There are many arguments to support the hypothesis that there is a causal relationship between the presence of endometriosis and subfertility. These arguments are reviewed in this article and include: (1) an increased prevalence of endometriosis in subfertile women compared with women of proven fertility; (2) a reduced monthly fecundity rate (MFR) in baboons with mild to severe (spontaneous or induced) endometriosis compared with those with minimal endometriosis or a normal pelvis; (3) a trend toward a reduced MFR in infertile women with minimal to mild endometriosis compared with women with unexplained infertility; (4) a dose-effect relationship: a negative correlation between the r-AFS stage of endometriosis and the monthly fecundity rate and crude pregnancy rate; (5) a reduced monthly fecundity rate and cumulative pregnancy rate after donor sperm insemination in women with minimal-mild endometriosis compared with those with a normal pelvis; (6) a reduced MFR after husband sperm insemination in women with minimal to mild endometriosis compared with those with a normal pelvis; (7) a reduced implantation rate per embryo after IVF in women with moderate to severe endometriosis compared with women with a normal pelvis; and (8) an increased monthly fecundity rate and cumulative pregnancy rate after surgical removal of minimal to mild endometriosis.
PMID 12917793 12917793 DOI 10.1055/s-2003-41330 10.1055/s-2003-41330 D'Hooghe et al. 2003, D'Hooghe 2003
Cite this article
D'Hooghe, T. M., Debrock, S., Hill, J. A., & Meuleman, C. (2003). Endometriosis and subfertility: is the relationship resolved?. Seminars in reproductive medicine, 21(2), 243-254. https://doi.org/10.1055/s-2003-41330
D'Hooghe TM, Debrock S, Hill JA, Meuleman C. Endometriosis and subfertility: is the relationship resolved?. Semin Reprod Med. 2003;21(2):243-254. doi:10.1055/s-2003-41330
D'Hooghe, T. M., et al. "Endometriosis and subfertility: is the relationship resolved?." Seminars in reproductive medicine, vol. 21, no. 2, 2003, pp. 243-254.
Does IVF worsen pelvic pain in women with endometriosis? Nearly half of women with endometriosis reported perceived worsening of pelvic pain after IVF. Prior studies generally suggested no IVF-related pain worsening, but few assessed delayed flares or longer-term trajectories. International cross-sectional study based on an online survey conducted between September 2024 and April 2025 including 546 respondents. PARTICIPANTS/MATERIALS Women aged ≥18 years with surgically or imaging-confirmed endometriosis and at least one completed IVF cycle. A 25-item questionnaire captured demographics, reproductive history, comorbidities, and patient-reported pain trajectories before, during, and after IVF. The primary outcome was perceived worsening of pelvic pain after IVF (patient-reported outcome measure; PROM). Secondary outcomes were worsening of dysmenorrhoea and dyspareunia. Group comparisons and exploratory multivariable logistic regressions were performed. Predictor analyses were exploratory. MAIN Among 546 respondents, 48.9% reported worsening pelvic pain after IVF, 49.1% reported worsening dysmenorrhoea, and 35.5% worsening dyspareunia. Current pain scores were significantly higher in women reporting worsening versus no worsening (all P < 0.001). In multivariable analyses, immediate post-cycle pain flare emerged as the strongest and most consistent predictor across all pain outcomes, independently associated with worsening of pelvic pain (adjusted odds ratio [aOR] 5.91, 95% CI 3.88-9.14), dysmenorrhoea (aOR 4.03, 95% CI 2.08-8.05), and dyspareunia (aOR 3.17, 95% CI 2.07-4.90) (all P < 0.001). For the primary outcome, reporting oocyte retrieval as the most painful IVF step (aOR 0.53, 95% CI 0.31-0.88; P = 0.016) and achieving a live birth after IVF (aOR 0.63, 95% CI 0.42-0.92; P = 0.020) were independently associated with lower odds of pelvic pain worsening. In secondary outcome models, live birth was associated with lower odds of dysmenorrhoea worsening, while bladder pain syndrome/interstitial cystitis independently predicted worsening of dyspareunia. A formal response rate could not be calculated due to open online dissemination without a known denominator. LIMITATIONS Self-reported, retrospective data are prone to recall and selection bias, and the cross-sectional design precludes causal inference. Recruitment via associations and social media without a denominator limits generalizability, absence of baseline pain scores impedes assessment of change, and incomplete capture of peri-IVF hormonal regimens may confound results. IVF may not be pain-neutral in endometriosis. Monitoring pain trajectories at key IVF milestones may help identify women at risk of long-term exacerbation. Prospective studies should test whether early monitoring combined with tailored interventions-optimized analgesia, psychological support, or adapted stimulation protocols-can mitigate chronic pain trajectories throughout the IVF journey and ultimately improve quality of life. No specific funding; authors declare no conflicts of interest. N/A.
Fertility and Outcomes · Conception After Excision
Neutens S et al., 2026·Journal of Minimally Invasive Gynecology·
To study whether bilateral nonpatency of fallopian tubes is correlated with a lower recurrence rate of endometriosis. Retrospective 2:1 matched case-control study. University hospital with a tertiary referral center for fertility and endometriosis surgery in Leuven, Belgium. All patients undergoing complete laparoscopic excision of any revised system of the American Society of Reproductive Medicine-stage endometriosis between 2010 and 2014 (n = 896). Comparison between patients with bilateral nonpatent or absent fallopian tubes and matched controls with at least 1 patent fallopian tube. MAIN Primary outcome was the recurrence rate, which was analyzed on 4 levels: overall recurrence, symptom recurrence, recurrence on imaging, and need for reintervention. Of 896 patients, 49 had bilateral nonpatent or absent fallopian tubes. These cases were compared with 98 matched controls with at least 1 patent fallopian tube. Symptoms recurred in 12.2% of the cases (n = 6) and 25.5% of the controls (n = 25) (p = .09). Recurrence was confirmed by imaging in 8% of the cases (n = 4) and 10.2% of the controls (n = 10) (p = .77). In 3 patients of the case group and 12 patients of the control group, there was a need for reintervention (p = .39). Within this subgroup, recurrence of endometriosis was histologically confirmed in none of the patients of the case group and 5 patients of the control group (p = .51). This study did not observe a statistically significant reduction in endometriosis recurrence in patients with bilateral occlusion/absence of the fallopian tubes after endometriosis surgery. A type II error may count for this result.
Fertility and Outcomes · Conception After Excision
The use of hormonal treatments for endometriosis has increased in recent years. Their effectiveness lies in creating a stable hormonal environment, reducing peripheral estrogen levels, and suppressing ovulation and menstruation. Although these agents do not cure endometriosis and symptoms often return after discontinuation, they effectively relieve pain in most cases and help prevent disease progression or recurrence. Women are therefore typically managed with long-term hormonal treatments, with or without surgery. However, this approach is unsuitable for those seeking natural pregnancy or undergoing IVF, as all hormonal treatments hinder conception. For women pursuing natural pregnancy, these treatments should be discontinued for about 1 year, the time needed to diagnose infertility. However, this suspension exposes women to the risk of recurrence or progression and is therefore clinically acceptable only if the woman has a reasonable likelihood of achieving pregnancy naturally. In women with endometriosis who are infertile and therefore require IVF, ovarian stimulation significantly raises estrogen levels-up to 10 times those of a natural cycle-potentially boosting the risk of endometriosis relapse. Evidence is reassuring on this issue even if some limited data suggest that ovarian stimulation may promote deep invasive endometriosis progression. Overall, physicians and patients must balance the chances of natural or ART-assisted pregnancy against the risk of disease recurrence or progression during treatment discontinuation or IVF. This choice is also complicated by the increased risk of severe pregnancy complications in women with endometriosis, possibly depending on the conception method. This review discusses the available evidence that can be helpful in guiding the decision-making process.
Fertility and Outcomes · Conception After Excision
Zhang J et al., 2024·Eur J Obstet Gynecol Reprod Biol·
Open Access
To analyze the factors that might influence the pregnancy rate in patients with infertility related to endometriosis (EMs) after undergoing laparoscopic surgery, providing guidance for our clinical diagnostic and therapeutic decision-making. A retrospective analysis was conducted on clinical records and 1-year postoperative pregnancy outcomes of 335 patients diagnosed with endometriosis-related infertility via laparoscopic surgery, admitted to our department from January 2018 to December 2020. The overall pregnancy rate for patients with endometriosis (EMs) related infertility 1-year post-surgery was 57.3 %, with the highest pregnancy rate observed between 3 to 6 months after surgery. Factors such as Body Mass Index (BMI) (P = 0.515), presence of dysmenorrhea (P = 0.515), previous pelvic surgery (P = 0.247), type of EMs pathology (P = 0.893), and preoperative result of serum carbohydrate antigen 125 (CA125)（P = 0.615）had no statistically significant effect on postoperative pregnancy rates. The duration of infertility (P = 0.029), coexistence of adenomyosis (P = 0.042), surgery duration (P = 0.015), intraoperative blood loss (P = 0.050), preoperative result of serum anti-Müllerian hormone (AMH) (P = 0.002) and age greater than 35 (P = 0.000) significantly impacted postoperative pregnancy rates. The post-surgery pregnancy rate in patients with mild (Stage I-II) EMs was notably higher than those with moderate to severe (Stage III-IV) EMs (P = 0.009). Age (P = 0.002), EMs stage (P = 0.018), intraoperative blood loss (P = 0.010) and adenomyosis (P = 0.022) were the factors that affected the postoperative live birth rate. For patients with EMs-related infertility undergoing laparoscopic surgery, factors such as age > 35 years, infertility duration > 3 years, concurrent adenomyosis, severe EMs, surgery duration ≥ 2 h, intraoperative blood loss ≥ 50 ml, and low AMH before surgery are detrimental for the pregnancy rate within the first postoperative year. However, BMI, dysmenorrhea, past history of pelvic surgery, EMs pathology types (ovarian, peritoneal, deep infiltrating),and preoperative result of serum CA125 barely show any statistical difference in their effect on postoperative pregnancy rates. In terms of postoperative live birth rate, age > 35 years, severe EMs, intraoperative blood loss ≥ 50 ml, and adenomyosis were adverse factors.