Struggling to understand how endometriosis and adenomyosis conditions may be impacting your fertility? You’re not alone—and getting clear, expert answers can make all the difference.
In this webinar, Dr Elias Tsakos, MD, FRCOG, Medical Director at Embryoclinic IVF Unit, explains how adenomyosis and endometriosis can impact fertility, implantation, and IVF success rates. These common but often underdiagnosed conditions can affect the uterine environment, hormone balance, and embryo implantation — even when embryo quality is good.
For women trying to conceive, endometriosis can complicate fertility in ways that are easy to miss and hard to predict, but careful diagnosis, thoughtful timing, and fertility-preserving planning can still leave plenty of room for optimism.
Endometriosis is a chronic inflammatory condition in which tissue similar to the lining of the uterus grows outside the uterus, most often in the pelvic organs, though it can appear elsewhere in the body. It affects about 10% of women overall and may be present in up to 50% of women with infertility or subfertility. That makes it far more than a pain condition. It is also a fertility condition.
The way it affects fertility is not limited to one mechanism. It can distort pelvic anatomy, damage the ovaries, and create inflammation that interferes with reproduction. That inflammatory effect is not always confined to the pelvis, either. Fatigue can be part of the picture alongside pain, which helps explain why some patients feel unwell even when the disease has not yet been diagnosed.
One of the most frustrating features of endometriosis is how poorly symptoms reflect severity. Some women with minimal disease have severe pain and fatigue. Others with extensive disease have few or no obvious symptoms. That mismatch is one reason diagnosis is often delayed for about 6 to 7 years, costing patients valuable time during their reproductive years.
Natural conception is still possible with endometriosis, and IVF can also succeed, including in women who have already had one, two, or three operations. But success often depends on recognising the condition early enough to avoid losing time and ovarian function unnecessarily.
For many patients, endometriosis only comes into focus after infertility, miscarriage, or repeated IVF failure. That is not unusual. In fertility care, the absence of classic symptoms does not rule it out.
This matters because a missed diagnosis can send treatment down the wrong path. A patient may move straight into embryo transfer plans without fully assessing the pelvis, ovaries, tubes, or uterus. If endometriosis or adenomyosis is later found, the strategy may need to change completely.
A high level of suspicion becomes especially important when IVF has failed without a clear explanation. In that setting, a formal high-resolution 3D scanning or 4D scanning assessment by an endometriosis expert can be valuable. In experienced hands, a high-quality ultrasound scan may detect as much as 90% of endometriosis. Even then, there is no completely reliable noninvasive way to diagnose it with 100% certainty, which is why specialist review can be so important.
When MRI suggests adenomyosis or another abnormality, the scan may need a second look by a very experienced endometriosis surgeon, pelvic surgeon, or specialist centre team. Different expert opinions can reveal lesions that were previously missed. For patients, that can mean the difference between another failed cycle and a more targeted plan.
Patients often ask whether endometriosis affects egg quality. The answer is yes. The condition can impair oocyte quality through several mechanisms, with inflammation described as the commonest one.
It can also reduce ovarian reserve. In practice, that may show up as lower AMH, low AFC on ultrasound, and a lower number of eggs retrieved during IVF. This is one reason endometriosis deserves attention even before treatment begins. By the time a patient reaches IVF, the condition may already have affected the number of eggs available.
That risk becomes even more significant when surgery enters the picture. Surgery can help some patients, but it is also one of the biggest threats to ovarian reserve if ovarian tissue is removed or damaged in the process. The challenge is not simply deciding whether surgery is needed. It is deciding when it should happen, what should happen first, and how to protect future fertility before any operation is done.
There is no simple “operate or don’t operate” rule in endometriosis. The disease requires personalised care, and treatment decisions have to balance symptom relief, disease control, and fertility preservation at the same time.
An overly enthusiastic surgical approach can reduce fertility if it damages the ovaries. That is why the sequence of treatment matters so much. In this approach, eggs are generally collected first, and surgery is considered afterwards. The goal is to make sure good embryos or eggs frozen are secured before any intervention that could reduce ovarian reserve.
When surgery is performed, the standard is high. The aim is complete removal of the disease, especially when the ovaries are involved, without diminishing ovarian reserve. That is easier said than done. Endometriosis surgery is highly challenging, which is why patients with suspected disease may benefit from review in a specialist centre and from collaboration between fertility specialists and endometriosis specialists.
A multidisciplinary approach is not a luxury here. It is central to decision-making. Patients may need imaging experts, surgeons, fertility specialists, and embryology input to decide whether a lesion can be watched, treated medically, or removed surgically.
For young women with endometriosis who are not ready to pursue pregnancy, fertility preservation deserves serious discussion. In this practice, endometriosis is the commonest indication for fertility preservation apart from social reasons.
The reason is straightforward. Endometriosis itself can reduce ovarian reserve. Surgery can reduce it further. Age adds another layer of decline. Together, endometriosis, surgery, and age can make later fertility treatment much more difficult.
That is why oocyte freezing may need to be considered before surgery, and in some cases after surgery as well. It may even need to be done a couple of times or 3 times. For patients, this is one of the most practical takeaways: if endometriosis is affecting the ovaries and pregnancy is not an immediate goal, preserving eggs early may protect options later.
A recurring strategy is to treat IVF as two separate stages: stimulation and egg collection first, then implantation later.
During egg collection, the priority is to retrieve as many eggs as possible in a stimulated IVF cycle and secure good-quality embryos or blastocysts. In adenomyosis, there is limited scope to medically manipulate the condition during stimulation because treatment would interfere with the ovaries. That makes the first phase largely about maximising egg and embryo yield.
Only after that does the focus shift to the uterus and implantation. Before embryo transfer, suppression treatment may be used, including progesterone and other medications, to suppress adenomyosis and optimise the environment for implantation. This sequencing matters because it avoids compromising ovarian response while still addressing the uterine condition before transfer.
In this approach, the aim is often to have 3, 4, or 5 top-quality embryos before moving on to implantation treatment. PGT-A is used selectively rather than routinely. It is not recommended here for younger women under 37 or 38 years without a failed implantation or miscarriage history. It is considered when there have been more than two or three failed implantations or miscarriages, or when the woman is older than 38.
Although often discussed alongside endometriosis, adenomyosis is different. In adenomyosis, tissue similar to the endometrium grows into the muscle of the uterus rather than outside it. It commonly causes heavy bleeding, prolonged bleeding, cramps, bloating, difficulty conceiving, and miscarriages.
It is generally easier to diagnose and scan for endometriosis when the right signs are being sought. Pregnancy is still possible, especially when the condition is mild or moderate, and assisted reproduction can also succeed.
The challenge comes when embryo transfers keep failing. In a patient with adenomyosis and recurrent treatment failure, the uterus becomes the first place to look. That evaluation can include:
The tubes may also need reassessment, with a low threshold for laparoscopy to look for hidden pelvic abnormalities, infection, hydrosalpinx, or endometriosis. For a young patient with regular periods, a natural cycle may be favoured over a medicated cycle for embryo transfer.
One of the strongest warnings in these notes concerns hematosalpinx. Its impact on IVF is described as major. It is considered abnormal and should be removed because it is a source of infection, inflammation, toxic effects, and potential IVF failure.
It is also said to be invariably associated with hydrosalpinx and to increase the risk of ectopic pregnancy. In practical terms, this means a patient should not proceed to embryo transfer while such a tube remains in place. A healthy pregnancy is unlikely to thrive in an inflammatory environment.
This is also where repeated IVF failure should trigger a broader rethink. When routine evaluation looks normal but transfers continue to fail, a low threshold for laparoscopy may be appropriate to search for hidden pelvic disease.
Patients are often told that egg retrieval is a routine part of IVF. In endometriosis, it may not be routine at all.
Retrieval can be high-risk because of infection, distorted anatomy, and accidental puncture of an endometriotic cyst. Distorted anatomy can shift organs out of position and increase the risk of trauma. If an endometriotic cyst is punctured, leaked fluid may worsen inflammation. Sometimes follicles are visible but hard to reach because access to the ovaries is poor.
For that reason, prophylactic antibiotics may be given during egg collection when endometriosis is present. In very rare situations, laparoscopy may even be required to retrieve eggs that cannot be accessed through the vaginal route.
For patients, the message is not that IVF is impossible. It is that endometriosis can make even standard IVF steps more technically demanding, which increases the value of an experienced team.
Not every patient with endometriosis is trying to conceive immediately. For young women who do not wish to become pregnant, the oral contraceptive pill may be used as a first-line treatment to gain time and relieve symptoms.
That does not solve the fertility question permanently, but it can be a practical bridge while longer-term plans are made. It also reinforces a broader point: endometriosis management is not only about surgery or IVF. Supportive care, lifestyle management, and holistic support also matter.
The lifestyle advice here is simple rather than prescriptive: a balanced diet and improvement in daily routine. Industrial dioxins have also been connected with endometriosis. Just as important is education. After diagnosis, awareness becomes part of treatment. Patients who understand the disease are better positioned to advocate for timely imaging, specialist review, fertility preservation, and the right sequence of care.
Endometriosis and adenomyosis can delay diagnosis, reduce ovarian reserve, complicate egg retrieval, and interfere with implantation. They can also be managed. Pregnancy may still happen naturally, and IVF can still work, even after prior surgery.
The most useful mindset is neither panic nor passivity. It is planned. Early diagnosis, specialist imaging, careful use of surgery, and timely fertility preservation can protect options that might otherwise be lost. For patients facing IVF, the goal is not just to treat the disease. It is important to choose the order of treatment wisely, so that every step supports the next one.
Yes. In about 50% of infertility patients, endometriosis may be present even if symptoms are minimal or absent. There is no completely reliable noninvasive way to diagnose it with 100% certainty, although a high-quality three-dimensional ultrasound in experienced hands may detect as much as 90% of endometriosis.
A high level of suspicion is important, especially after miscarriage or unexplained IVF failure. A formal high-resolution 3D or 4D scan by an endometriosis expert is recommended. Identifying endometriosis or adenomyosis can change the treatment strategy, for example by separating stimulation and embryo transfer cycles.
A key issue is expertise. Many younger IVF specialists now have little real exposure to surgery, unlike in the past when IVF specialists were also trained in laparoscopic and hysteroscopic surgery. Clinics should have both high-quality diagnostic ultrasound expertise and access to advanced endoscopic surgery, including robotic surgery.
Endometriosis surgery is highly challenging and often more complex than many cancer surgeries. Ultrasound performed by experienced hands can sometimes be superior to MRI for pelvic disease.
The impact is huge. Hematosalpinx is abnormal and should be removed because it is a source of infection, inflammation, toxic effects, and potential IVF failure. It is invariably associated with hydrosalpinx and increases the risk of ectopic pregnancy.
IVF should not proceed while this is present. There should be a low threshold for laparoscopy when there has been repeated IVF failure or when pathology is suspected.
The uterus should be the first focus. This work-up includes MRI, top-quality 3D scanning, hysteroscopy with endometrial biopsies, microbiome testing, and discussion of NK cells. The tubes should also be checked, with a low threshold for laparoscopy to rule out hidden pelvic abnormalities, inflammation, infection, hydrosalpinx, or endometriosis.
For embryo transfer, a natural cycle is favoured at a young age rather than a medicated cycle. It also makes sense to use the most experienced embryologist and gynaecologist and to discuss Embryoglue or similar technologies. With four remaining PGT-A tested blastocysts, the chance of success is extremely high.
Latrozole is an ovulation induction tablet and can work well for some women, especially those with polycystic ovaries. It is cheap, inexpensive, and not associated with major complications. However, by itself, it is not enough for IVF.
It is not used alone in IVF, although it may be used in a mild cycle or modified natural cycle. Its use should be discussed with the treating team because IVF generally needs more than letrozole alone.
Treatment depends on the goal, such as pregnancy, fertility, implantation, or pain relief. A practical approach is to separate IVF into two phases: egg collection and embryo transfer.
The first step is collecting as many eggs as possible in a stimulated IVF cycle, then securing good-quality embryos, with PGT-A used selectively based on age and prior failures. For implantation, suppression treatment is used, including progesterone and other medications, to reduce adenomyosis. Surgery is rarely performed unless the disease is localised or severe, because surgery can be very difficult and may require robotic reconstruction of the myometrium. When the timing is right, embryo transfer should be done with the most experienced team members.
Yes. It affects oocyte quality through various mechanisms, and the commonest mechanism is inflammation. It also affects ovarian reserve.
One of the biggest risks is surgery, because it can damage ovarian reserve. Fertility preservation and surgery must be balanced carefully. If surgery is done, it must be performed perfectly so that the endometriosis is completely removed, especially when the ovaries are involved, without reducing ovarian reserve. Fertility preservation is often considered both before and after surgery when appropriate.
For young patients with endometriosis who have not decided about pregnancy, oocyte freezing should be considered seriously. It may need to be done a couple of times or three times because age, surgery, and endometriosis together can severely affect fertility.
The MRI should be assessed by a very experienced endometriosis surgeon, pelvic surgeon, or specialist centre team. Different expert opinions may reveal lesions that were missed, so the scan should be reviewed in a specialist centre, often one focused on endometriosis.
After that, the next step is to discuss the course of action with a fertility specialist to decide whether the condition can be ignored or should be addressed. In general, it is preferable to collect the eggs first and then consider surgery, making sure some good embryos or eggs are frozen before any surgical intervention.
Yes, it can be high risk. The risks include infection, distorted anatomy, and accidental puncture of an endometriotic cyst. Prophylactic antibiotics are used for egg collection when endometriosis is present because inflammation is already there.
Distorted anatomy can place organs where they should not be, increasing trauma risk. If a cyst is punctured accidentally, leakage of fluid may worsen inflammation. Access to the ovaries may also be poor, so follicles may be seen but not reachable. In very rare situations, laparoscopy is needed to retrieve eggs that cannot be accessed vaginally.
The oral contraceptive pill is often prescribed to young women who do not wish to become pregnant to gain time and relieve symptoms as a first-line treatment.
For lifestyle management, a balanced diet and improving daily routine are important, and industrial dioxins have been linked to endometriosis. Awareness and education are also essential after diagnosis. Learning through books, online resources, and patient groups can improve personal care and help patients advocate for others in the future.
