Endometriosis and Fertility: When to Test and What Your Options Are
Last updated: 27 Aug 2026
Endometriosis is one of the most common gynaecological conditions in the world. It affects an estimated 6 to 10 per cent of women of reproductive age. Between 25 and 50 per cent of women investigated for infertility are found to have it. And 30 to 50 per cent of women with endometriosis experience difficulty conceiving.
Yet the average time from first symptom to diagnosis is 7 to 10 years.
That diagnostic delay is not because endometriosis is rare. It is because the symptoms are normalised. Severe period pain is dismissed as "just bad cramps." Pain during sex is endured silently. Chronic pelvic discomfort is attributed to stress or digestive issues. And by the time a diagnosis is made, the condition may have progressed to a stage where fertility has already been affected.
Understanding what endometriosis does to fertility, recognising when your symptoms warrant investigation, and knowing what your GP can do as a first step, can shorten that 7 to 10 year delay to months.
Comprehensive Women's Health Assessment
Patient-first, Holistic, Dedicated Healthcare
What Endometriosis Is and How It Affects Fertility
Endometriosis occurs when tissue similar to the lining of the uterus (endometrium) grows outside the uterus. These implants are most commonly found on the ovaries, fallopian tubes, the tissue lining the pelvis, and the ligaments supporting the uterus. Less commonly, they can appear on the bowel, bladder, or other pelvic structures.
This ectopic tissue responds to the same hormonal signals as the uterine lining. Each month, it thickens, breaks down, and bleeds. But unlike the uterine lining, which exits through the vagina, this blood has nowhere to go. The result is chronic inflammation, scar tissue formation (adhesions), and, on the ovaries, blood-filled cysts called endometriomas.
Endometriosis impairs fertility through several mechanisms simultaneously;
- Inflammation in the pelvic cavity creates a hostile environment for eggs, sperm, and embryos, reducing the probability of fertilisation and implantation.
- Adhesions can distort the anatomy of the fallopian tubes and ovaries, physically blocking the egg's passage from ovary to tube or preventing the tube from capturing the egg after ovulation.
- Endometriomas on the ovaries can damage surrounding ovarian tissue, reducing egg quality and ovarian reserve over time.
- Chronic inflammatory environment may impair the receptivity of the uterine lining itself, even when the endometrium appears structurally normal.
The severity of fertility impact does not always correlate with the severity of the disease. Some women with minimal endometriosis struggle to conceive, while others with more extensive disease conceive without difficulty. This unpredictability is one reason diagnosis and individual assessment matter more than general statistics.
The Symptoms That Should Prompt Investigation
Endometriosis does not always produce dramatic symptoms. Roughly 20 to 25 per cent of cases are asymptomatic, discovered only when fertility investigations are undertaken. But when symptoms are present, they follow recognisable patterns that should raise suspicion.
- Severe period pain (dysmenorrhoea) that is progressive - Some degree of cramping during menstruation is normal. But pain that worsens over months or years, begins days before your period and continues after bleeding stops, requires strong painkillers, or causes you to miss work or cancel plans is not normal. Progressive dysmenorrhoea, pain that was manageable at 22 but debilitating at 30, is one of the strongest clinical indicators.
- Pain during or after sex (dyspareunia) - Deep pelvic pain during intercourse, particularly in certain positions, or aching that persists for hours or days after sex, is commonly associated with endometriosis, particularly when implants are located behind the uterus or on the uterosacral ligaments.
- Chronic pelvic pain - Pain that persists throughout the cycle, not just during your period. This may be constant or fluctuating, dull or sharp, and often worsens in the days leading up to menstruation.
- Cyclical bowel or bladder symptoms - Painful bowel movements during your period, rectal bleeding timed with menstruation, urgency, bloating, or diarrhoea that worsens around your period suggest endometriosis affecting the bowel or bladder. These symptoms are frequently misdiagnosed as irritable bowel syndrome.
- Difficulty conceiving - For some women, infertility is the first and only symptom. If you have been trying to conceive for 12 months (or 6 months if over 35) without success, endometriosis should be considered as part of the fertility evaluation, even if you do not have pain symptoms.
If you recognise several of these patterns, particularly the combination of progressive period pain and difficulty conceiving, do not wait years for a diagnosis. Bring them to your GP.
What Your GP Can Do First
Many women assume endometriosis requires a specialist from the outset. In reality, your GP is the appropriate first point of contact and can begin the assessment that either confirms suspicion or directs the investigation elsewhere.
A thorough history. This is the single most important diagnostic tool for endometriosis. Your GP should ask about the nature, timing, and progression of your pain, its relationship to your menstrual cycle, pain during sex, bowel or bladder symptoms that fluctuate with your period, family history of endometriosis, and any difficulty conceiving. A careful history alone often provides enough clinical suspicion to warrant further investigation.
Relevant blood tests. While no blood test diagnoses endometriosis definitively, several tests are valuable in the assessment.
- A female hormonal test (FSH, LH, estradiol, progesterone, testosterone, prolactin) assesses your ovulatory function and hormonal environment. Mid-luteal progesterone confirms whether you are ovulating.
- AMH assesses your ovarian reserve, which may be reduced if endometriomas have damaged ovarian tissue.
- Thyroid function test rules out thyroid causes of cycle disruption.
- Ferritin test and a full blood count assess whether chronic heavy periods have depleted your iron.
- CA-125 may be elevated in endometriosis, though it is not specific enough to be diagnostic on its own.
Referral for imaging. Your GP can refer you for a transvaginal ultrasound, which can identify endometriomas (ovarian cysts) and deep infiltrating endometriosis. While ultrasound cannot detect all endometriosis (superficial implants are not visible), it can identify significant disease that warrants specialist referral.
Referral to a gynaecologist. If clinical suspicion is high, your GP can refer you to a gynaecologist with expertise in endometriosis for further assessment, which may include MRI or diagnostic laparoscopy (the gold standard for definitive diagnosis).
The value of starting with your GP is speed and thoroughness. Rather than waiting months for a specialist appointment without any preliminary workup, your GP can begin the hormonal, metabolic, and fertility assessment in parallel with the referral. By the time you see the specialist, the relevant blood work and initial imaging are already done.
Endometriosis Does Not Mean You Cannot Conceive
The statistics can sound alarming: 30 to 50 per cent of women with endometriosis experience infertility. But that means 50 to 70 per cent of women with endometriosis conceive, many of them naturally. The condition makes conception more difficult, but it does not make it impossible.
Several factors influence the likelihood of natural conception with endometriosis. The stage and location of the disease matter.
- Minimal or mild endometriosis has less impact on fertility than moderate or severe disease with extensive adhesions or large endometriomas.
- Your age matters, because the same age-related egg quality decline that affects all women applies regardless of endometriosis status.
- Your ovarian reserve matters. If endometriomas have not significantly damaged the ovaries, reserve may be well preserved.
- And your partner's fertility matters. Male factor contributes to 40 to 50 per cent of infertility cases and should always be assessed.
Treatment Options for Fertility
Treatment depends on the severity of the disease, your age, your ovarian reserve, and how long you have been trying to conceive.
- Expectant management - For women with minimal or mild endometriosis who are young (under 35) and have been trying for less than 12 months, continued natural attempts may be reasonable, particularly if the fallopian tubes are open and the partner's semen analysis is normal. Monthly conception rates in mild endometriosis, while lower than in women without the condition, are still meaningful.
- Surgical treatment - Laparoscopic excision or ablation of endometriosis implants and removal of endometriomas can improve natural conception rates, particularly in moderate disease. Surgery may also restore tubal anatomy if adhesions have caused distortion. However, surgery carries risks including reduced ovarian reserve (if ovarian tissue is removed alongside cysts), and the decision should be made carefully with a specialist.
- Ovulation induction with IUI - For mild endometriosis, ovarian stimulation with intrauterine insemination (IUI) may improve monthly conception rates by increasing the number of eggs available and placing sperm closer to the site of fertilisation.
- IVF - For moderate to severe endometriosis, particularly if tubal damage is present or other treatments have not succeeded, IVF bypasses many of the mechanisms through which endometriosis impairs natural conception. IVF success rates in women with endometriosis are generally comparable to those in women with other causes of infertility, though response to ovarian stimulation may be reduced if ovarian reserve is affected.
Your GP can initiate the assessment that determines which of these pathways is most appropriate. A female fertility test provides the hormonal and ovarian reserve data. A clinical history identifies the symptom pattern. And timely referral ensures you reach the right specialist without unnecessary delay.
Do Not Wait 7 Years
The most damaging consequence of endometriosis is not the disease itself. It is the delay. Seven to ten years of undiagnosed endometriosis is seven to ten years during which the condition can progress, adhesions can form, ovarian reserve can diminish, and the fertility window can narrow.
If you have progressive period pain, pain during sex, chronic pelvic discomfort, cyclical bowel or bladder symptoms, or unexplained difficulty conceiving, bring these to your GP. Do not dismiss them. Do not normalise them. And do not wait for them to become severe before seeking help.
At our women's health clinic, our Doctors take pelvic pain and fertility concerns seriously. A comprehensive assessment including clinical history, hormonal testing, fertility markers, and appropriate referral can begin at a single visit to our GP clinic. A health screening adds the metabolic context that ensures nothing is missed.
The earlier endometriosis is recognised, the more options you have. Your pain is not normal. Your difficulty conceiving deserves investigation. And your GP is the right place to start.
Comprehensive Women's Health Assessment
Patient-first, Holistic, Dedicated Healthcare
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