Endometriosis and adenomyosis: what really changes in an IVF journey

One in ten women lives with endometriosis, and it still takes an average of seven years for a diagnosis to be made in France. Many find out during infertility investigations. The first question is almost always the same: does this mean that IVF won’t work? The honest answer is no, but the treatment programme must be adapted.

Two distinct conditions

Endometriosis is the presence of endometrium-like tissue outside the uterus: on the ovaries (endometriomas), the peritoneum, the ligaments, and sometimes the rectum or bladder. It causes pain, inflammation and adhesions.

Adenomyosis is the presence of this tissue within the uterine muscle itself. It causes heavy periods, a rounded uterus on an ultrasound scan, and, most importantly, has a direct impact on implantation. It is frequently associated with endometriosis but can occur on its own, and it remains under-diagnosed: this is one of the reasons why a pelvic MRI scan is worth requesting following unexplained pregnancy failures.

Impact on fertility

On ovarian reserve: ovarian endometriosis, and particularly surgery to treat it, reduces the number of available follicles. An endometrioma cystectomy causes a measurable and sometimes lasting reduction in AMH levels. This is why the decision to operate prior to IVF must be carefully weighed up.

As for the outcomes of IVF itself, meta-analyses are generally reassuring: with comparable ovarian reserve, birth rates per transfer are similar to those of patients without endometriosis. The main disadvantage relates to the number of eggs retrieved, and therefore to the cumulative chances per egg retrieval.

Adenomyosis, on the other hand, clearly reduces the implantation rate and increases the risk of miscarriage. This is where the protocol changes most significantly.

Adapted protocols

The long-acting agonist protocol, or preparation using GnRH agonists for two to three months prior to transfer, is the most well-documented approach for adenomyosis. It allows the uterus to rest and improves implantation rates. It extends the timeline by several weeks, which is important when organising a trip abroad.

The ‘freeze all’ strategy — freezing all embryos and transferring them during a subsequent cycle — allows the stimulation phase, which raises oestrogen levels and may exacerbate inflammation, to be separated from the transfer itself. The procedure for a frozen embryo transfer is detailed here.

The accumulation of embryos over several egg retrieval procedures, in cases where the ovarian reserve has been reduced by illness or previous surgery.

Should surgery be carried out beforehand, or not?

This is the most difficult decision. European guidelines advise caution: surgery for an endometrioma does not improve IVF outcomes and depletes ovarian reserve. It may be considered if the cyst is large, painful, if it obstructs access to the follicles during egg retrieval, or if there is any doubt as to its nature. A second operation on the same ovary is particularly costly in terms of ovarian reserve.

On the other hand, a hydrosalpinx — a dilated fallopian tube filled with fluid — must be treated before any embryo transfer: it significantly reduces the chances of implantation, and there is a consensus on this.

What I check in a patient’s file

1. A recent pelvic MRI scan, or an ultrasound scan carried out by a practitioner trained in endometriosis. A standard ultrasound scan often fails to detect adenomyosis.
2. An AMH test and an antral follicle count dated within the last six months, particularly following surgery. The article on AMH explains how to interpret these results.
3. The surgical report if surgery has taken place: what was removed, and from which ovary.
4. An assessment of the uterine cavity, either via hysteroscopy or 3D ultrasound.

With these four elements, a doctor can propose a well-founded treatment plan. Without them, they will propose a standard protocol, and that is precisely what must be avoided in this situation.

What about egg donation?

This is considered when the ovarian reserve is severely depleted – often following several surgical procedures – and when egg retrieval no longer yields a sufficient number of eggs. As the adenomyotic uterus remains the limiting factor, endometrial preparation is then just as important as the source of the eggs. It is not a magic solution, and a reputable clinic will tell you as much.

Frequently asked questions

Source: https://fertilitegrece.com/en/blog/endometriosis-adenomyosis-ivf/ — Triada Baloukoudis, IVF patient coordination in Greece. General information, not medical or legal advice. Printed on

Triada Baloukoudis
Independent IVF patient coordinator in Thessaloniki, with 24 years of experience supporting patients travelling from abroad. More · Contact · Facebook