Endometriosis is one of the most under-recognised gynecological conditions in India. Women suffer with it for an average of 7-10 years before diagnosis — long years of being told "periods are supposed to hurt", "it's just stress", or "you'll feel better after marriage". Many only learn what they have when they try to conceive and can't.
Here's what endometriosis is, how it affects fertility, and what to do about it.
What endometriosis actually is
The lining of the uterus (the endometrium) is supposed to be inside the uterus. In endometriosis, tissue similar to that lining grows in places it shouldn't — usually on the ovaries, fallopian tubes, the outer surface of the uterus, the bowel, the bladder, or pelvic peritoneum.
This misplaced tissue still responds to monthly hormonal cycles. It thickens, bleeds, and tries to shed — but unlike normal menstrual blood, it has nowhere to go. The result: chronic inflammation, scarring, adhesions, and cysts. Over time these changes affect the entire pelvic environment.
The symptoms — including the ones that get dismissed
- Severe period pain that disrupts daily life — not just "uncomfortable" but "can't go to work" pain.
- Pelvic pain outside the period — chronic dull ache, deep pain with intercourse, pain on bowel movement.
- Heavy or prolonged periods.
- Spotting between periods.
- Bowel/bladder symptoms that worsen during periods.
- Fatigue beyond what's explained by the cycle.
- Difficulty conceiving — sometimes the first symptom a woman notices.
Period pain that requires pain medication every month is not normal. Mild discomfort is normal. Severe pain that interferes with school, work, or daily life is a clue worth investigating — at any age.
How it affects fertility
Endometriosis affects fertility through multiple mechanisms — which is why even "mild" endometriosis can have outsized effect:
- Distorted anatomy — scar tissue and adhesions can block fallopian tubes or pull ovaries out of position.
- Endometriomas (cysts on the ovary) reduce ovarian reserve and egg quality.
- Inflammatory environment — chronic pelvic inflammation creates a less hospitable environment for sperm, egg, fertilisation and embryo development.
- Altered immune response in the uterus, sometimes affecting implantation.
- Reduced ovarian reserve — sometimes from the disease itself, sometimes from prior surgeries.
About 30-50% of women with endometriosis experience some degree of subfertility. The reverse is also true: 20-30% of women with infertility turn out to have endometriosis.
How it's diagnosed
- Clinical suspicion from your symptom pattern — often the most important step.
- Pelvic examination — sometimes reveals tenderness in specific spots or palpable nodules.
- Ultrasound — can detect endometriomas (chocolate cysts) but often misses surface endometriosis.
- MRI — better for deep infiltrating disease.
- Laparoscopy (gold standard) — only way to see and treat surface endometriosis with certainty. Often done diagnostic+therapeutic in one procedure.
Treatment depends on your priority
This is where decisions get personal. The right path depends on whether your current priority is pain management, fertility, or both.
If your priority is fertility
- Mild-moderate disease + good ovarian reserve — laparoscopic surgery can improve natural conception rates. Try for 6-12 months after surgery before considering IUI/IVF.
- Endometriomas — surgical removal vs. proceeding directly to IVF is a nuanced decision. Surgery can reduce ovarian reserve; leaving the cyst alone may affect IVF response. We discuss tradeoffs case by case.
- Severe disease, distorted anatomy, or older age — IVF often the most efficient path. Bypasses many of the mechanisms by which endometriosis impairs natural conception.
If your priority is pain (and pregnancy is later)
- Hormonal suppression — combined OCPs, progestins, or GnRH analogues — pause the disease.
- NSAIDs for pain.
- Surgery to remove visible disease.
- Lifestyle adjustments — anti-inflammatory diet, regular exercise, stress management — modest but real benefit.
One important detail: hormonal suppression treats symptoms but doesn't improve fertility. If pregnancy is the goal, suppressing the disease is sometimes counterproductive.
The role of laparoscopic surgery
Minimally invasive surgery — done at most fertility-focused clinics including ours — is the most effective single intervention for many endometriosis cases. A skilled surgeon can remove visible disease, restore anatomy, free trapped ovaries, and clear adhesions. Recovery is quick (back to normal in 1-2 weeks).
But surgery has costs: it's invasive, anaesthesia is involved, repeat surgeries get progressively less useful (each one reduces ovarian reserve a little). The decision to operate vs. proceed to IVF should be made together.
A note on the journey
Endometriosis is genuinely under-treated in India — partly cultural, partly because it requires specialist input. If you've been told for years that your period pain is "normal" and now you're struggling to conceive, this might be your missing diagnosis.
Both Dr. Shankar and I do laparoscopic surgery for endometriosis as well as the fertility planning that follows. The two skill sets are complementary — and increasingly, patients are coming to us with disease that's been mismanaged elsewhere.
If anything in this article reflected your experience — pain, irregular cycles, repeated treatment failures, "unexplained" infertility — a single consultation can either rule out or confirm endometriosis as part of the picture.
