By Karina Hoan, M.D., gynecology and minimally invasive surgery

As a minimally invasive gynecologic surgeon specializing in endometriosis and infertility, I frequently meet patients who are feeling overwhelmed. Endometriosis is a complex condition, and when it intersects with family planning, it can be incredibly stressful. The good news is that with a nuanced, evidence-based approach, we have many tools to help manage symptoms and optimize your chances of a healthy pregnancy.

Q: How exactly does endometriosis affect fertility?

Endometriosis occurs when tissue similar to the lining of the uterus grows outside of the uterus. While retrograde menstruation (backward flow of menstrual blood) happens in many people, those with endometriosis experience a unique, persistent inflammatory response to this tissue in the pelvis.

This chronic inflammation creates a “hostile” pelvic environment. It increases the release of chemical messengers (like prostaglandins and cytokines) that can disrupt ovulation, impair sperm function and have a negative impact on egg quality. Furthermore, advanced endometriosis can cause anatomical distortions. Scar tissue (adhesions) can block the fallopian tubes or alter the normal relationship between the ovaries and the tubes, making it physically difficult for an egg and sperm to meet.

Q: How is endometriosis diagnosed when trying to conceive?

We typically start with a detailed clinical history, thorough physical exam, and high-quality pelvic ultrasound. While a standard ultrasound cannot detect superficial endometriosis, specialized imaging can often identify advanced disease, such as deep infiltrating endometriosis or endometriomas (endometriosis cysts on the ovaries).

Historically, diagnostic laparoscopy was the standard first step to confirm the disease. Today, however, we are much more strategic. If you are trying to conceive, we don’t always rush to surgery just for a diagnosis. Instead, we look at the whole picture — your pain levels, your age and ovarian reserve, and your fertility goals — to decide if surgery is the right next step or if we should move directly to fertility treatments.

Q: If endometriosis is affecting my fertility, is surgery the best treatment?

The answer is highly individualized. Surgery is not a one-size-fits-all solution for infertility, and current medical guidelines emphasize a careful, tailored approach.

For patients with mild (Stage I/II) endometriosis who are trying to conceive naturally, minimally invasive excision surgery can reduce inflammation and modestly improve natural pregnancy rates. However, if a patient is already planning to undergo in vitro fertilization (IVF), routine surgery prior to IVF is not always recommended, as it may not significantly increase the chance of a successful pregnancy and can delay other treatment options.

For advanced (Stage III/IV) endometriosis, surgery can be highly beneficial for restoring normal pelvic anatomy and relieving severe pain. However, as a surgeon, my top priority during these procedures is ovarian preservation. Removing endometriomas (ovarian cysts) requires immense precision, as aggressive surgery can inadvertently damage healthy ovarian tissue and lower your ovarian reserve (egg count). We must carefully balance the benefits of removing the disease with the need to protect your future fertility.

Q: How does age factor into fertility and endometriosis?

Age is a critical variable. A woman’s ovarian reserve and egg quality naturally begin to decline more rapidly after age 35. Because endometriosis can also have a negative impact on egg quality, the combination of advancing age and endometriosis requires a proactive approach.

While older data suggested that endometriosis drastically increased miscarriage rates, recent evidence shows that when patients with endometriosis conceive via IVF, their miscarriage rates are comparable to those without the condition. The primary hurdle is often achieving that initial high-quality embryo implantation.

Q: Does age change your treatment recommendations?

Absolutely. Age heavily influences our timeline. If you are 28, have suspected endometriosis and are just starting to try to conceive, we might consider surgical excision to optimize your pelvis for natural conception.

Conversely, if you are 37 and have been trying to conceive for over a year, time is of the essence. In this scenario, I am more likely to collaborate closely with a reproductive endocrinologist (fertility specialist). We may recommend proceeding directly to IVF to retrieve and bank healthy embryos before considering any extensive pelvic surgery that could affect your egg count.

Q: Can diet and lifestyle changes improve fertility for endometriosis patients?

I strongly believe in a holistic, integrative approach to care. Alongside medical and surgical treatments, lifestyle modifications can help manage pain and support overall well-being. Working with our pelvic floor physical therapists can be incredibly beneficial for pelvic function and pain management.

Regarding diet, you may have read that you must strictly eliminate gluten or dairy. It is important to know that current scientific evidence does not support a universal “endometriosis diet.” While some patients do find that an anti-inflammatory diet (which may include reducing gluten or dairy) helps alleviate gastrointestinal bloating and pelvic pain, there is no strong data proving these restrictive diets directly improve fertility. I encourage patients to focus on a balanced, nutrient-dense diet that makes their unique body feel good, rather than adopting overly stressful dietary restrictions.

How The Portland Clinic Can Help

Navigating infertility and endometriosis requires a compassionate team that understands the delicate balance between treating the disease and preserving your reproductive potential. If you are struggling with pelvic pain or infertility, the gynecology and minimally invasive surgery team at The Portland Clinic is here to partner with you.

Dr. Karina Hoan practices at The Portland Clinic’s Alberty Surgical Center, Northeast, and Beaverton locations. She specializes in advanced minimally invasive excision surgery for endometriosis, chronic pelvic pain and fertility preservation.