds her baby

Many women with endometriosis not only suffer from pain, but they also wonder about the disorder’s potential impact on their fertility.

The good news first: Fortunately, about half of all patients with endometriosis have no problems whatsoever with conception, pregnancy and childbirth. However, in some cases, endometriosis can unfortunately make things difficult.

When can endometriosis affect fertility?

Sometimes, the location of endometriomas is problematic. If they are located on ovaries or fallopian tubes, they may interfere with normal physiological function. When endometriomas are located in the uterine muscles, they may impede implantation and development of the embryo, increasing risk of miscarriage. Therefore, healthcare providers will want to check on fallopian tubes – are they obstructed, are there endometriomas? If adhesions are a likely reason for difficulties conceiving, they will be loosened as far as possible and endometriomas surgically removed.

This significantly increases the chances of pregnancy. But: Even if the operation was successful, some women may still not get pregnant. Reasons for this are, among other things, inflammatory processes associated with endometriosis, hormonal changes such as estrogen dominance and increased oxidative stress.

Hormonal changes in endometriosis

Endometriosis patients often experience an imbalance of their hormonal system. Too much estrogen and too little progesterone is a classic. Endometriosis patients may also have progesterone resistance, which means that the sex hormone cannot fully develop its effects, even though it is present in sufficient quantities. Unfortunately, too much estrogen and too little progesterone promote inflammation and the development of further lesions. This creates a vicious circle in which the estrogen dominance caused by the endometriosis favors the further progression of the endometriosis.

Estrogen also has a regulating effect on other hormone cycles that are important for female fertility. Therefore, many women with endometriosis also have altered levels of LH (luteinizing hormone). This can affect follicle growth, ovulation, and the development of the corpus luteum in the ovary. Impaired folliculogenesis in women with endometriosis is visible by a reduction in the number of preovulatory follicles, follicle growth, dominant follicle size, and follicular estradiol concentrations.

Inflammation, oxidative stress and fertility

Another major problem for patients with endometriosis is inflammation. It leads to greatly increased oxidative stress. The problem: Oxidative stress may significantly damage oocyte quality, so that women with endometriosis may not only have fewer oocytes, but their quality may be impaired as well.

In addition, increased oxidative stress also has an impact on the partner’s sperms. It hampers their motility, they get more likely to be attacked by the partner’s immune system, make less progress in general and binding to the oocyte is not easy either.

Finally, inflammation and oxidative stress even affect the genetic health of ova and sperm: Peritoneal fluid from women with endometriosis has been shown to increase the amount of DNA fragmentation in sperms from healthy donors.

Fertility treatment

Good to know: Fertility treatment offers very good prospects of success.

The patient herself can support success of treatment by protecting oocytes from  inflammation and increased oxidative stress. Experts advise to stick to an anti-inflammatory diet and consume plenty of antioxidants.

Endometriosis and pregnancy

Studies show that pregnant women with endometriosis can have a pregnancy just as uncomplicated as any other woman. During pregnancy, they are usually spared from endometriosis symptoms and sometimes the improvement continues even after pregnancy.

There is no evidence that endometriosis may adversely affect the course of the pregnancy or the health of the baby. The babies of endometriosis patients are always a little smaller than children of non-endometriosis patients, but not to an extent that would give cause for concern. However, risk of high blood pressure and risk of so-called placenta previa is slightly increased during pregnancy. This is when the placenta is directly in front of or at the edge of the cervix. It requires closer monitoring of the pregnancy and – depending on the exact location of the placenta – delivery by caesarean section.

Speaking of childbirth: In the past, people sometimes worried about natural delivery after an endometriosis operation. There were concerns that vaginal tears or birth complications could occur more often. Today we know that women with endometriosis give birth just as often spontaneously as other women and without any tendency towards increased complications for mother and child. Women with endometriosis may however have slightly higher loss of blood during childbirth.

Sometimes, after giving birth, endometriosis patients may benefit from a multivitamin with iron and a number of other vitamins and minerals that are needed in larger amounts after childbirth and while breastfeeding. 😊





Al-Fadhli R, Kelly SM, Tulandi T, Tanr SL. Effects of different stages of endometriosis on the outcome of in vitro fertilization. J Obstet Gynaecol Can. 2006; 28:888–891.

Allaire C. Endometriosis and infertility: a review. J Reprod Med. 2006; 51:164–168.

Augoulea A, Mastorakos G, Lambrinoudaki I, Christodoulakos G, Creatsas G. The role of the oxidative-stress in the endometriosis-related infertility. Gynecol Endocrinol. 2009;25:75–81.

Bancroft K, Williams CAV, Elstein M. Pituitary–ovarian function in women with minimal or mild endometriosis and otherwise unexplained infertility. Clin Endocrinol. 1992;36:177–181.

Bulletti C, Coccia ME, Battistoni S, Borini A. Endometriosis and infertility. J Assist Reprod Genet. 2010;27:441–447.

Carvalho LF, Abrão MS, Biscotti C, Sharma R, Nutter B, Falcone T. Oxidative cell injury as a predictor of endometriosis progression. Reprod Sci. 2013 Jun;20(6):688-98.

Chen I et al. Association between surgically diagnosed endometriosis and adverse pregnancy outcomes. Fertil Steril. 2018 Jan;109(1):142-147.

Coddington CC, Oehninger S, Cunningham DS, Hansen K, Sueldo CE, Hodgen GD. Peritoneal fluid from patients with endometriosis decreases sperm binding to the zona pellucida in the hemizona assay: a preliminary report. Fertil Steril. 1992;57:783–786.

Garrido N, Navarro J, Remohi J, Simon C, Pellicer A. Follicular hormonal environment and embryo quality in women with endometriosis. Hum Reprod Update. 2000;6:67–74.

Garrido N, Navarro J, Garcia-Velasco J, Remoh J, Pellice A, Simon C. The endometrium versus embryonic quality in endometriosis-related infertility. Hum Reprod Update. 2002;8:95–103.

Garrido N, Pellicer A, Remohi J, Simon C. Uterine and ovarian function in endometriosis. Semin Reprod Med. 2003;21:183–192.

González-Comadran M et al. The impact of endometriosis on the outcome of Assisted Reproductive Technology. Reprod Biol Endocrinol. 2017 Jan 24;15(1):8.Gupta S, Ashok Agarwala A. Role of oxidative stress in endometriosis. RBM online 2006, Volume 13, Issue 1, Pages 1261/ww

Harada T, Yoshioka H, Yoshida S, Iwabe T, Onohara Y, Tanikawa M, Terakawa N. Increased interleukin-6 levels in peritoneal fluid of infertile patients with active endometriosis. Am J Obstet Gynecol. 1997;176:593–597.

Iwabe T, Harada T, Terakawa N. Role of cytokines in endometriosis-associated infertility.Gynecol Obstet Invest. 2002;53:19–25.

Jackson LW, Schisterman EF, Dey-Rao R, Browne R, Armstrong D. Oxidative stress and endometriosis. Hum Reprod. 2005;20:2014–2020.

Jana SK, K NB, Chattopadhyay R, Chakravarty B, Chaudhury K. Upper control limit of reactive oxygen species in follicular fluid beyond which viable embryo formation is not favorable.Reprod Toxicol. 2010;29:447–451.

Kissler S, Zangos S, Wiegratz I, Kohl J, Rody A, Gaetje R, Doebert N, Wildt L, Kunz G, Leyendecker G, et al. Utero-tubal sperm transport and its impairment in endometriosis and adenomyosis. Ann N Y Acad Sci. 2007;1101:38–48.

Mansour G, Aziz N, Sharma R, Falcone T, Goldberg J, Agarwal A. The impact of peritoneal fluid from healthy women and from women with endometriosis on sperm DNA and its relationship to the sperm deformity index. Fertil Steril. 2009;92:61–67.

Marquardt RM, Kim TH, Shin JH, Jeong JW. Progesterone and Estrogen Signaling in the Endometrium: What Goes Wrong in Endometriosis? Int J Mol Sci. 2019 Aug 5;20(15):3822. doi: 10.3390/ijms20153822.

Nirgianakis K, Gasparri ML, Radan AP, Villiger A, McKinnon B, Mosimann B, Papadia A, Mueller MD. Obstetric complications after laparoscopic excision of posterior deep infiltrating endometriosis: a case-control study. Fertil Steril. 2018 Aug;110(3):459-466. doi: 10.1016/j.fertnstert.2018.04.036. PMID: 30098698.

Reeve L, Lashen H, Pacey AA. Endometriosis affects sperm-endosalpingeal interactions. Hum Reprod. 2005;20:448–451.

Singh AK, Chattopadhyay R, Chakravarty B, Chaudhury K. Markers of oxidative stress in follicular fluid of women with endometriosis and tubal infertility undergoing IVF. Reprod Toxicol. 2013 Aug 28.

Yoshida S, Harada T, Iwabe T, Taniguchi F, Mitsunari M, Yamauchi N, Deura I, Horie S, Terakawa N. A combination of interleukin-6 and its soluble receptor impairs sperm motility: implications in infertility associated with endometriosis. Hum Reprod. 2004; 19:1821–1825.

Zeller JM, Henig I, Radwanska E, Dmowski WP. Enhancement of human monocyte and peritoneal macrophage chemiluminescence activities in women with endometriosis. Am J Reprod Immunol Microbiol. 1987;13:78–82.






About the author

Dr. rer. nat. Birgit Wogatzky

For many years now, biologist and nutritionist Dr Birgit Wogatzky, has been focusing on the special needs of fertility patients. For the readers of this blog, she sums up interesting novel information and developments from current research projects regarding lifestyle and nutrition of fertility patients.