Endometriosis and fertility: getting pregnant with endometriosis or adenomyosis

Many women with endometriosis want a child. The diagnosis often triggers fear: “Can I still get pregnant at all?” That worry is easy to understand. The research gives an honest answer: yes, pregnancy is possible with endometriosis, both naturally and with fertility treatment. How good your chances are depends less on the stage than on your age, your fallopian tubes, your ovarian reserve, and how long you have been trying.

In this guide you will find what the three most important guidelines recommend: the European guideline from ESHRE (2022), the German-language S2k guideline AWMF 015-045 from the medical societies of Germany, Austria, and Switzerland (version 5.1, valid since April 2025), and the British guideline NICE NG73 (last updated 2024). Where they disagree, we present both sides. Every medical figure comes from a study, a guideline, or a registry, and we say who was studied and how it was measured.

At a glance: endometriosis and fertility

• Without treatment: In a Canadian study of women with minimal or mild endometriosis, 17.7% had a pregnancy lasting at least 20 weeks within 36 weeks. After the lesions were removed, it was 30.7% (Marcoux 1997, 341 women with infertility).
• After IVF or ICSI: The live birth rate per woman is similar overall to that without endometriosis, and lower in severe endometriosis (Hamdan 2015, 36 studies).
• Hormone therapy: ESHRE, AWMF, and NICE advise against it when you are trying to conceive now. A fertility benefit has not been shown (AWMF).
• Endometrioma: Any surgery lowers AMH. Before IVF, ESHRE does not recommend routine surgery.
• Adenomyosis: After IVF, the live birth rate is lower and miscarriages are about twice as common (Cozzolino 2022, Vercellini 2014).

How to read the study figures: Many results are given as an odds ratio (OR) or relative risk (RR). A value of 1 means no difference from the comparison group. Values below 1 mean less common, values above 1 more common. The 95% confidence interval is shown in parentheses. If it includes 1, the difference is not statistically established.

What is endometriosis

Endometriosis is a chronic condition in which tissue similar to the uterine lining (endometrium) grows outside the uterus. These lesions can occur anywhere in the abdominal cavity: on the peritoneum, on the ovaries, on the ligaments that support the uterus, or even on the bowel. When such tissue grows into the muscle layer of the uterus, it is called adenomyosis. The German guideline lists it as endometriosis of the uterus (ICD-10 N80.0). A separate section below is devoted to it.

Endometriosis lesions: where they develop

The displaced tissue behaves much like the normal uterine lining. It builds up during the cycle and bleeds during menstruation. But the blood cannot drain away.

According to the AWMF guideline, the following sites are affected, in decreasing order of frequency:

• the peritoneum in the pelvis (pelvic peritoneum)
• the ovaries, often as cysts (endometriomas, also called “chocolate cysts”)
• the ligaments that support the uterus (uterosacral ligaments)
• the tissue between the vagina and the rectum (rectovaginal septum) and the posterior vaginal fornix
• organs outside the genital tract, such as the bladder and bowel

How often the fallopian tubes themselves are affected is not known. Adhesions can, however, narrow or distort them. When lesions grow deeper into the tissue, for example into the wall of the bowel or bladder, specialists speak of deep infiltrating endometriosis (DIE).

Recognizing the symptoms

Many affected women long considered severe period pain to be “normal.” Typical signs are:

• Severe menstrual pain (dysmenorrhea)
• Pain during intercourse
• Chronic lower abdominal pain
• Irregular or very heavy bleeding
• Digestive problems during your period
• Infertility: The AWMF guideline explicitly lists infertility among the leading symptoms (recommendation 3.E7)

Symptoms are not a prerequisite, however. In a Belgian study, endometriosis was still found at laparoscopy in 40% of women with infertility who had no pain (Meuleman 2009, 108 women without pain).

Pain during sex can make it harder to get pregnant, simply because intercourse is less often possible. The guideline therefore recommends that doctors actively ask about possible sexual problems during the consultation (AWMF 3.E11). So feel free to bring up the topic yourself. It is part of the examination.

How common is endometriosis?

The World Health Organization estimates that about 10% of women of reproductive age are affected, around 190 million worldwide (WHO 2025). The German guideline considers a reliable estimate impossible because the studies differ so widely (AWMF 1.S1). In German health insurance data, the diagnosis is documented each year in 0.66% of insured women (2019, compared with 0.53% in 2010). In a survey from Canada, the lifetime share was 7.0%. Many cases remain undiagnosed for a long time. Nobody knows exactly how many.

Endometriosis is considerably more common in women with infertility. The WHO cites 25% to 50%, and the AWMF guideline “up to 50%.” In the Belgian study of 221 women with regular cycles and a normal semen analysis in their partner, laparoscopy found endometriosis in 47%. Of these, 39% were stage I, 24% stage II, 14% stage III, and 23% stage IV (Meuleman 2009, retrospective case series from a specialized center).

In the German IVF Registry (Deutsches IVF-Register, D.I.R.), endometriosis was named in 2024 in 3,445 of 23,168 indications given for IVF (14.9%) and in 4,917 of 53,861 indications given for ICSI (9.1%). Several indications can be recorded per treatment, so these figures are not shares of all cycles.

How does endometriosis affect fertility

Now to the central question: yes, you can get pregnant with endometriosis. Fertility is often reduced, though. How much is hard to express as a single number. Older reviews give a chance of 2% to 10% per month for untreated endometriosis and 15% to 20% for couples without fertility problems. The US professional society ASRM already wrote in 2012 that, because of the wide range in the literature, this can hardly be put into numbers.

A randomized trial from Canada is more reliable. In women with minimal or mild endometriosis whose lesions were only identified and not removed, there were 2.4 pregnancies per 100 months of observation. After the lesions were removed, it was 4.7 (Marcoux 1997). Only pregnancies lasting at least 20 weeks were counted.

Mechanisms of reduced fertility

Endometriosis can impair fertility on several levels. Not all of this is equally well supported.

Mechanical disruption: Adhesions can cause the fallopian tubes to stick together or become distorted. This makes it harder to pick up the egg. Endometriomas on the ovaries can displace healthy ovarian tissue. The AWMF guideline names these anatomical changes as a cause.

Inflammatory processes: Researchers are discussing whether an overproduction of inflammatory messengers such as prostaglandins, cytokines, and chemokines disrupts egg maturation, egg quality, and implantation (AWMF 015-045, chapter 7.2). The guideline deliberately uses the word “discussed.” This is not an established chain of cause and effect.

Receptivity of the uterus: It is also being discussed whether the uterine lining is less receptive in endometriosis, for example because of resistance to progesterone. So far this is a hypothesis. Data from egg donation point at most to a small effect: In US and British registry data covering 162,082 cycles, the live birth rate was slightly lower in recipients with endometriosis (OR 0.89; 0.81 to 0.97). A meta-analysis of published studies covering 7,212 cycles showed no established difference (Paffoni 2024).

Effects on eggs and ovarian reserve

In IVF, on average about 2 fewer eggs are retrieved from women with endometriosis (Hamdan 2015). The embryos that develop from them do not look worse under the microscope, however. A meta-analysis of 22 studies found no difference in the share of high-quality embryos (RR 1.00; 0.94 to 1.06), including in stage III or IV (Dongye 2021).

Endometriomas in particular affect the ovarian reserve. They can displace healthy tissue, and any surgery on an endometrioma lowers the AMH level. What this means for your decision is covered in the section Endometrioma surgery and AMH.

Chances without treatment

Many couples first wonder whether it can work without surgery and without fertility treatment. For some women, it does. The best data come from the control groups of randomized trials, that is, from women whose lesions were only identified at laparoscopy but not removed.

Important for putting this in context: In Marcoux and Parazzini, all women already had infertility; in Larraín, only some did. The studies ran for months. For you personally, the chance may be higher or lower. It depends heavily on age, the fallopian tubes, and your partner.

How long should you wait?

No guideline gives an evidence-based time window, such as “try for six months after surgery.” The AWMF guideline recommends explaining the influence of age (recommendation 7.E60). The US professional society ASRM advises that, when endometriosis is known, you should not wait the usual year but begin the evaluation right away (ASRM 2021). How this evaluation works and what it costs is explained in our guide Infertility.

If you have already had surgery, your chance can be estimated more precisely: with the Endometriosis Fertility Index.

Diagnosis when trying to conceive

A careful diagnosis is the foundation for every decision about whether to wait, operate, or go straight to fertility treatment. The guidelines have changed considerably here in recent years: laparoscopy is no longer the only route to a diagnosis.

Medical history and physical examination

Targeted medical history:

• Character and location of the pain
• Whether symptoms follow the cycle
• Duration of childlessness
• Sexual history, for example pain during intercourse
• Family history

Gynecologic examination: On manual examination, nodules or hardened areas can sometimes be felt, especially around the ligaments that support the uterus or in the pouch of Douglas behind the uterus.

Ultrasound and MRI

Transvaginal ultrasound is the first imaging test. The AWMF guideline recommends it as the first procedure and MRI as a second-line addition (recommendation 3.E10). NICE also recommends ultrasound for any suspicion (1.5.2) and, for deep endometriosis, a specialist ultrasound or an MRI of the pelvis (1.5.9). Endometriomas are often easy to recognize on ultrasound as cysts with typical “ground-glass” content.

According to the AWMF, ultrasound or MRI can establish the diagnosis with sufficient reliability, with one exception: superficial lesions on the peritoneum. ESHRE therefore stresses that a normal finding does not rule out endometriosis (strong recommendation).

Further tests that are added when you are trying to conceive:

• Fallopian tubes: Before an insemination, the tubes are checked, either by contrast ultrasound (HyCoSy) or during laparoscopy with a dye test (chromopertubation) (AWMF chapter 7.2).
• Kidneys: If deep infiltrating or ovarian endometriosis is suspected, the guideline recommends an ultrasound of the kidneys (AWMF 3.E9).
• Adenomyosis: In endometriosis with a wish to conceive, adenomyosis should also be looked for (AWMF chapter 7.2).

Laboratory tests

CA-125: This blood value is still often measured but is not suitable for diagnosis. AWMF (3.S8), ESHRE (strong recommendation), and NICE (1.5.8) agree in advising against using CA-125 or other biomarkers to diagnose endometriosis.

Anti-Müllerian hormone (AMH): The AMH level estimates the ovarian reserve. If there is an endometrioma, the AWMF recommends measuring it before the treatment decision (6.E45) and, before endometrioma surgery, together with or instead of the count of small follicles on ultrasound (7.E61).

Other hormone levels: FSH, LH, estradiol, progesterone, thyroid levels, and prolactin are part of the general fertility work-up and are not specific to endometriosis. Our guide to the fertility test for women explains what they tell you.

Laparoscopy

For a long time, laparoscopy was considered the gold standard. The ESHRE guideline of 2022 explicitly questions this. The AWMF guideline names persistent pain, damage to organs, and the evaluation of infertility as reasons for laparoscopy. NICE recommends considering it even when imaging is normal if suspicion remains (1.5.11).

When you are trying to conceive, laparoscopy has three advantages: lesions can be removed during the same operation, tubal patency can be checked, and the surgeon can determine the EFI. Tissue samples confirm the diagnosis.

Endometriosis stages: what rASRM tells you

Classification is usually done with the rASRM score (revised American Society for Reproductive Medicine). It divides endometriosis into four stages by the size and depth of the lesions and the extent of adhesions. The point thresholds are given in the appendix of the AWMF guideline.

What the stage does not tell you

The stage describes what the surgeon sees. It says little about pain and fertility. The AWMF guideline states: pain and infertility are not captured by the rASRM score or the #Enzian classification, and the classifications do not predict the course of the disease (statement 2.S4). Two doctors can also classify the same situation differently, with disagreement between examiners of up to 40%. NICE therefore recommends treating according to symptoms, wishes, and priorities, not according to stage (1.6.1).

Stage and symptoms also often do not match. Some women with stage I have severe pain, while others with stage IV barely feel anything.

Monthly pregnancy rates by stage, as often found on the internet (for example “stage IV under 2% per month”), cannot be traced to any reliable primary study. We have therefore removed such figures from this article. What is supported, however: in IVF, women with stage III and IV do worse than women without endometriosis, and women with stage I and II hardly do worse (more on this under IVF and ICSI in endometriosis).

Endometriosis Fertility Index (EFI)

The EFI was developed because the rASRM stage is a poor predictor of the chance of a natural pregnancy. Adamson and Pasta developed it using 801 women with infertility (579 women) and then tested it prospectively (222 women). All had surgically confirmed and treated endometriosis and afterward tried to conceive without IVF (Adamson and Pasta 2010).

The ESHRE guideline states that the EFI should be used because it is validated, reproducible, and inexpensive. The AWMF guideline describes it as useful for counseling women who want to conceive.

How the EFI is calculated

The EFI awards 0 to 10 points. Part comes from the medical history, the other part from the findings at surgery. It therefore cannot be calculated without laparoscopy. The surgeon assigns the points.

Source: AWMF 015-045, appendix 5, after Adamson and Pasta 2010.

What the EFI predicts

A meta-analysis of 17 studies and 4,598 women after endometriosis surgery examined how many became pregnant within 36 months without IVF or ICSI (Vesali 2020):

Pregnancies were counted, not births. The predictive power is moderate (area under the curve 72%), and the individual studies differ widely. The EFI is therefore a guide for the conversation with your doctor, not a personal prognosis. With a low EFI, ESHRE leans toward recommending IVF (weak recommendation).

Surgery, insemination, or IVF: what the guidelines recommend

Whether to operate first, perform an insemination, or go straight to IVF is the hardest decision in endometriosis and fertility. There is no one-size-fits-all answer. ESHRE lists these criteria: pain, age, your wishes, previous surgeries, other fertility factors such as an abnormal semen analysis, ovarian reserve, and the estimated EFI (good practice point).

The guidelines compared

The biggest discrepancy concerns surgery for deep lesions. The AWMF text is much more optimistic, stating that surgical removal improves fertility in all forms of the disease. ESHRE sees no convincing evidence of this in deep infiltrating endometriosis.

Mild endometriosis: what surgery achieves

Two randomized trials reached different results. In the Canadian trial (Marcoux 1997, 341 women), 30.7% became pregnant within 36 weeks after the lesions were removed, compared with 17.7% without removal (rate ratio 1.9; 1.2 to 3.1). In the Italian trial (Parazzini 1999, 96 women), there was no advantage after one year: 24% with treatment compared with 29% without.

The Cochrane review summarizes 14 randomized trials with 1,563 women. Its conclusion: operative laparoscopy probably improves the rate of viable intrauterine pregnancies (OR 1.89; 1.25 to 2.86; 3 trials, 528 women; moderate certainty). None of the trials reported live births (Bafort 2020).

Excision or ablation: Lesions can be cut out (excision) or destroyed by heat (ablation). According to Cochrane, it cannot be said whether either method is better for superficial lesions. The data cover only pain and come from a single study with 103 women. For women trying to conceive, NICE offers both methods, together with the release of adhesions (adhesiolysis), which is especially important for fallopian tube function.

First surgery or repeat surgery: After a first operation, a spontaneous pregnancy was 2.1 times as likely as after a repeat operation (OR 2.1; 1.5 to 2.8; Cao 2026, 7 retrospective studies with 2,101 women). This argues for planning the first operation well. In deep endometriosis, nerve-sparing techniques are important to preserve organ function.

Endometrioma: cystectomy, drainage, or waiting

For an endometrioma, there are several surgical approaches: complete removal of the cyst wall (cystectomy), opening and emptying the cyst with ablation of the inner lining (drainage and ablation), or opening only (fenestration).

Here the guidelines weigh things differently:

• AWMF: Complete removal increases the spontaneous pregnancy rate compared with fenestration and is superior to medication-based approaches for reducing pain and preventing recurrence (6.S15). The recurrence rate is lower after cystectomy than after other methods.
• ESHRE: Cystectomy rather than drainage and electrocoagulation, to prevent pain recurrence (strong). The guideline adds that the risk of a reduced ovarian reserve must be taken into account.
• NICE: When you are trying to conceive, cystectomy or drainage with ablation, because drainage and ablation may spare the ovarian reserve better (1.10.2). In general, NICE leans toward excision and requires that the wish to conceive and the ovarian reserve be taken into account (1.9.6).

A meta-analysis of 24 prospective studies with 2,458 women found a natural pregnancy in 40.25% after cystectomy and in 34.08% after ablation. The difference was not significant. Coagulation and fenestration performed worse, and the recurrence rate was up to 38.79% (Askary 2025).

Another option is sclerosing the cyst with alcohol (sclerotherapy). According to the AWMF, there are increasing data for large endometriomas and a smaller drop in AMH than after cystectomy. The evidence is low, however, and there is no graded recommendation.

Deep infiltrating endometriosis and bowel involvement

For deep lesions, for example on the bowel, ESHRE sees no convincing evidence that surgery improves fertility. For women with symptoms, it can be an option. NICE recommends discussing benefits and risks openly.

The largest review comes from 48 observational studies with 5,963 women with bowel endometriosis (Larraín 2026). The cumulative pregnancy rates were:

• without surgery, spontaneous: 36% (15% to 57%)
• with fertility treatment (assisted reproduction) as the first treatment: 40% (25% to 55%)
• after surgery, spontaneous: 29% (25% to 34%), and 24% (19% to 30%) when infertility had been confirmed beforehand
• after surgery overall, that is, spontaneous or with fertility treatment: 56% (51% to 62%)

The authors write that the choice between surgery and fertility treatment should not be seen as either-or. There are no randomized trials.

Insemination (IUI)

In an insemination, prepared sperm is placed directly into the uterus at the time of ovulation. In endometriosis, it makes sense only if the fallopian tubes are open.

• ESHRE: In rASRM I/II, IUI with ovarian stimulation rather than expectant management or IUI without stimulation, because this increases pregnancy rates (weak). In rASRM III/IV with open fallopian tubes, it can be considered, but the benefit is uncertain (weak).
• AWMF: Endometriosis is not an indication for hormonal stimulation alone, without insemination. The fallopian tubes are checked beforehand. More than three to four insemination cycles make little sense.

The data: In a randomized trial with 103 couples and 311 cycles in minimal or mild endometriosis, the live birth rate per cycle was 11% after stimulation with FSH plus IUI and 2% without treatment (OR 5.6; 1.8 to 17.4; Tummon 1997). In stage III/IV, a retrospective study found ongoing pregnancies in 40.0% (8 of 20 women) with stimulation and in 15.6% (7 of 45 women) who first had three cycles without stimulation (van der Houwen 2014).

A review found weak indications that IUI may increase the risk of endometriosis recurrence (Somigliana 2019, low certainty). There are no studies on letrozole as a stimulation drug in endometriosis (AWMF). Letrozole is not approved for this and is used off-label. You can find more on the procedure and requirements in our guide to IUI treatment.

Going straight to IVF or ICSI: when it makes sense

ESHRE recommends IVF or ICSI in endometriosis especially when fallopian tube function is impaired, a male factor is present, the EFI is low, or other treatments have not been successful (weak).

For women with an endometrioma, the AWMF guideline lists criteria for both paths:

No guideline gives fixed deadlines such as “after 6 to 12 months of unsuccessful treatment.”

Surgery before IVF: usually not necessary

If IVF is planned anyway, the guidelines advise against routine surgery beforehand:

• ESHRE: In rASRM I/II, no routine surgery before IVF to improve the live birth rate (strong). Likewise for endometriomas, because surgery probably reduces the ovarian reserve (strong). In deep endometriosis, the decision depends mainly on pain and your wishes (strong).
• AWMF: Removing an endometrioma beforehand presumably does not increase the chances of success of IVF (chapter 6.2). Elsewhere (chapter 7.2), however, it describes the chances after previous surgery as “tending to be higher.” The guideline is therefore not consistent here.

Newer data support the “no benefit” position. For endometrioma, a meta-analysis found no higher live birth rate after surgery before IVF (OR 0.90; 0.63 to 1.28; 5 studies, 655 women; Hamdan 2015). The most recent review of 22 studies and 3,590 women reaches the same result: live birth rate in endometrioma OR 0.89 (0.68 to 1.16), in deep endometriosis OR 1.82 (0.70 to 4.77), neither established. After surgery, AMH was on average 0.57 ng/ml lower, and 1.24 fewer eggs were retrieved. The certainty of the evidence is very low. The authors recommend favoring IVF or ICSI as the first treatment (Riemma 2026).

Good reasons for surgery before IVF remain: severe pain, ovaries that are hard to reach for egg retrieval (ESHRE, good practice point), a finding that needs to be investigated, and a fluid-filled, blocked fallopian tube (hydrosalpinx). With a hydrosalpinx, removing the tube before IVF probably increases the clinical pregnancy rate (RR 2.02; 1.44 to 2.82; 4 randomized trials, 455 women; Melo 2020). Live births were not reported.

Fixed thresholds such as “operate from 4 cm (1.6 in),” “do not operate below AMH 1 ng/ml,” or “no longer operate from age 38” appear in none of the three guidelines. The decision remains individual. It helps if the surgeon and the fertility clinic coordinate beforehand. You can find an overview of clinics under Fertility clinics compared.

Endometrioma surgery and AMH

Anti-Müllerian hormone (AMH) reflects the number of remaining follicles. With an endometrioma, it is the most important value before any decision. The AWMF guideline states it clearly: all known surgical methods for endometriomas reduce the ovarian reserve (statement 6.S13). The effect is especially pronounced for endometriomas larger than 7 cm (2.8 in) and for bilateral endometriomas, but it is also measurable when only one side is affected.

This is how much AMH drops after cystectomy in studies:

Interestingly, the number of small follicles on ultrasound (antral follicle count) did not change significantly in the Younis review. The values are averages across studies. How to interpret your own AMH level can only be judged by your doctor in the context of age, ultrasound, and history. How AMH levels are distributed by age in studies is shown in our AMH Chart.

What this means for the decision

The AWMF guideline recommends measuring the ovarian reserve with AMH or a follicle count before endometrioma surgery (7.E61). Before any treatment of an endometrioma, ovarian function and age should be taken into account, and reproductive medicine counseling and, where appropriate, freezing of eggs or embryos should be offered (AWMF 6.E47). Fertility treatment before surgery can also be offered (7.E62).

A possible approach then looks like this: first eggs are retrieved and frozen, then surgery is performed, and the transfer follows later. This is an option for certain situations, not a standard. ESHRE considers the actual benefit of such fertility preservation in endometriosis to be unknown. More on this in the section Elective egg freezing in endometriosis.

Egg retrieval with an existing endometrioma

If an endometrioma is not operated on, IVF is still possible. The live birth rate was similar with and without an endometrioma in a meta-analysis, with no established difference (OR 0.98; 0.71 to 1.36; 5 studies, 928 women). Fewer eggs were retrieved, however, and cycles were canceled more often (OR 2.83; 1.32 to 6.06; 3 studies, 491 women; Hamdan 2015).

Preventive antibiotics can be considered at egg retrieval. According to ESHRE, the risk of an ovarian abscess after retrieval is low. An increased risk of cyst rupture or ovarian hyperstimulation syndrome (OHSS) because of the endometrioma is not supported in the sources reviewed.

Hormone therapy after surgery

Hormone therapies are used in endometriosis mainly against pain. The picture is different when you are trying to conceive: they suppress ovulation, so pregnancy is not intended while you are using them.

What the guidelines say

All three guidelines advise against hormone therapy to improve fertility when you are trying to conceive now:

• ESHRE: no suppression of ovarian function to improve fertility (strong), and no hormone therapy after surgery with the sole aim of increasing later pregnancy rates (strong). Women who do not want to become pregnant right after surgery can be offered hormone therapy because it does not worsen fertility (weak).
• NICE: no hormone treatment alone or in combination with surgery for women who want to become pregnant (1.10.4).
• AWMF: A positive effect on fertility has not been shown so far. Therapy after surgery is still generally advised against when you are trying to conceive now. If you want to conceive later, hormone therapy after surgery makes sense to prevent recurrence.

What the Cochrane reviews show

A closer look is worthwhile here, because the evidence is not quite as clear-cut as the guidelines suggest.

The older Cochrane review (Hughes 2007, 24 studies) found no higher pregnancy rate after ovulation suppression compared with placebo or no treatment (OR 0.79; 0.54 to 1.14; in couples with fertility problems OR 0.80; 0.51 to 1.24). The authors write that there is no evidence of benefit in women who want to conceive.

The newer Cochrane review (Chen 2020) covers 26 randomized trials with 3,457 women. Before surgery, hormone therapy showed no established effect (RR 1.16; 0.99 to 1.36; 1 trial, 262 women; very low certainty). After surgery, on the other hand, the pregnancy rate was probably higher than after surgery alone (RR 1.22; 1.06 to 1.39; 11 trials, 932 women; moderate certainty).

Why do the guidelines advise against it anyway? The AWMF explains this by noting that the studies did not record how long it took to get pregnant. During hormone therapy lasting several months, pregnancy is not intended because ovulation is suppressed. Chances decline with increasing age, so this time counts (AWMF 7.E60). If hormone therapy is recommended to you after surgery, ask about the goal: pain relief and protection against recurrence when you want to conceive later are good reasons. For trying to conceive now, the guidelines do not recommend it.

Also not recommended: pentoxifylline, other anti-inflammatory drugs, or letrozole outside of ovulation induction to increase the natural pregnancy rate (ESHRE, strong).

Active ingredients and approval at a glance

All active ingredients named here are prescription-only. The approval status refers to Germany.

Sources: AWMF 015-045 chapter 4.1; prescribing information for leuprorelin acetate 3.75 mg monthly depot (as of May 2026); prescribing information for letrozole.

GnRH analogs: They sharply reduce estrogen production and temporarily put the body into a state like menopause. Side effects are accordingly menopausal symptoms and a decrease in bone density. Because of the side effects, ESHRE recommends GnRH agonists and GnRH antagonists only as a second choice (good practice point). The AWMF likewise sees GnRH agonists as second-line (4.E13) but already names oral GnRH antagonists with add-back after a surgically confirmed diagnosis as a first-line option alongside a progestin (4.E12). For pain, dienogest works just as well according to the AWMF. With GnRH agonists, ESHRE recommends a combined hormonal add-back therapy with estrogen and progestin (strong).

Dienogest: approved for the treatment of endometriosis. It is not approved as a contraceptive but inhibits ovulation at a dose of 1 mg daily or more.

Levonorgestrel intrauterine system and combined pill: After surgery, ESHRE recommends one of the two for at least 18 to 24 months to prevent recurring period pain (strong). Both are off-label in endometriosis and act as contraception, so they only fit if trying to conceive can wait. For adenomyosis, no drug class has been shown to be superior (AWMF 6.S12).

Aromatase inhibitors: The AWMF envisions them only for symptoms that do not respond to other therapies, and only within clinical trials. ESHRE likewise names them for therapy-resistant pain. Letrozole is not on the off-label list of the Federal Joint Committee (Gemeinsamer Bundesausschuss) (as of June 2026), so coverage by the health insurance fund is possible only in individual cases.

IVF and ICSI in endometriosis

If natural attempts or insemination are not enough, or the starting situation points that way, reproductive medicine is the next step. The good news up front: overall, the live birth rate after IVF or ICSI in endometriosis is similar to that for other causes. How an IVF cycle works step by step is explained in our guide to the IVF process.

Results compared with women without endometriosis

The German IVF Registry does not publish its own success rates for endometriosis. As a point of reference across all indications: in 2024, the pregnancy rate per embryo transfer in a fresh cycle was 30.5%. The live birth rate per transfer in 2023 was 22.5% in a fresh cycle and 21.9% in a frozen cycle (D.I.R. Yearbook 2024). Both values fall markedly with age; more on this in the frequently asked questions.

Stimulation protocol

For hormonal stimulation, the ESHRE endometriosis guideline does not recommend a specific protocol. Antagonist and agonist protocols can be chosen according to preference; no difference in pregnancy or live birth rate has been shown (weak). A review of 8 studies (1 randomized, 7 observational) with 2,695 women also found no difference (Kuan 2023).

For IVF in general, the ESHRE guideline on ovarian stimulation from 2025 applies:

• The antagonist protocol is recommended over agonist protocols (strong).
• If a GnRH agonist is used, then in the long protocol and not in the short or ultrashort protocol (strong). This argues against variants such as the “micro-flare protocol” that was often mentioned in the past, which is one of the short agonist protocols.
• Adding LH to FSH is not superior in women aged 35 and older. Both variants are considered equivalent (conditional recommendation).

The guidelines do not contain a specific dosing recommendation for endometriosis.

Long pretreatment with GnRH agonists

In the past, women with endometriosis were often hormonally “shut down” for several months before IVF (ultralong protocol). The guidelines assess this differently:

• ESHRE: Prolonged use of GnRH agonists before IVF is not recommended because the benefit is uncertain (strong).
• AWMF: A definitive recommendation cannot currently be given. The decision should be made individually with the patient; taking the stage into account can make sense.

Newer network meta-analyses of randomized trials argue against a benefit. One (9 studies, 2,087 women) sees no indication for hormonal pretreatment before IVF (Riemma 2025). The other (11 studies, 1,435 women) found no clear improvement in clinical pregnancy rate or live birth rate with either GnRH agonists or dienogest (Li D 2026). For pretreatment with dienogest alone as well, a review of 4 studies with 422 women showed no effect on pregnancy (OR 1.07) or live birth (OR 1.09), with very different individual results (Li X 2023). For pretreatment with the pill or a progestin, the evidence is insufficient according to ESHRE.

Fresh or frozen embryo transfer

A meta-analysis of 6 studies with 3,010 women with endometriosis found a higher live birth rate after the first frozen embryo transfer than after the first fresh embryo transfer (OR 1.53; 1.13 to 2.08) and fewer miscarriages (OR 0.70; 0.50 to 0.97). The clinical pregnancy rate showed no established difference (OR 1.26; 0.95 to 1.69). All six studies were retrospective, and the authors describe the evidence as “not yet abundant” (Chang 2022). How a transfer with frozen embryos works is explained in our guide to frozen embryo transfer.

Does IVF make endometriosis worse?

Many people worry about this. According to current data, no: ESHRE states that recurrences are not more common after IVF (weak recommendation, moderate certainty). A systematic review concludes that IVF does not worsen endometriosis pain (Somigliana 2019, moderate certainty). The same review found weak indications of more recurrences after IUI and very weak indications that deep lesions may progress under stimulation.

Additional treatments (“add-ons”)

Many clinics offer additional treatments. ESHRE assessed them in 2023:

• Endometrial scratching: not recommended for routine use.
• Immunomodulation (for example fat emulsions as an infusion, immunoglobulins, TNF inhibitors): not recommended.
• Glucocorticoids (cortisone) in fertility treatment: not recommended.

None of the guidelines reviewed recommends blood thinners to improve IVF outcomes in endometriosis.

IVF or ICSI? Endometriosis alone is not a reason for ICSI. ESHRE does not recommend ICSI when there is no male cause. When male factors are also present, however, ICSI is the appropriate method. More on this in our decision guide ICSI or IVF.

Nutrition, acupuncture, naturopathy: For non-medical measures, ESHRE cannot make a recommendation to increase fertility. For homeopathy, the AWMF cites only one study with 128 women on period pain; there are no data on fertility. According to the AWMF, osteopathy can be considered for symptoms (4.E28).

Elective egg freezing and fertility preservation in endometriosis

Some women with endometriosis consider freezing eggs before they have surgery. The guidelines are cautious here:

• ESHRE: In extensive endometriosis of the ovaries, the pros and cons of fertility preservation should be discussed (strong). The actual benefit in endometriosis is unknown, however.
• AWMF: Before any treatment of an endometrioma, ovarian function and age should be taken into account, and reproductive medicine counseling and, where appropriate, freezing of eggs or embryos should be offered (6.E47). Fertility treatment or freezing of eggs or ovarian tissue before surgery can also be offered (7.E62).

What the data show

The largest study is a retrospective analysis (Cobo 2020). It includes 485 women with endometriosis who froze eggs between 2007 and 2018. The mean age was 35.7 years. 83.2% of the eggs survived thawing. Among the women who later used their eggs, the cumulative live birth rate was 46.4%. In women up to age 35 who had not had surgery before freezing, it was 72.5%, and in women of the same age with previous surgery, 52.8%.

A follow-up analysis of the same group shows how much age and egg number matter: when about 20 eggs were thawed and used, the estimated cumulative live birth rate was 95.4% in women up to age 35 and 79.6% in older women, with large statistical uncertainty (Cobo 2021). These values come from a single retrospective analysis and cannot simply be transferred to other clinics.

One important difference from classic elective egg freezing: according to ESHRE, 43% of the women in this group came back to use their eggs, on average after 1.5 years. For most, freezing was therefore part of a fertility treatment and not a precaution for many years.

You can find general information on the process, costs, and chances of success in our guide to elective egg freezing.

Who pays for freezing?

This section applies to Germany only.

In Germany, people with statutory health insurance are entitled to freezing of egg or sperm cells or germ cell tissue if it appears medically necessary because of an illness and its treatment with a germ cell-damaging therapy (Section 27a, paragraph 4, of Book V of the Social Code, SGB V). The details are set out in the Cryopreservation Directive (Kryokonservierungs-Richtlinie, Kryo-RL) of the Federal Joint Committee (current version of 2022, in force since November 15, 2022):

• The directive names, among other things, the surgical removal of the gonads as germ cell-damaging.
• Whether a treatment damages germ cells is determined by the specialist physician who treats the underlying condition. The indication for freezing is made by a specialist physician qualified in reproductive medicine.
• For women, the entitlement lasts until the 40th birthday.
• Eggs and ovarian tissue are covered, but not embryos (Kryo-RL Section 2 (1), Section 5).

An endometrioma operation is not explicitly named in the directive. Whether it counts as germ cell-damaging in an individual case must be determined by a physician and clarified with the health insurance fund. Elective egg freezing without a medical reason remains self-pay. How individual insurance funds handle this is described in our article on egg freezing and costs at AOK.

Adenomyosis and fertility

Adenomyosis is often called “internal endometriosis” and is easily overlooked when you are trying to conceive. In it, tissue like the uterine lining grows into the muscle layer of the uterus (myometrium). The uterus can thicken, enlarge, and become painful. According to the AWMF, adenomyosis occurs without other endometriosis in 38% to 64% of cases, and 30% of those affected have no symptoms.

A distinction is made mainly between a diffuse form, in which the muscle layer is evenly infiltrated, and a focal form with circumscribed nodules (adenomyomas). There are also cystic forms.

How common adenomyosis is among people trying to conceive is hard to say. In a Spanish study, it was found on 3D ultrasound in 24.4% of 1,015 women (Puente 2016). The women were selected, however: they were referred for evaluation before fertility treatment, after at least three failed IVF attempts, or after at least two miscarriages. In addition, older diagnostic criteria applied at the time. The figure therefore cannot be transferred to all women who want to conceive.

Diagnosis according to MUSA

The AWMF guideline recommends transvaginal ultrasound as the first and MRI as the second test. Both are equivalent in their informative value (recommendation 6.E37). MRI is thus no longer the sole gold standard.

For ultrasound, there has been a common language since 2015, the MUSA criteria (Morphological Uterus Sonographic Assessment). They were revised in 2022 in a Delphi process of European experts and distinguish two groups of signs:

• Direct signs (agreed unanimously): small cysts in the muscle, echogenic islands, and echogenic lines and buds directly beneath the lining.
• Indirect signs: a globular uterus, an asymmetrically thickened wall, fan-shaped shadowing, vessels running transversely through the finding, and an irregular or interrupted junctional zone between the lining and the muscle.

If only indirect signs are present, the diagnosis is considered uncertain according to the AWMF. On accuracy, the guideline cites a sensitivity of 75% to 78% and a specificity of 78% to 81% for 3D ultrasound, and 77% and 89% for MRI. On MRI, a junctional zone widened to more than 12 mm is considered an indication, although one study found no association with this threshold. A tissue sample should not be taken for diagnosis (6.E38), and blood values such as CA-125 are unsuitable for routine use.

Effect on IVF and miscarriage

There are no reliable figures for natural fertility in adenomyosis. The AWMF describes a possibly negative effect, both for spontaneous pregnancy and after fertility treatment. IVF is better studied:

The AWMF summarizes: Several meta-analyses show a 30% reduced probability of pregnancy, and the miscarriage rate after IVF or ICSI is two to three times higher. As limitations, most studies do not distinguish between focal and diffuse adenomyosis, and the diagnostic criteria are inconsistent.

Compared with endometriosis without adenomyosis, the effects appear larger: live birth OR 0.59 in adenomyosis compared with OR 0.94 in endometriosis overall. No study has compared them directly, however, so this is only a tendency.

If you want to get pregnant again after a miscarriage, our guide Pregnant after miscarriage answers questions about timing, tests, and chances.

GnRH agonist before frozen embryo transfer

In adenomyosis, a GnRH agonist, which suppresses ovarian function, is sometimes given for one or several months before a frozen embryo transfer. How well is this supported?

The AWMF guideline states: current observational studies suggest a possibly higher live birth rate in adenomyosis after frozen embryo transfer with prior suppression by GnRH analogs (statement 7.S22, expert consensus). The newer reviews are more reserved:

Two smaller randomized trials also show no benefit. In 140 women having a frozen embryo transfer, pregnancy, miscarriage, and live birth rates did not differ with and without a GnRH agonist (Eslami Moayed 2023). In 72 women, a three-month course was no better than the usual shorter suppression; only early and clinical pregnancies were reported (Ansaripour 2024). A third randomized trial compared two pretreatments with each other: in 156 women with diffuse adenomyosis with pronounced symptoms, the live birth rate after three months of low-dose letrozole was 17.7% and after three months of GnRH agonist 19.5% (Sharma 2025). There was no group without pretreatment.

A large randomized trial is underway: GOLD-FET compares one or two doses of a GnRH agonist with and without letrozole in 432 women aged 20 to 38, with live birth as the primary endpoint. The first participants were enrolled in August 2025, and completion of the main analysis is planned for May 2027.

Approval: The GnRH agonist leuprorelin acetate is approved for symptomatic endometriosis confirmed by laparoscopy. Pretreatment in adenomyosis before frozen embryo transfer to improve the chance of pregnancy is not covered by this and is therefore off-label. Letrozole is approved only for breast cancer; here too, use is off-label.

Bottom line: GnRH pretreatment before frozen embryo transfer can be considered, but its benefit for live birth is not established. Ask your clinic why it recommends it and how long it should last.

Treating adenomyosis when trying to conceive

Hormone therapy: Combined pill, progestins, a suitable progestin intrauterine system, GnRH agonists, and GnRH antagonists relieve symptoms. No drug class has been shown to be superior (AWMF 6.S12). Pregnancy is not intended during therapy; not every one of these drugs is an approved contraceptive. The combined pill and the hormonal IUD are off-label in endometriosis, and GnRH antagonists are not approved for endometriosis in Switzerland (see table above). The AWMF mentions that therapy with GnRH analogs is associated with a higher pregnancy rate afterward, but without a figure and without a randomized trial.

Organ-sparing surgery: In focal or cystic adenomyosis, the lesion can be removed to control pain and bleeding (AWMF 6.E40). Whether this helps when you are trying to conceive has not been shown by randomized trials. Observational data:

• A review of 64 studies and 1,049 women found a pregnancy rate of 60.5% after complete removal and 46.9% after partial removal (Grimbizis 2014).
• A meta-analysis of 32 studies and 2,501 women, without randomized trials, found after adenomyomectomy a pregnancy rate of 50.1% (40.0% to 60.2%), a live birth rate of 39.5%, a miscarriage rate of 16.3%, and a preterm birth rate of 18.4%. Nearly all babies (99.6%) were delivered by cesarean section (Liu 2025).

How high the risk is that the uterus ruptures during pregnancy after such an operation is not quantified in the sources reviewed. You should definitely raise this before surgery.

Procedures only in studies: Focused ultrasound (HIFU), embolization of the uterine arteries, transvaginal electroablation, and microwave ablation should, according to the AWMF, only be used within studies (6.E39). This applies even when individual observational data look good, such as a pregnancy rate of 52.0% after thermal ablation (Liu 2025).

Procedures that end fertility: Removal of the uterus (hysterectomy) is an option only when family planning is complete and there is insufficient improvement with conservative therapy (AWMF 6.E41). Ablation of the uterine lining (endometrial ablation) is also not an option when you are trying to conceive.

Pregnancy with adenomyosis

In adenomyosis, some pregnancy complications are more common, even after accounting for age and mode of conception: preeclampsia, preterm birth, cesarean delivery, abnormal fetal position, a baby that is small for gestational age, and heavier bleeding after birth (Nirgianakis 2021). The AWMF cites pooled values: preeclampsia OR 4.35 to 7.87, preterm birth OR 2.65 to 3.09, and a small baby or low birth weight OR 2.86 to 3.90. When endometriosis and adenomyosis occur together, the risk of a small baby is further increased.

The authors of the meta-analysis therefore recommend close monitoring of pregnancy in adenomyosis. This differs from the recommendation for endometriosis without adenomyosis, for which ESHRE does not provide additional monitoring (see next section). Bring up the diagnosis with your gynecologist early.

Pregnancy with endometriosis

When it has worked, the next worry often follows: Is pregnancy riskier with endometriosis? Some complications are somewhat more common. ESHRE stresses, however, that they are rare and neither justify additional monitoring nor are a reason to advise against pregnancy (strong).

Risks in numbers

The largest meta-analysis includes 33 observational studies with more than 3.2 million women (Lalani 2018):

Placenta previa and preterm birth were also more common in women who became pregnant without fertility treatment. The values are relative figures: an OR of 1.70 does not mean that 70% of babies are born early, but that the probability is increased compared with women without endometriosis. How large the actual risk is depends on how common the complication is overall.

ESHRE points to a possibly increased risk of miscarriage in the first trimester and of ectopic pregnancy (strong). The AWMF adds to its list, among other things, premature placental abruption and, very rarely, spontaneous bleeding into the abdominal cavity. You should therefore always have new, severe abdominal pain in pregnancy checked by a doctor.

If a pregnancy ends so early that it could only be detected through the pregnancy hormone hCG and was not yet visible on ultrasound, it is called a biochemical pregnancy. We explain there what that means for the next attempt.

Does endometriosis get better during pregnancy?

Often, but not reliably. In an ultrasound study of 65 pregnant women, 85% of endometriomas (29 of 34) and 84% of deep lesions (43 of 51) regressed. By contrast, 6% of endometriomas and 4% of deep lesions grew (Bean 2023). In the first and second trimesters, temporary worsening is also possible (AWMF).

A systematic review concludes that pregnancy cannot generally be expected to reduce the size and number of lesions (Leeners 2018). ESHRE explicitly advises against recommending pregnancy to women as a treatment for endometriosis (strong).

A particular feature: endometriomas can change in pregnancy because of hormones and look like a malignant finding on ultrasound. ESHRE recommends having suspicious-looking endometriomas in pregnancy assessed in an experienced center (strong). According to the AWMF, an ultrasound finding from before the pregnancy makes interpretation easier.

Birth

Deep infiltrating endometriosis, whether treated surgically or still present, does not argue against a vaginal birth (AWMF 7.S23). For endometriosis of the rectum, there is no recommendation for a specific mode of delivery, but the risks should be discussed (7.E63). Because a cesarean section becomes necessary more often during labor in deep infiltrating endometriosis, the birth should take place in a hospital (7.E64).

Breastfeeding

In a large US cohort of 72,394 women who had had at least one pregnancy, women who had breastfed for a total of 36 months or longer were less often newly diagnosed with endometriosis (HR 0.60; 0.50 to 0.72; Farland 2017). Whether breastfeeding prevents a recurrence in already known endometriosis has not been studied.

Costs and insurance coverage in Germany, Austria, and Switzerland

This section applies to Germany, Austria, and Switzerland.

Financing of endometriosis treatment differs considerably between Germany, Austria, and Switzerland. Here is an overview of the most important rules. With the cost calculator, you can estimate your out-of-pocket cost for IVF or ICSI for Germany, Austria, and Switzerland.

Germany: statutory and private health insurance

Diagnostics: All diagnostic measures are covered by the health insurance funds:

• Ultrasound examinations
• MRI when indicated
• Laparoscopy for diagnosis
• Laboratory tests

Drug therapy:

• GnRH analogs: covered by insurance, statutory copayment of €5 to €10
• Progestins: prescription-only, copayment of €5 to €10
• Aromatase inhibitors: off-label use, coverage only in individual cases

Surgical treatment: Laparoscopic procedures are covered in full. Additional costs may arise with combined procedures.

Reproductive medicine treatment

IVF/ICSI cycles:

• 3 attempts with 50% of the costs covered, for married couples (IVF or ICSI, not both in addition)
• Age limit: both partners at least 25; the woman must not yet have reached her 40th birthday and the man not yet his 50th
• The treatment plan must be approved by the health insurance fund before it begins
• Out-of-pocket cost: according to a fertility clinic in Augsburg, about €1,200 to €1,700 per IVF attempt and €1,400 to €1,900 per ICSI attempt, medication included (details and calculator under Cost coverage)

Additional costs:

• Services outside the approved treatment plan, such as a frozen embryo transfer, you pay for yourself (Section 27a, paragraph 3, SGB V; Directive on Assisted Reproduction, no. 10)
• Freezing and storage of surplus eggs or embryos from an IVF: self-pay service, costs differ by clinic
• Freezing of unfertilized eggs before a germ cell-damaging treatment: covered by insurance under Section 27a, paragraph 4, SGB V and the Kryo-RL up to the 40th birthday, details under Who pays for freezing?

You can find more details on reimbursement in our AOK Fertility Guide.

Austria: social insurance

General rules: Diagnosis and treatment of endometriosis are health insurance benefits.

Diagnostics and therapy:

• Coverage of the necessary examinations
• Medication for a prescription fee (2026: €7.55 per package)
• Surgical procedures covered by insurance

IVF Fund (IVF-Fonds):

• Endometriosis is explicitly one of the indications for which the fund pays
• 70% of costs covered for up to 4 attempts (IVF, ICSI, and frozen embryo transfers), medication included
• Age limit: the woman must be younger than 40 at the start of an attempt, the partner younger than 50
• Requirement: at least one partner with their main residence in Austria
• Out-of-pocket share of 30%: about €970 to €1,330 per attempt, depending on age, method, and clinic

Special points:

• Marriage, registered partnership, and cohabiting partnership are treated equally
• Only at Austrian contracted clinics, no reimbursement for treatment abroad
• No retroactive reimbursement for self-financed treatment

Switzerland: mandatory basic health insurance (Grundversicherung) and supplemental insurance

Mandatory basic health insurance (under the Federal Health Insurance Act, KVG): Mandatory health insurance covers:

• Diagnostic measures in full
• Drug therapy subject to co-insurance
• Surgical procedures after prior cost approval

Co-insurance and deductible:

• Annual deductible: CHF 300 to CHF 2,500
• Co-insurance: 10% up to a maximum of CHF 700 per year
• Hospital stays: additional costs possible

Reproductive medicine in Switzerland

Coverage:

• Basic insurance: diagnostic evaluation and up to 3 inseminations (IUI) per pregnancy, each subject to deductible and co-insurance
• IVF/ICSI: not covered by insurance
• Full self-payment necessary

Treatment costs:

• IVF and ICSI cycles cost several thousand Swiss francs in Switzerland
• Prices differ considerably between clinics, and medication is usually added
• A written cost estimate before starting provides clarity

Supplemental insurance: Some supplemental insurance plans cover part of the costs:

• Flat-rate payments toward treatment costs
• Medication subsidies
• Supplemental hospital insurance for added comfort

Cost comparison: Germany, Austria, Switzerland

Application and approval

Germany: For IVF or ICSI, the clinic issues a treatment plan. The health insurance fund must approve it before treatment begins.

Austria: No separate application to the IVF Fund is needed: the contracted clinic checks the indication and eligibility, you pay 30%, and the clinic bills the rest directly with the fund.

Switzerland: Request cost approval from the health insurance fund. A detailed medical report is required.

Frequently asked questions

Can you get pregnant naturally with endometriosis?

Yes. In a randomized trial of women with minimal or mild endometriosis, 17.7% had a pregnancy lasting at least 20 weeks within 36 weeks without removal of the lesions, and 30.7% after removal of the lesions (Marcoux 1997, 341 women with infertility). In an Italian study, 29% became pregnant within one year without treatment (Parazzini 1999). Pregnancies also occur without surgery in bowel endometriosis, cumulatively in 36% in observational studies (Larraín 2026). Because age strongly influences the chances, the AWMF recommends explaining this openly. When endometriosis is known, ASRM advises starting the evaluation right away instead of waiting a year (ASRM 2021).

How many women with infertility have endometriosis?

An estimated 25% to 50% (WHO 2025); the AWMF guideline says “up to 50%.” In a Belgian study of 221 women with regular cycles and a normal semen analysis in their partner, laparoscopy found endometriosis in 47% (Meuleman 2009).

Which endometriosis stage is worst for fertility?

In IVF, women with stage III and IV do worse: the implantation and clinical pregnancy rates were about one fifth lower (RR 0.79; Harb 2013). For natural pregnancies, there are no reliable monthly rates by stage. The stage predicts pain and fertility poorly anyway (AWMF 2.S4), and the stage often does not match the severity of symptoms. More informative are the condition of the fallopian tubes, the ovarian reserve, your age, and, after surgery, the EFI.

What is the chance of getting pregnant naturally after endometriosis surgery?

It depends on the Endometriosis Fertility Index, which the surgeon determines after laparoscopy. In a meta-analysis of 17 studies and 4,598 women, the cumulative pregnancy rate within 36 months without IVF or ICSI ranged from 10% (EFI 0 to 2) to 69% (EFI 9 to 10) (Vesali 2020). There is no evidence-based time window in which most pregnancies occur after surgery.

Does dienogest or another hormone therapy help you get pregnant?

No. ESHRE (strong recommendation), NICE, and the AWMF advise against hormone therapy when you are trying to conceive now. It suppresses ovulation and costs time. A Cochrane analysis did find somewhat higher pregnancy rates after surgery followed by hormone therapy (RR 1.22; 11 studies, 932 women), but the studies did not record how long it took to become pregnant (Chen 2020; AWMF 2025). If you want to conceive later, hormone therapy after surgery makes sense to prevent recurrence.

Should you have surgery before IVF?

As a rule, not routinely. In mild endometriosis and in endometriomas, ESHRE does not recommend routine surgery before IVF (strong). Endometrioma surgery lowers the ovarian reserve, and a higher live birth rate has not been shown (OR 0.89; very low certainty; Riemma 2026). Reasons for surgery are severe pain, ovaries that are hard to reach, a finding that needs to be investigated, or a fluid-filled fallopian tube (hydrosalpinx). Fixed thresholds such as a certain cyst size or an AMH cutoff appear in no guideline. In mild endometriosis with open fallopian tubes, an insemination can also be an option before IVF.

Does endometrioma surgery lower AMH?

Yes. After cystectomy, AMH fell on average by 1.17 to 2.13 ng/ml in a review of 14 studies, which corresponds to 35% to 54% (Younis 2022, 650 women). According to the AWMF, all surgical methods reduce the ovarian reserve. The AWMF therefore recommends measuring AMH before the treatment decision (6.E45).

How successful is IVF in endometriosis?

Overall similar to IVF without endometriosis: the live birth rate per woman showed no established difference in a meta-analysis (OR 0.94; Hamdan 2015). In rASRM III/IV, implantation and clinical pregnancy rates are lower (RR 0.79; Harb 2013). The German IVF Registry does not publish its own success rates for endometriosis.

Do I need ICSI instead of IVF with endometriosis?

Not because of endometriosis alone. ESHRE recommends ICSI only when there is a male cause (ESHRE add-ons 2023). If your partner's semen analysis is abnormal, however, ICSI makes sense.

Does long GnRH pretreatment before IVF help?

According to current data, not reliably. ESHRE does not recommend it (strong); two network meta-analyses of randomized trials from 2025 and 2026 found no benefit for live birth. The AWMF considers an individual decision possible in severe endometriosis.

Is a frozen embryo transfer better than a fresh transfer in endometriosis?

Possibly. Six retrospective studies with 3,010 women show a higher live birth rate after the first frozen embryo transfer than after the first fresh transfer (OR 1.53; Chang 2022). Randomized trials are lacking. More on the process in our guide to frozen embryo transfer.

Does insemination make sense in endometriosis?

In mild endometriosis with open fallopian tubes, yes, with hormonal stimulation (ESHRE, weak recommendation). In a randomized trial, the live birth rate per cycle was 11% after stimulation plus IUI and 2% without treatment (Tummon 1997). The fallopian tubes should be checked beforehand. According to the AWMF, more than three to four cycles make little sense.

Should I freeze eggs before endometriosis surgery?

In extensive endometriosis of the ovaries, this should be discussed. ESHRE considers the actual benefit to be unknown. Statutory health insurance pays for freezing unfertilized eggs before a germ cell-damaging treatment until the 40th birthday (Section 27a, paragraph 4, SGB V, Kryo-RL). Whether an endometrioma operation counts is not explicitly regulated and is determined by a physician in the individual case.

Does fertility treatment make endometriosis worse?

With IVF, not according to current data: pain and recurrences do not increase (ESHRE; Somigliana 2019, moderate certainty). For IUI, there are weak indications of more recurrences, and deep lesions may possibly progress under stimulation (low and very low certainty).

Does endometriosis affect egg quality?

In IVF, on average about 2 fewer eggs are retrieved (Hamdan 2015). Embryo quality under the microscope is not worse, however, including in stage III/IV (Dongye 2021, 22 studies). For nutrition, dietary supplements, or other non-medical measures, ESHRE cannot give a recommendation to increase fertility.

Does endometriosis get worse during pregnancy?

Usually not, but pregnancy is not a therapy. In an ultrasound study, 85% of endometriomas and 84% of deep lesions regressed, and 6% and 4%, respectively, grew (Bean 2023, 65 pregnant women). In the first and second trimesters, temporary worsening is possible. ESHRE advises against recommending pregnancy to women as a treatment (strong). Endometriomas that look suspicious in pregnancy should be assessed in an experienced center.

Is endometriosis dangerous in pregnancy?

Some complications are more common, such as placenta previa (OR 3.31) and preterm birth (OR 1.70) (Lalani 2018, 33 studies). ESHRE stresses that these complications are rare and sees no reason to advise against pregnancy or to monitor more often as a routine (strong). With additional adenomyosis, by contrast, experts recommend close monitoring (Nirgianakis 2021).

Is a natural birth possible with endometriosis?

Yes. Even deep infiltrating endometriosis, whether treated surgically or still present, does not argue against a vaginal birth (AWMF 7.S23). Because a cesarean section is needed more often in deep infiltrating endometriosis, even after surgery, the birth should take place in a hospital (AWMF 7.E64).

Can endometriosis come back after a pregnancy?

Yes, that is possible. Pregnancy does not cure endometriosis permanently, even though many lesions regress during it (Bean 2023; Leeners 2018). How often symptoms return after birth has not been reliably studied. Long breastfeeding was associated with fewer new endometriosis diagnoses in a large study (Farland 2017). Whether it prevents a recurrence in known endometriosis is not known. When family planning is complete or on hold, hormone therapy can prevent recurrences. After surgery, ESHRE recommends a levonorgestrel intrauterine system or a combined pill for at least 18 to 24 months against recurring period pain (strong); both are off-label in endometriosis and prescription-only.

What role does age play in endometriosis and trying to conceive?

A big one. Both endometriosis and age lower the chances, and the AWMF recommends explaining the effect of age (7.E60). How much age counts in IVF is shown by the data of the German IVF Registry across all indications (IVF, data years 2019 to 2023): in women aged 30 to 34, the pregnancy rate was 39.0% and the live birth rate 30.9% per embryo transfer; in women aged 41 to 44, 17.1% and 9.3%. For an endometrioma, the AWMF guideline names an age over 35 as an argument for starting directly with IVF. Egg donation is prohibited in Germany and Switzerland and allowed in Austria only under narrow conditions (Embryo Protection Act (Embryonenschutzgesetz, ESchG), Section 1; Federal Act on Medically Assisted Reproduction in Switzerland (Fortpflanzungsmedizingesetz, FMedG), Art. 4; Reproductive Medicine Act in Austria (Fortpflanzungsmedizingesetz, FMedG), Sections 2b and 3). You can find more on the individual ages in our guide Getting pregnant at 35 and older.

Can you get pregnant with adenomyosis?

Yes, but the chances after IVF are lower: live birth OR 0.59 and clinical pregnancy OR 0.66 compared with women without adenomyosis (Cozzolino 2022). Reliable figures for the natural pregnancy rate in adenomyosis are lacking.

Does adenomyosis increase the risk of miscarriage?

Yes. After IVF or ICSI, miscarriages were about twice as common as without adenomyosis (RR 2.12, Vercellini 2014; OR 2.17, Nirgianakis 2021). In the Vercellini meta-analysis, the share of miscarriages among clinical pregnancies was 31.9% with adenomyosis and 14.1% without.

How is adenomyosis diagnosed?

First with a transvaginal ultrasound according to the MUSA criteria, followed by MRI as second-line. Both are considered equivalent (AWMF 6.E37). Direct signs are small cysts in the muscle, echogenic islands, and lines and buds beneath the lining (MUSA 2022). A tissue sample is not recommended (AWMF 6.E38).

Does a GnRH injection before frozen embryo transfer help in adenomyosis?

That is unclear. The AWMF considers a higher live birth rate possible on the basis of observational studies. The most recent meta-analysis (Steinmann 2025) and small randomized trials show no benefit. Use is off-label. A large randomized trial is underway (GOLD-FET); results are expected in 2027 at the earliest.

Can adenomyosis be operated on, and can you get pregnant afterward?

In focal or cystic adenomyosis, organ-sparing removal is possible (AWMF 6.E40). After adenomyomectomy, the pregnancy rate in observational studies was around 50% (Liu 2025); comparison studies are lacking. Nearly all births were by cesarean section. Embolization, HIFU, and ablation procedures should only be used within studies (AWMF 6.E39).

Do homeopathy, osteopathy, or naturopathy help with endometriosis and trying to conceive?

There is no evidence for better fertility. ESHRE cannot recommend any non-medical measure. According to the AWMF, osteopathy can be considered for symptoms (4.E28).

Is letrozole approved for endometriosis?

No. In Germany, letrozole is approved only for breast cancer. In endometriosis and to induce ovulation, it is used off-label, and it is not on the off-label list of the Federal Joint Committee. The AWMF envisions aromatase inhibitors in endometriosis only in studies, for symptoms that do not respond to other therapies.

Conclusion

Endometriosis and the wish for a baby do not have to be at odds. How good the chances are depends mainly on the condition of the fallopian tubes, the ovarian reserve, age, and, after surgery, the EFI, and less on the stage. In mild endometriosis, surgery or an insemination with stimulation can help. If IVF is planned anyway, the guidelines advise against routine surgery beforehand, especially for endometriomas. Hormone therapy is not recommended when you are trying to conceive now. In adenomyosis, the chances after IVF are lower and miscarriages more common; here, careful diagnosis according to the MUSA criteria is worthwhile.

A careful evaluation is the foundation for every decision about whether to wait, operate, or go straight to fertility treatment. Get the support you need, ideally at a clinic where endometriosis surgery and reproductive medicine work closely together. Our comparison of fertility clinics gives you an overview, and our Fertility Clinic Finder helps you sort out the next steps.

Sources

Guidelines and position statements

• Diagnosis and treatment of endometriosis, S2k guideline AWMF 015-045, version 5.1, as of April 1, 2025, valid until March 31, 2030, DGGG, OEGGG, and SGGG
• Becker CM et al.: ESHRE guideline: endometriosis, Hum Reprod Open 2022;2022(2):hoac009, ESHRE, 2022
• ESHRE Guideline Endometriosis, guideline page, European Society of Human Reproduction and Embryology, 2022
• NICE guideline NG73: Endometriosis: diagnosis and management, recommendations, National Institute for Health and Care Excellence, last updated November 11, 2024
• ESHRE good practice recommendations on add-ons in reproductive medicine, Hum Reprod 2023;38(11):2062-2104, ESHRE, 2023
• ESHRE Guideline Ovarian Stimulation for IVF/ICSI, Update 2025, Hum Reprod 2026;41(4):498-514, ESHRE, 2025
• Endometriosis, Fact Sheet, World Health Organization, October 15, 2025
• Fertility evaluation of infertile women, Fertil Steril 2021;116:1255-1265, ASRM Practice Committee, 2021
• Endometriosis and infertility: a committee opinion, Fertil Steril 2012;98:591-598, ASRM Practice Committee, 2012 (historical source)
• Endometriosis: symptoms and treatment, gesund.bund.de (Federal Ministry of Health), 2025

Law, registries, and medications

• Yearbook 2024, German IVF Registry (D.I.R.), 2025
• Section 27a SGB V: Assisted reproduction, paragraph 4 Cryopreservation, gesetze-im-internet.de
• Cryopreservation Directive (Kryo-RL), version of August 18, 2022, in force since November 15, 2022, Federal Joint Committee
• Directive on Assisted Reproduction, no. 10, version of December 16, 2021, in force since February 9, 2022, Federal Joint Committee
• Cost regulations, Kinderwunschzentrum Augsburg, retrieved October 3, 2026
• Section 1 Embryo Protection Act (ESchG), paragraph 1, nos. 1 and 2: Abusive use of reproductive techniques, Federal Ministry of Justice, as of 2026
• Federal Act on Medically Assisted Reproduction (FMedG), Switzerland, Art. 4: Prohibited practices, Swiss Confederation (Fedlex), as of August 1, 2025
• Reproductive Medicine Act (FMedG), Austria, Sections 2b and 3, Federal Legal Information System (RIS), as of 2026
• Pharmaceuticals Directive Annex VI: Off-label use, as of June 11, 2026, Federal Joint Committee
• Prescribing information for letrozole 2.5 mg film-coated tablets, section 4.1 Therapeutic indications, fachinfo.de
• Prescribing information for leuprorelin acetate 3.75 mg monthly depot (gynecological use), sections 4.1 and 4.2, as of May 2026, fachinfo.de
• Fertility treatment: what is allowed and who bears the costs?, familienplanung.de (Federal Institute for Public Health), 2026
• We would like a baby: coverage of costs by the IVF Fund, Federal Ministry of Labor, Social Affairs, Health, Care, and Consumer Protection (Austria), 2025
• Health Care Benefits Ordinance (KLV), Annex 1, Federal Office of Public Health (Switzerland), 2026

Studies: prevalence, fertility, and prognosis

• Meuleman C et al.: High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners, Fertil Steril 2009;92:68-74
• Marcoux S et al.: Laparoscopic surgery in infertile women with minimal or mild endometriosis, N Engl J Med 1997;337:217-222
• Parazzini F: Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women, randomized trial, Hum Reprod 1999
• Bafort C et al.: Laparoscopic surgery for endometriosis, Cochrane Database Syst Rev 2020, CD011031
• Adamson GD, Pasta DJ: Endometriosis fertility index: the new, validated endometriosis staging system, Fertil Steril 2010;94:1609-1615
• Vesali S et al.: Endometriosis Fertility Index and natural pregnancy after surgery, meta-analysis, BJOG 2020;127:800-809
• Dongye H et al.: Endometriosis and embryo quality, meta-analysis, Front Med 2021
• Paffoni A et al.: Endometriosis and live birth rate after egg donation, meta-analysis and registry data, JAMA Netw Open 2024

Studies: surgery, endometrioma, and ovarian reserve

• Askary E et al.: Surgical techniques for endometrioma and natural pregnancy, meta-analysis, Reprod Biomed Online 2025
• Larraín D et al.: Fertility in bowel endometriosis with and without surgery, meta-analysis, J Minim Invasive Gynecol 2026
• Cao M et al.: First and repeat surgery for endometriosis and spontaneous pregnancy, meta-analysis, Eur J Obstet Gynecol Reprod Biol 2026
• Riemma G et al.: Surgery before IVF/ICSI in endometriosis, meta-analysis, Reprod Biomed Online 2026;52:105178
• Raffi F et al.: The impact of excision of ovarian endometrioma on ovarian reserve, meta-analysis, J Clin Endocrinol Metab 2012
• Younis JS et al.: AMH trajectory after cystectomy for endometrioma, meta-analysis of prospective studies, Am J Obstet Gynecol 2022
• Melo P et al.: Surgical treatment for tubal disease in women due to undergo in vitro fertilisation, Cochrane Database Syst Rev 2020

Studies: hormone therapy, insemination, and IVF

• Hughes E et al.: Ovulation suppression for endometriosis for women with subfertility, Cochrane Database Syst Rev 2007
• Chen I et al.: Hormone therapy before and after endometriosis surgery, Cochrane Database Syst Rev 2020
• Tummon IS et al.: Randomized controlled trial of superovulation and insemination for infertility associated with minimal or mild endometriosis, Fertil Steril 1997
• van der Houwen LE et al.: Insemination with and without stimulation in endometriosis stage III/IV, retrospective study, 2014
• Hamdan M et al.: Influence of endometriosis on assisted reproductive technology outcomes, meta-analysis, Obstet Gynecol 2015;125:79-88
• Hamdan M et al.: The impact of endometrioma on IVF/ICSI outcomes, meta-analysis, Hum Reprod Update 2015;21:809-825
• Harb HM et al.: The effect of endometriosis on in vitro fertilisation outcome, meta-analysis, BJOG 2013;120:1308-1320
• Senapati S et al.: Impact of endometriosis on in vitro fertilization outcomes, SART registry analysis, Fertil Steril 2016;106:164-171
• Liao L et al.: Endometriosis and IVF outcomes, meta-analysis, Arch Gynecol Obstet 2025
• Kuan KKW et al.: Stimulation protocols in endometriosis, meta-analysis, 2023
• Riemma G et al.: Hormonal pretreatment before IVF in endometriosis, network meta-analysis, Int J Gynaecol Obstet 2025
• Li D et al.: GnRH agonist and dienogest pretreatment before IVF in endometriosis, network meta-analysis, Sci Rep 2026
• Li X et al.: Dienogest before IVF in endometriosis, meta-analysis, 2023
• Chang Y et al.: Frozen or fresh embryo transfer in endometriosis, meta-analysis, J Assist Reprod Genet 2022
• Somigliana E et al.: Ovarian stimulation and progression or recurrence of endometriosis, systematic review, 2019

Studies: fertility preservation

• Cobo A et al.: Egg vitrification in endometriosis, retrospective study of 485 women, 2020
• Cobo A et al.: Live birth rate after egg vitrification in endometriosis by age and number of eggs, 2021

Studies: adenomyosis

• Van den Bosch T et al.: Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses (MUSA), Ultrasound Obstet Gynecol 2015;46:284-298
• Harmsen MJ et al.: Consensus on revised definitions of MUSA features of adenomyosis, Ultrasound Obstet Gynecol 2022;60:118-131
• Puente JM et al.: Adenomyosis in women before fertility treatment, cross-sectional study, Reprod Biol Endocrinol 2016
• Vercellini P et al.: Uterine adenomyosis and in vitro fertilization outcome, meta-analysis, Hum Reprod 2014;29:964-977
• Younes G, Tulandi T: Effects of adenomyosis on in vitro fertilization treatment outcomes, meta-analysis, Fertil Steril 2017;108:483-490
• Nirgianakis K et al.: Adenomyosis, IVF outcomes, and pregnancy risks, meta-analysis, Reprod Biomed Online 2021;42:185-206
• Cozzolino M et al.: Adenomyosis and outcomes of fertility treatment, meta-analysis, Reprod Sci 2022;29:3177-3193
• Grimbizis GF et al.: Uterus-sparing operative treatment for adenomyosis, Fertil Steril 2014
• Liu L et al.: Fertility after organ-sparing treatment of adenomyosis, meta-analysis, BMC Pregnancy Childbirth 2025
• Steinmann M et al.: GnRH agonist before frozen embryo transfer in adenomyosis, meta-analysis, Reprod Biomed Online 2025;51:105075
• Galati G et al.: GnRH agonist pretreatment in adenomyosis, meta-analysis, J Assist Reprod Genet 2025
• Latif S et al.: GnRH agonist before IVF/ICSI in adenomyosis, meta-analysis, Eur J Obstet Gynecol Reprod Biol 2024
• González-Comadran M et al.: Protocols in adenomyosis and frozen embryo transfer, meta-analysis, JBRA Assist Reprod 2025
• Eslami Moayed M et al.: Frozen embryo transfer with and without GnRH agonist in adenomyosis, randomized trial, 2023
• Ansaripour S et al.: Three-month GnRH agonist course in adenomyosis, randomized trial, 2024
• Sharma S et al.: Letrozole or GnRH agonist before frozen embryo transfer in adenomyosis, randomized trial, 2025
• GOLD-FET: Study protocol on GnRH agonist and letrozole before frozen embryo transfer in adenomyosis, Trials 2026
• GOLD-FET, registry entry NCT07065539, ClinicalTrials.gov

Studies: pregnancy and breastfeeding

• Lalani S et al.: Endometriosis and adverse maternal, fetal and neonatal outcomes, meta-analysis, Hum Reprod 2018;33:1854-1865
• Leeners B et al.: The effect of pregnancy on endometriosis: facts or fiction?, Hum Reprod Update 2018;24:290-299
• Bean E et al.: Endometriomas and deep endometriosis on ultrasound during pregnancy, prospective study, 2023
• Farland LV et al.: History of breast feeding and risk of incident endometriosis, prospective cohort study, BMJ 2017