Endometriosis and IVF: should I have surgery first?

Endometriosis is the presence of tissue similar to the lining of the womb outside it, most often in the pelvis and on the ovary. It can lower fertility in several ways: through inflammation that harms the environment where egg and sperm meet, through adhesions that distort the anatomy of the tubes and ovaries, and, when it affects the ovary as an endometrioma, by affecting the reserve. Importantly, the degree of pain does not indicate the degree of the fertility problem; some women with severe pain conceive easily, while others with no symptoms struggle.

Endometriosis is therefore always assessed in context: how long you have been trying, your age, ovarian reserve, the state of the tubes and the male factor. The diagnosis alone does not dictate treatment; it is the point at which a considered plan begins.

When endometriosis forms a cyst on the ovary, called an endometrioma, removing it intuitively looks like the right solution. But removal also takes away some healthy ovarian tissue along with the cyst wall, and this lowers the ovarian reserve as measured by AMH and the antral follicle count. In a woman whose reserve is already limited, or when there are endometriomas on both ovaries, this loss can be considerable and irreversible.

For this reason international guidelines do not recommend removing an endometrioma simply to 'prepare' the ovary before IVF when the cyst is small, causes no pain and does not block egg retrieval. In many cases IVF is done with the endometrioma in place, results are comparable, and the reserve is preserved.

Surgery remains the right choice in a few clear situations: severe pain not controlled by medical treatment, a large mass or one with features that need clarifying to rule out something else, an endometrioma blocking access to follicles during egg retrieval, or an accompanying hydrosalpinx that lowers IVF success. In these cases the benefit outweighs the possible loss of reserve.

When surgery is decided, it should be done by a team experienced in endometriosis surgery, because technique directly affects how much healthy tissue is preserved. For young women with a small, painless endometrioma, the wiser choice is often to preserve fertility — for example to discuss egg freezing — before any intervention is considered.

There is no single rule that fits everyone. The decision weighs three things: the wish and time for pregnancy, the level of pain, and the ovarian reserve. For a 39-year-old with a low reserve and a small painless endometrioma, time is the main factor and going straight to IVF is often the safer route. For a younger woman with severe pain affecting daily life, treating the pain may come first.

What helps most is a calm conversation in which the benefits and costs of each route are explained, without pressure and without promises. The aim is neither to operate at all costs nor to avoid surgery at all costs, but to choose what best serves your situation.