ACOG (2026) states a clinical diagnosis of endometriosis — made through symptom assessment, physical examination, or both — is sufficient to begin empiric medical treatment. You do not need to wait for laparoscopy. Negative imaging does not rule it out.
Endometriosis and fertility
The direction of current guidance: less surgery before IVF, not more
This is the most important thing to know if surgery has been suggested to improve your IVF chances.
ESHRE (2022) makes a strong recommendation that clinicians are not recommended to routinely perform surgery prior to ART to improve live birth rate.
And specifically for ovarian endometrioma: routine surgery prior to ART to improve live birth rates is not recommended, because current evidence shows no benefit — also a strong recommendation.
A distinction that changes the conversation
ESHRE does state that surgery for endometrioma prior to ART can be considered to improve endometriosis-associated pain, or to improve accessibility of follicles at egg collection.
Same operation. Different indication. Opposite recommendation.
So the question to ask before agreeing to surgery is: which of these are we treating? If the answer is "to improve IVF success", the evidence does not support it.
Why this matters beyond the statistics
Cystectomy removes functional ovarian tissue adjacent to the cyst wall. That is the principal harm of operating without a clear indication — particularly with bilateral endometriomas or already-reduced ovarian reserve. AMH commonly falls after the procedure.
Where surgery is indicated
ESHRE recommends cystectomy over drainage and coagulation, as cystectomy reduces recurrence. Cystectomy and CO2 laser vaporisation can both be considered, with similar recurrence beyond the first year.
Deep endometriosis
ESHRE makes a strong recommendation that the decision to surgically excise deep endometriosis lesions prior to ART should be individualised — rather than recommending for or against generally.
That framing is deliberate. Deep endometriosis surgery carries risks that endometrioma cystectomy does not — bowel resection, ureteric injury, long-term bladder dysfunction — and outcomes depend heavily on surgeon and centre volume. Referral to a centre with dedicated expertise is appropriate.
A protocol that is no longer recommended
Extended GnRH agonist administration before ART — the "ultralong" protocol — is not recommended, a strong recommendation, because benefit is uncertain. This was explicitly withdrawn from the previous version of the guideline.
If your clinic proposes months of downregulation before IVF because of endometriosis, that is working from superseded guidance.
The Endometriosis Fertility Index
Added in this guideline version as a step to support decision-making on the most appropriate route to pregnancy after surgery. It is under-used, and worth asking about if you have had surgery and are deciding what next.
Sources
- ESHRE Guideline: Endometriosis (2022)
Frequently Asked Questions
Can I get pregnant naturally with endometriosis?▾
Many women with endometriosis conceive naturally, particularly those with Stage I–II disease who are younger and have no other fertility issues. For Stage I–II, laparoscopic excision of visible disease modestly improves natural conception rates. For Stage III–IV with endometriomas or blocked tubes, IVF is typically recommended. Time is a significant factor — seek specialist evaluation early.
Does endometrioma surgery reduce fertility?▾
Yes — endometrioma surgery carries a 30–40% risk of reducing ovarian reserve, as healthy ovarian tissue is inevitably removed with the cyst wall. The 2026 ACOG guideline advises against routine endometrioma surgery before IVF for cysts under 40mm, particularly in women with already-low AMH. For cysts ≥40mm, surgery is generally recommended before IVF.
Is IVF more successful with or without endometriosis?▾
Women with endometriosis generally have slightly lower IVF success rates than age-matched women without endometriosis, primarily due to impaired egg quality. However, for many women — particularly those under 38 — IVF outcomes are still very good. Frozen embryo transfer (FET) may improve outcomes by allowing a natural cycle without the inflammatory effects of ovarian stimulation.
How do I know if I have deep infiltrating endometriosis (DIE)?▾
DIE is suggested by: severe dysmenorrhoea not responding to NSAIDs, deep dyspareunia, cyclical dyschezia (painful bowel movements), cyclical rectal bleeding, or bladder symptoms. Transvaginal ultrasound can detect some DIE features but pelvic MRI with a DIE protocol is the preferred imaging modality per ACOG 2026 for complete DIE mapping.
Should I freeze my eggs if I have endometriosis?▾
Egg or embryo freezing should be considered for women with endometriosis, particularly if: ovarian reserve is already low, bilateral endometriomas are present, or surgery is planned that may further reduce reserve. ACOG 2026 recommends discussing fertility preservation with all women of reproductive age diagnosed with endometriosis, before any surgical intervention.