Endometriosis affects an estimated 10% of women of reproductive age, and for those who are trying to conceive after 35, understanding how the condition may interact with fertility—and what options exist—is an important part of navigating the path forward. While endometriosis is associated with reduced fertility in some cases, many women with the condition do conceive naturally, and a range of medical and assisted reproductive options is available for those who need additional support.
Endometriosis is a condition in which tissue similar to the uterine lining grows outside the uterus—commonly on the ovaries, fallopian tubes, and pelvic peritoneum. According to the American College of Obstetricians and Gynecologists (ACOG), endometriosis can cause pelvic pain, painful periods, pain with intercourse, and in some cases, fertility difficulties—though the degree of impact varies considerably between individuals.
How Endometriosis May Affect Fertility
The relationship between endometriosis and fertility is complex and not fully understood. Several mechanisms are thought to contribute, depending on the location and severity of endometrial implants.
Anatomical Factors
Severe endometriosis (Stage III or IV) can cause adhesions—bands of scar tissue—that distort pelvic anatomy, affect tubal function, or damage ovarian tissue (particularly in the case of endometriomas, or ovarian cysts filled with old blood). These structural changes can directly impair egg release, fertilisation, or embryo transport. Women with endometriomas may have reduced ovarian reserve, which becomes particularly relevant after 35 when reserve is already declining.
Inflammatory Environment
Even mild or moderate endometriosis (Stages I–II) may affect fertility through an altered pelvic inflammatory environment. Research has found elevated levels of certain inflammatory mediators in the peritoneal fluid of women with endometriosis, which may impair sperm function, egg quality, or early embryo development. However, many women with mild endometriosis conceive naturally without intervention, so the clinical significance varies considerably between individuals.
Endometriosis After 35: Timing Considerations
For women with known endometriosis who are approaching or are over 35, the intersection of endometriosis and age-related fertility decline adds a time-sensitive dimension to fertility planning. Because ovarian reserve may be reduced more quickly in women with significant endometriosis—particularly those with endometriomas—earlier consultation with a reproductive specialist is generally advisable rather than waiting the standard twelve months before seeking help.
A reproductive endocrinologist can assess ovarian reserve (through AMH testing and antral follicle count), evaluate tubal anatomy, and review whether medical or surgical treatment before attempting conception might be appropriate for your specific stage and presentation of endometriosis. Our overview of fertility evaluations after 35 outlines the types of tests typically involved in this assessment.
Treatment Options and Fertility Implications
Surgical Considerations
Surgery to remove endometrial implants or endometriomas may improve natural conception rates in some cases, particularly for Stage III–IV disease. However, surgery on ovarian endometriomas carries a risk of reducing ovarian reserve, which is a significant consideration for women over 35 who already have limited reserve. The decision about whether and when to pursue surgery should involve detailed discussion with both a gynaecologist experienced in endometriosis and a reproductive specialist.
Assisted Reproduction
IVF is a common pathway for women with endometriosis who have not conceived naturally after an appropriate period of trying, or who have significant tubal or ovarian involvement. Research suggests that IVF success rates for women with endometriosis may be somewhat lower than for women without the condition, though outcomes vary considerably by stage of disease, age, and ovarian reserve. Discussing realistic expectations with a fertility specialist is an important part of the decision-making process. For a broader overview of IVF after 35, see our article on IVF after 35: what to expect.
Frequently Asked Questions
Can I conceive naturally with endometriosis after 35?
Many women with endometriosis—including those over 35—conceive naturally. The likelihood depends on the stage and location of endometriosis, ovarian reserve, and other individual factors. A reproductive specialist can provide a more personalised assessment of your situation and advise on whether a period of natural trying is appropriate or whether earlier intervention may be beneficial.
Does endometriosis get worse over time?
The progression of endometriosis is highly variable—it does not necessarily worsen over time in all women, and hormonal treatments can suppress its activity. After menopause, when estrogen levels decline significantly, endometriosis typically becomes less active. However, because endometriosis is estrogen-dependent, it generally remains a consideration throughout the reproductive years.
Should I freeze my eggs if I have endometriosis?
Egg freezing may be considered by some women with endometriosis—particularly those with endometriomas—as a way to preserve fertility before potential further ovarian reserve decline. Whether this is appropriate depends on current ovarian reserve, age, relationship status, and personal reproductive goals. A reproductive endocrinologist can help evaluate whether fertility preservation is worth considering in your individual situation.
How is endometriosis diagnosed?
Definitive diagnosis of endometriosis traditionally requires laparoscopy—a minimally invasive surgical procedure. However, clinical diagnosis based on symptoms, pelvic examination, and imaging (particularly for endometriomas) is increasingly used to guide treatment without requiring surgery in all cases. If endometriosis is suspected, a gynaecologist experienced in the condition can advise on the most appropriate diagnostic approach for your circumstances.
Key Takeaways
- Endometriosis affects approximately 10% of women of reproductive age and is associated with fertility difficulties in some—but not all—cases.
- The impact on fertility depends on endometriosis stage, location, and individual ovarian reserve; many women with the condition conceive naturally.
- Women over 35 with known endometriosis are generally advised to seek reproductive specialist consultation earlier rather than waiting the standard twelve months.
- Surgical treatment decisions require careful consideration of the risk to ovarian reserve, particularly in women over 35.
- IVF is a well-established option for women with endometriosis who need additional fertility support; outcomes vary by disease stage and ovarian reserve.
Medical Disclaimer
This content is for informational purposes only and does not constitute medical advice. Individual health situations vary significantly. Always consult a qualified healthcare provider before making decisions related to your health, fertility, or pregnancy.
About the Author
Emily Carter is a women’s health writer focused on fertility, pregnancy after 35, and sleep changes in midlife. She writes research-informed, non-alarmist content to help women navigate reproductive and hormonal transitions with clarity and confidence.