Endometriosis and Infertility: Surgery or IVF First?

By Dr Devora Lieberman

Recent media coverage, including the Four Corners program examining endometriosis care in Australia, has caused understandable concern for many women living with endometriosis and infertility.

The prolonged time to get a diagnosis of endometriosis has been widely documented and is a source of anger and frustration for many women living with pain. Until recent advances in ultrasound for deep infiltrating endometriosis, laparoscopy was the only way to make a diagnosis. Removal of endometriotic tissue at the time of surgery can help many sufferers.

If you think you may have endometriosis, or you have a diagnosis and your pain is manageable, and are trying to conceive, you may be wondering:

Is surgery necessary- or should you go straight to IVF?

When I first started my training, success rates with IVF were very low, so every woman having difficulty conceiving had a laparoscopy.  Now that IVF success rates are dramatically better, the advice is more nuanced and the answer depends on your individual situation.

This guide explains your options, the evidence, and how to choose the safest and most effective treatment.

Quick Answer: Surgery or IVF First for Endometriosis?

IVF is often the most effective fertility treatment for women with endometriosis, particularly if you are over 35, have reduced egg reserve, or have been trying to conceive for some time.

Laparoscopic surgery may help in younger women, those with pain, or when anatomy is distorted.

The right approach depends on your age, fertility potential, and treatment goals.

What Is Endometriosis and How Does It Affect Fertility?

Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus, commonly affecting the ovaries, fallopian tubes, and pelvic lining.

It can reduce fertility by:

• Blocking or damaging fallopian tubes
• Affecting egg quality
• Creating inflammation
• Causing scar tissue and adhesions

Up to 50% of women with infertility have endometriosis, making it one of the most common causes.

However, many women with endometriosis conceive successfully—with the right treatment.

Fertility Treatment Option 1: Laparoscopic Surgery for Endometriosis

Laparoscopy is keyhole surgery used to remove endometriosis tissue, cysts, and scar tissue.

Benefits of laparoscopy for fertility, surgery may: 

• Improve chances of natural pregnancy
• Restore pelvic anatomy
• Remove ovarian cysts (endometriomas)
• Reduce pain symptoms

Some women conceive naturally after surgery, especially if they are younger.

Risks of endometriosis surgery

It is important to understand the potential risks:

• Reduced egg supply (ovarian reserve)
• Surgical complications (uncommon)
• Recurrence of endometriosis
• Delays if pregnancy does not occur

These risks highlight why surgery is not always necessary.

Fertility Treatment Option 2: IVF for Endometriosis

IVF (In Vitro Fertilisation) involves fertilising eggs in a laboratory and transferring an embryo into the uterus.

IVF helps bypass many fertility problems caused by endometriosis.

Why IVF is often the most effective treatment: 

• Bypasses blocked or damaged tubes
• Avoids pelvic inflammation
• Offers higher pregnancy rates
• Does not reduce egg supply
• Provides the fastest path to pregnancy

For many women, IVF offers the highest chance of having a baby.

Evidence: IVF vs Surgery for Endometriosis Fertility

Research and international fertility guidelines show:

• IVF provides higher overall pregnancy rates than surgery alone
• Surgery can help selected younger women conceive naturally
• Surgery before IVF is not always necessary
• Repeat surgery may reduce egg supply

Importantly, treatment should always be individualised.

When Surgery May Be Recommended First

Surgery may be appropriate if:

• You have severe pelvic pain
• You have large ovarian cysts
• Your pelvic anatomy is distorted
• You are under 35
• Your egg reserve is normal
• You want to try natural conception

When IVF May Be the Better First Option

IVF is often recommended if:

• You are aged 35 or older
• Your ovarian reserve is reduced
• You have been trying to conceive for over 1–2 years
• You have had prior surgery
• You have severe endometriosis
• You want the fastest path to pregnancy

Reassurance Following Recent Media Coverage

The recent Four Corners program has highlighted important concerns and may have caused distress or uncertainty.

It is important to know:

• Surgery remains appropriate when medically indicated
• However, surgery is not always required for fertility
• IVF is often safer and more effective in many cases
• Treatment decisions should always be personalised

Seeking a second opinion is entirely appropriate if you feel unsure.

Can You Get Pregnant Naturally With Endometriosis?

Yes. Many women with endometriosis conceive naturally.

Your chances depend on:

• Age
• Severity of disease
• Egg reserve
• Other fertility factors

When natural conception does not occur, effective treatments such as IVF are available.

When Should You See a Fertility Specialist?

You should seek specialist advice if:

• You have endometriosis and have tried for 6–12 months
• You are over 35
• You have had previous endometriosis surgery
• You have ovarian cysts
• You want to understand your fertility options

Early advice improves outcomes and protects fertility.

Natural Conception Rates in Women with Endometriosis

Endometriosis can reduce fertility, but many women with the condition still conceive naturally. The likelihood depends largely on disease severity, age, ovarian reserve, and other fertility factors.

Overall Natural Conception Rates

Approximately 50–70% of women with endometriosis will conceive naturally at some point without IVF or fertility treatment. Conversely, around 30–50% may experience difficulty conceiving or require assistance.

Natural Conception Rates by Severity

Clinical Interpretation

• Mild endometriosis is associated with only a small reduction in fertility.
• Moderate endometriosis significantly reduces fertility, but natural conception remains possible.
• Severe endometriosis markedly reduces fertility, and assisted reproductive technologies such as IVF are often recommended.
• Age, ovarian reserve, and male factor fertility frequently have a greater impact on fertility than endometriosis severity alone.
• Endometriosis is a common cause of infertility
• IVF often offers the highest pregnancy rates
• Surgery may help selected women
• Repeat surgery should be avoided unless necessary
• Treatment should always be individualised

Most importantly, many women with endometriosis successfully have children.

FAQ 

Is IVF better than surgery for endometriosis infertility?

IVF is often more effective than surgery, particularly in women over 35, those with reduced ovarian reserve, or prolonged infertility.

Should endometriosis be removed before IVF?

Not always. Surgery before IVF is only recommended when there is pain, large cysts, or distorted anatomy.

Can surgery improve fertility in endometriosis?

Yes, particularly in younger women with mild disease. However, surgery may reduce egg reserve in some cases.

What is the best fertility treatment for endometriosis?

IVF provides the highest pregnancy rates overall, but treatment should be personalised.