Endometriosis and infertility: EFI, surgery, IVF and ovarian reserve

Key Takeaways

Endometriosis is common in women being checked for infertility, but its effect on fertility varies widely. After surgery, a score called the EFI helps estimate the chance of pregnancy without IVF. Before IVF, ESHRE advises against routine surgery on an endometrioma (an ovarian cyst caused by endometriosis), because it has not been shown to help and can lower ovarian reserve. It also advises against months of injections that switch off the ovaries (GnRH agonists), because the benefit is uncertain.

Key evidence: ESHRE guideline: endometriosis (2022) · Endometriosis fertility index (EFI)

How often is endometriosis the cause?

Older studies summarised by the American Society for Reproductive Medicine (ASRM) found endometriosis in about 25% to 50% of women with infertility. The range is wide because it depends on who was studied and how the disease was diagnosed. ASRM also notes that a cause-and-effect link has not been proven.

The stage of disease is a poor guide to fertility. The revised ASRM classification has limited power to predict pregnancy after surgery, as an Italian validation study notes. That is why a purpose-built score, the EFI, is described below.

The ESHRE 2022 guideline advises against three practices that were once common when the goal is a pregnancy:

• No routine surgery for an endometrioma (an ovarian “chocolate” cyst). Removing it before IVF has not been shown to improve the chance of a live birth (a baby born), and surgery is likely to lower ovarian reserve.
• No extended GnRH-agonist treatment. Months of injections that switch the ovaries off before IVF (the “ultra-long” protocol) are not recommended, because the benefit is uncertain.
• No hormone suppression to improve fertility. Hormonal treatment is not prescribed to raise the chance of pregnancy, including after surgery.

For a broader overview, see our complete endometriosis guide.

Why endometriosis reduces fertility

Several mechanisms probably act together, and their weight differs from one woman to another.

• Anatomy. Adhesions or damaged fallopian tubes, more often in advanced disease, can stop the tube picking up the egg.
• Inflammation. Inflammatory signals and oxidative stress in the pelvis may interfere with fertilisation and early embryo development.
• Egg quality. A review by Sanchez and colleagues found that eggs from women with endometriosis are more likely to fail in-vitro maturation and to look different under the microscope. It also notes that meta-analyses link endometriosis to fewer mature eggs retrieved. The review calls the evidence far from conclusive.
• Womb lining. Resistance to progesterone has been proposed as a reason for poorer receptivity, but its clinical weight is not settled.
• Ovarian reserve. Women with an unoperated endometrioma already have lower AMH than women without one. AMH is a blood marker of the egg supply. The finding shows an association; it does not show how much fertility changes in one person.

In IVF, women with an endometrioma had a similar live birth rate to women without one, but fewer eggs retrieved and more cancelled cycles.

The EFI score: the decision tool

The Endometriosis Fertility Index (EFI) is a score from 0 to 10. It estimates the chance of pregnancy without IVF in women whose endometriosis was documented and treated at surgery (Adamson & Pasta 2010). Part of it is scored during the operation, so it cannot be worked out from symptoms or imaging alone.

The score combines three kinds of information:

• History: age, years of infertility and any previous pregnancy.
• Function scores: how well the fallopian tubes, their fringed ends (fimbriae) and the ovaries work on each side, as judged by the surgeon.
• Disease scores: the extent of lesions and adhesions on the revised ASRM (r-ASRM) classification.

In a cohort of 279 women operated on for stage III–IV disease, the EFI tracked live births closely. A higher score meant a better chance of a live birth without IVF. A lower score pointed towards earlier IVF.

Can surgery help you conceive without IVF?

ESHRE gives cautious advice for women who want to try without IVF:

• Stage I/II (minimal or mild) disease: surgery through keyhole incisions (laparoscopy) can be offered. ESHRE’s reason is that it improves the rate of ongoing pregnancy (a pregnancy that continues past the early weeks). This is a weak recommendation.
• Endometrioma: surgery may be considered, although no comparative studies exist.
• Deep endometriosis: there is no compelling evidence that surgery improves fertility. It may be an option when symptoms are troublesome and you want to conceive.

ESHRE says the decision should rest on pain, age, your preferences, any previous surgery, other causes of infertility, ovarian reserve and the estimated EFI. Our guide to endometriosis surgery covers the operation itself.

Ovarian surgery and reserve: what to know

Impact of cystectomy on AMH

Cystectomy means cutting an endometrioma out of the ovary. It lowers AMH, a blood marker of ovarian reserve. The fall is greater after surgery on both ovaries. AMH is only a marker, so these studies do not show how much one person’s chance of pregnancy changes.

Possible reasons for the fall include loss of healthy ovarian tissue stuck to the cyst wall and heat damage from the coagulation used to stop bleeding. ESHRE advises specific caution to minimise ovarian damage during surgery.

Why surgery before IVF does not improve live births

A systematic review and meta-analysis by Hamdan and colleagues (2015) pooled 33 studies. Most looked back at records, and only three were randomised trials (people were assigned to a group by chance). It compared women with an endometrioma who had surgery before IVF or ICSI with those who did not. The live birth figure rests on 5 of these studies (655 women). An odds ratio (OR) near 1 means no clear difference.

• Live birth: OR 0.90, 95% confidence interval 0.63 to 1.28.
• Clinical pregnancy (a pregnancy seen on ultrasound): OR 0.97, 95% confidence interval 0.78 to 1.20.
• Eggs retrieved: similar with and without surgery.

ESHRE therefore gives a strong recommendation against routine endometrioma surgery before IVF. Its reasons: the evidence has not shown a benefit, and surgery is likely to lower ovarian reserve.

When surgery before IVF may still be considered

ESHRE says surgery for an endometrioma can be considered to relieve pain or to make the follicles easier to reach at egg collection. For deep endometriosis, pain and your own preference should guide the decision, because its effect on pregnancy is uncertain.

Imaging that raises suspicion of cancer is a separate reason to operate and is assessed on its own terms.

GnRH-agonist pre-treatment: why it is no longer routine

The “ultra-long” protocol gave GnRH-agonist injections for 3 to 6 months before IVF. ESHRE 2022 now gives a strong recommendation against extended GnRH-agonist treatment before IVF to improve live birth, because the benefit is uncertain. It also found too little evidence to recommend long pre-treatment with the contraceptive pill or progestogens.

The Cochrane review of 2019 pooled eight randomised trials (640 women). The evidence was of low to very low certainty. The authors could not say whether the treatment changes the live birth rate or the clinical pregnancy rate. An earlier Cochrane review had suggested a benefit; this one replaces it.

The treatment also adds months of low oestrogen before IVF can start. That can cause hot flushes and bone loss, which is why ESHRE advises considering add-back hormones when a GnRH agonist is used for pain. Our guide to endometriosis pain treatment explains this.

Choosing the IVF protocol in endometriosis

ESHRE cannot recommend one IVF protocol for endometriosis. Both GnRH-antagonist and GnRH-agonist protocols can be offered according to patient and doctor preference, because no difference in pregnancy or live birth has been shown (weak recommendation).

• Antagonist protocol: often chosen for flexibility and a shorter treatment time. It has not been shown to improve pregnancy or live birth in endometriosis specifically.
• Low reserve or limited time: random-start stimulation (starting outside the usual early-cycle window), double stimulation (DuoStim, two egg collections in one cycle) or collecting embryos over several cycles may be discussed in selected cases. Evidence is limited, and none of these guarantees more usable embryos or a live birth.
• Fertility preservation: with extensive ovarian endometriosis, ESHRE advises discussing the pros and cons of freezing eggs or embryos. Its true benefit is unknown.
• Egg collection: with an endometrioma, antibiotics may be used at the time of collection. ESHRE notes that the risk of an ovarian abscess is low.

Decision: wait, try IUI, or go straight to IVF?

ESHRE says IVF can be used for endometriosis-related infertility. This applies especially when tubal function is compromised, there is a male factor, the EFI is low or other treatments have failed.

• After surgery with a high EFI: a limited period of trying naturally may be reasonable if age, tubal function and semen analysis are also favourable. The cohort data above show why.
• With an intermediate EFI: the choice between trying a little longer, stimulated IUI (insemination with ovarian stimulation) and IVF depends on age, the tubes and the semen analysis. In stage I/II disease, ESHRE says IUI with stimulation may be used instead of simply waiting.
• With a low EFI, older age or another cause of infertility: IVF is usually discussed sooner.
• With markedly reduced ovarian reserve: avoiding non-essential ovarian surgery comes first. AMH or antral follicle count alone does not decide the treatment.

The Turkish context: what changes for patients

Turkish law (Law No. 2238, Additional Article 1) prohibits egg, sperm and embryo donation, and surrogacy. Treatment uses the patient’s own eggs, so protecting ovarian reserve carries extra weight.

For international patients considering IVF in Turkey, this legal limit is part of the planning discussion.

Clinical Note

When endometriosis is diagnosed in an infertile patient, our primary goal is to preserve ovarian reserve and shorten the time to pregnancy.

We avoid unnecessary diagnostic or pre-IVF surgery that could compromise follicle count without improving live birth rates.

Every protocol should be tailored based on age, AMH levels, symptoms, and previous treatment history.

Dr. Senai Aksoy

Frequently Asked Questions for Dr. Aksoy

After endometriosis surgery, should we try naturally or go straight to IVF? How long should we wait?

I do not send every patient straight to IVF after endometriosis surgery. I look at the woman’s age, her ovarian reserve, the state of her tubes, her partner’s semen analysis and how completely the disease could be cleared at surgery. The Endometriosis Fertility Index (EFI) helps a good deal with this decision.

For example, I may allow 6–12 months of trying naturally for a 30-year-old with open tubes, good ovarian reserve and no other cause of infertility. After 35 I usually prefer to limit that period to 3–6 months. Over 38, or if reserve is low, the tubes are badly damaged or there is a male factor as well, I discuss IVF without losing time. What matters is not to wait a fixed time after the operation, but to judge how much time would be lost while waiting for a natural pregnancy.

When do you still recommend surgery for an endometrioma, and how do you protect ovarian reserve?

In a patient with an endometrioma who wants to conceive, my first thought is not surgery but protecting ovarian reserve. Operations for endometriomas on both sides, or repeat operations, can reduce ovarian reserve seriously.

I do consider surgery if there is severe pain that spoils quality of life despite medication, if the cyst looks suspicious on imaging or grows quickly, or if it clearly stops us reaching the ovaries during IVF. A large cyst on its own is not, for me, a reason to operate.

If surgery is needed, I assess AMH and antral follicle count beforehand. In women with low reserve I first discuss freezing eggs or embryos. In the operation it matters to protect healthy ovarian tissue, to separate the cyst wall carefully and to avoid excessive bipolar energy for bleeding control. Ablation techniques may also be considered in suitable patients. A successful operation is not only removing the cyst; it is leaving behind an ovary that can still work.

Do you use an ultra-long protocol or long-term GnRH agonist treatment before IVF?

It used to be common, especially in advanced endometriosis, to give a GnRH agonist for 3–6 months before IVF. Today there is not enough strong evidence that this raises the live birth rate. So I do not use the ultra-long protocol routinely just because someone has endometriosis. Waiting for months can be a real disadvantage, particularly for older women or those with low ovarian reserve.

If there is marked adenomyosis, severe pain or another special clinical situation, I may consider pre-suppression individually. What I tell the patient plainly is this: in some cases the treatment can help us control symptoms, but we cannot say it will necessarily increase IVF success.

FAQ: more questions about endometriosis and infertility

Why did my AMH drop after surgery?

Cystectomy lowers AMH. Across eight prospective studies the average fall was 1.13 ng/mL, and it tends to be larger after surgery on both ovaries. Possible reasons are the loss of healthy ovarian tissue stuck to the cyst wall and heat damage to nearby follicles from coagulation. AMH is a marker of reserve, not a forecast of your own chance of pregnancy.

What if my ovarian reserve is very low?

The first step is to read AMH and antral follicle count alongside age and the likely response to stimulation. Random-start, DuoStim or collecting embryos over several cycles may be discussed in selected cases, but none guarantees more usable embryos or a live birth. In Turkey, egg donation is not available, so avoiding unnecessary ovarian surgery can matter particularly.

Will endometriosis get worse with IVF stimulation?

Stimulation temporarily raises oestrogen, so the worry is understandable. ESHRE says women with endometriosis can be reassured about the safety of IVF (weak recommendation). Recurrence rates were not higher than in women who did not have IVF. Symptoms and treatment goals still need individual review.

Will I need a diagnostic laparoscopy before IVF?

Not routinely. ESHRE no longer treats laparoscopy as the diagnostic gold standard. It is kept for people with negative imaging and persistent symptoms, or when empirical treatment has failed or is unsuitable. If imaging already documents your disease and IVF is the plan, a purely diagnostic laparoscopy adds little. An operation for pain or deep disease is a separate decision.

Sources

• Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Human Reproduction Open 2022;2022(2):hoac009. PMID 35350465. doi:10.1093/hropen/hoac009.
• Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril 2012;98(3):591–598. PMID 22704630. doi:10.1016/j.fertnstert.2012.05.031.
• Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010;94(5):1609–1615. PMID 19931076.
• Maheux-Lacroix S, Nesbitt-Hawes E, Deans R, et al. Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis. Hum Reprod 2017;32(11):2243–2249. PMID 29040471. doi:10.1093/humrep/dex291.
• Garavaglia E, Pagliardini L, Tandoi I, et al. External validation of the endometriosis fertility index (EFI) for predicting spontaneous pregnancy after surgery: further considerations on its validity. Gynecol Obstet Invest 2015;79(2):113–118. PMID 25634444. doi:10.1159/000366443.
• Hamdan M, Dunselman G, Li TC, Cheong Y. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis. Hum Reprod Update 2015;21(6):809–825. PMID 26168799. doi:10.1093/humupd/dmv035.
• Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012;97(9):3146–3154. PMID 22723324. doi:10.1210/jc.2012-1558.
• Somigliana E, Berlanda N, Benaglia L, et al. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimüllerian hormone level modifications. Fertil Steril 2012;98(6):1531–1538. PMID 22975114. doi:10.1016/j.fertnstert.2012.08.009.
• Muzii L, Di Tucci C, Di Feliciantonio M, et al. Antimüllerian hormone is reduced in the presence of ovarian endometriomas: a systematic review and meta-analysis. Fertil Steril 2018;110(5):932–940.e1. PMID 30316440. doi:10.1016/j.fertnstert.2018.06.025.
• Georgiou EX, Melo P, Baker PE, et al. Long-term GnRH agonist therapy before in vitro fertilisation (IVF) for improving fertility outcomes in women with endometriosis. Cochrane Database Syst Rev 2019;(11):CD013240. PMID 31747470. doi:10.1002/14651858.CD013240.pub2.
• Sanchez AM, Vanni VS, Bartiromo L, et al. Is the oocyte quality affected by endometriosis? A review of the literature. J Ovarian Res 2017;10(1):43. PMID 28701212. doi:10.1186/s13048-017-0341-4.
• Republic of Turkey. Law No. 2238 on the Removal, Storage, Grafting and Transplantation of Organs and Tissues, Additional Article 1 (added by Law No. 7151, in force 5 December 2018). Consolidated text on mevzuat.gov.tr checked on 6 November 2026.

Dr. Senai Aksoy

Dr. Senai Aksoy studied and trained in France before returning to Turkey, where he was a member of the ICSI team at Sevgi Hospital, Ankara — the country's first ICSI centre (1994-95) — and a co-author on the first Turkish ICSI publications produced in collaboration with the Brussels Van Steirteghem group (Human Reproduction, 1996; PMID 8671323). He helped build the IVF programme at the American Hospital Istanbul and has been running his own fertility practice since 1998.

Verified profiles: PubMed · ORCID · LinkedIn

Read full profile → Instagram YouTube

The content has been created by Dr. Senai Aksoy and medically approved.