AGES / GP / Specialist Tutorial

Fertility Preservation in Endometriosis

Evidence-based guidance for optimal patient outcomes

Educational tool — does not replace clinical judgment

The Clinical Challenge with Fertility Preservation in Endometriosis

Endometriosis affects 10% of reproductive-aged women and frequently requires surgical management. However, surgical treatment carries significant risks to ovarian reserve and future fertility.

Up to 13% of women undergoing endometriosis surgery may develop premature ovarian insufficiency (POI)

Despite this substantial risk, there remains conflicting evidence and a lack of clear international guidelines on when to counsel patients about fertility preservation.

This tutorial synthesizes leading research to provide practical, evidence-based guidance for identifying patients who may benefit from fertility preservation consultation.

KEY EVIDENCE BASE

  1. La Marca A, et al. How Much Does AMH Really Vary in Normal Women? Int J Endocrinol. 2013
  2. Somigliana E, et al. Risks of conservative management in women with ovarian endometriomas undergoing IVF. Hum Reprod Update. 2015
  3. As-Sanie S, Mackenzie SC, Morrison L, et al. Endometriosis: A Review. JAMA. 2025;334(1):64-78. doi:10.1001/jama.2025.2975
  4. Casalechi M, Di Stefano G, Fornelli G, Somigliana E, Viganò P. Impact of endometriosis on the ovarian follicles. Best Pract Res Clin Obstet Gynaecol. 2023. doi:10.1016/j.bpobgyn.2023.102430
Introduction

Clinical Scenarios for Fertility Preservation Consideration

A growing body of evidence suggests potential benefits of fertility preservation in the following scenarios. Surgery for endometriosis has been associated with decreased ovarian reserve, particularly in certain patient populations.

Age over 35
Bilateral
endometriomas
Multiple
surgeries
Reduced ovarian
reserve
Endometrioma +
reduced reserve
Previous
unilateral surgery
Recurrent
endometrioma
Severe
endometriosis
Endometrioma
> 4cm
Unlikely natural
conception
Severe on
surgery
Low EFI
score
Stage
III-IV

Key Principle

Fertility preservation counseling should be discussed before ovarian surgery Research indicates that each surgical procedure is associated with approximately 40% reduction in ovarian reserve markers. Early referral allows optimal timing, comprehensive counseling, and preserves maximum fertility potential. However, individual patient circumstances vary, and fertility preservation may not be appropriate or desired by all patients.

EVIDENCE BASE

Clinical scenarios listed in order of prevalence across multiple studies. Full reference list below supports the evidence for fertility preservation consideration in these patient populations.

  1. Somigliana E, Benaglia L, Paffoni A, Busnelli A, Viganò P, Vercellini P. Risks of conservative management in women with ovarian endometriomas undergoing IVF. Hum Reprod Update. 2015;21:486–499.
  2. Carrillo L, Seidman DS, Cittadini E, Meirow D. The role of fertility preservation in patients with endometriosis. J Assist Reprod Genet. 2016;33:317–323.
  3. Llarena NC, Falcone T, Flyckt RL. Fertility preservation in women with endometriosis. Clin Med Insights Reprod Health. 2019;13:1179558119873386.
  4. Pluchino N, Roman H. Oocyte vitrification offers more space for a tailored surgical management of endometriosis. Reprod Biomed Online. 2020;41:753–755.
  5. Mathieu d'Argent E, Ferrier C, Zacharopoulou C, et al. Outcomes of fertility preservation in women with endometriosis. J Ovarian Res. 2020;13:18.
  6. Kim SJ, Kim SK, Lee JR, Suh CS, Kim SH. Oocyte cryopreservation for fertility preservation in women with ovarian endometriosis. Reprod Biomed Online. 2020;40:827–834.
  7. Cobo A, Giles J, Paolelli S, Pellicer A, Remohí J, García-Velasco JA. Oocyte vitrification for fertility preservation in women with endometriosis: an observational study. Fertil Steril. 2020;113:836–844.
  8. Santulli P, Bourdon M, Koutchinsky S, et al. Fertility preservation for patients affected by endometriosis should ideally be carried out before surgery. Reprod Biomed Online. 2021;43:853–863.
  9. Elizur SE, Aizer A, Yonish M, et al. Fertility preservation for women with ovarian endometriosis: results from a retrospective cohort study. Reprod Biomed Online. 2023;46:332–337.
  10. Carneiro MM, Filho JSLdC, Petta CA, et al. Fertility preservation in women with endometriosis. Rev Bras Ginecol Obstet. 2021;43:796–802.
  11. Fouks Y, Goaz S, Ryley D, et al. Fertility preservation in endometriosis: does patient symptomatology affect the extent of the ovarian response? Reprod Sci. 2023;30:2439–2448.
  12. Goyri E, Kohls G, Garcia-Velasco J. IVF stimulation protocols and outcomes in women with endometriosis. Best Pract Res Clin Obstet Gynaecol. 2024;92:102429.
  13. Mifsud JM, Pellegrini L, Cozzolino M. Oocyte cryopreservation in women with ovarian endometriosis. J Clin Med. 2023;12:6767.
  14. Sänger N, Menabrito M, Di Spiezo Sardo A, Estadella J, Verguts J. Fertility preservation counselling for women with endometriosis: a European online survey. Arch Gynecol Obstet. 2023;307:73–85.
  15. Calagna G, Della Corte L, Giampaolino P, Maranto M, Perino A. Endometriosis and strategies of fertility preservation: a systematic review of the literature. Eur J Obstet Gynecol Reprod Biol. 2020;254:218–225.
  16. Benaglia L, Somigliana E, Vighi V, Ragni G, Vercellini P, Fedele L. Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod. 2010;25:678–682.
  17. Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012;97:3146–3154.
  18. Muzii L, Achilli C, Lecce F, et al. Second surgery for recurrent endometriomas is more harmful to healthy ovarian tissue and ovarian reserve than first surgery. Fertil Steril. 2015;103:738–743.
  19. Goodman LR, Goldberg JM, Flyckt RL, et al. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol. 2016;215:589.e1–589.e6.
  20. Kasapoglu I, Ata B, Uyaniklar O, et al. Endometrioma-related reduction in ovarian reserve (ERROR): a prospective longitudinal study. Fertil Steril. 2018;110:122–127.

AMH Levels by Age

Reference ranges for ovarian reserve assessment

AMH Normogram

Oocyte Cryopreservation (Egg Freezing)

Best for: Women not in a relationship or preserving before surgery

Process: Ovarian stimulation (10-14 days) → Egg retrieval → Vitrification

Note: May require multiple cycles for optimal numbers, especially with diminished reserve

Public Funding: Available through Medicare for documented POI — criteria may change over time
📊 Calculate Your Egg Freezing Success Rate

Key Takeaways

Medicare Coverage Note

Fertility preservation may be covered by Medicare in the context of endometriosis or benign gynecological disease when there is documented evidence of POI (lower than 10th percentile for AMH).

For Fertility Preservation Referrals

Clinical consultation available for fertility preservation counseling in endometriosis patients

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Dr Yuval Fouks Fertility Specialist
Melbourne IVF
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