Dreaming of motherhood and still TTC after 12 months? Despite everyone’s advice, are you anxious? After a visit to your primary care provider, you may be given a diagnosis of infertility. At this point your future family, and future health, might depend on knowing endometriosis symptoms and being aware of their link to infertility. Mounting research links endometriosis associated infertility rates between 20 to 68% [1, 3] with prevalence of endometriosis in 44% of cases of unexplained infertility [2]. The researchers note:

“The high prevalence of endometriosis in this population is important for decision-making in patients who also suffer from pain symptoms suggestive of endometriosis.”[2] 

In fact the conclusions of a large 2020 study,  “A two-third majority of infertile women exhibit endometriosis” included 300 consecutive cases evaluated by laparoscopy to record the prevalence of endometriosis in infertile women in couples with non-male factor infertility. They concluded: 

“The prevalence of endometriosis in infertile women was higher than expected. The indication for operative infertility diagnostics by minimal invasive techniques should be made much more generous as well as the complete clarification of the causes of female infertility.”[3] 

It’s why TIER-1 testing for endometriosis, that either confirms or rules outs the disease, is so important. Having a diagnosis may change your treatment, as new research becomes available on the benefits of conservative (therapeutic medications) and aggressive treatment options (surgical excision of disease) both before IVF, and as an option after failed IVF.  

-endometriosis was largely unknown 15 years ago, even for gynecologists. 

-endometriosis is very prevalent with ~10%+ of women thought to have endometriosis[8] 

– some women with minimal endometriosis feel severe pain, while others with extensive endometriosis might have minimal discomfort [10] 

– Between 70 – 85% of endometriosis sufferers have stage I or stage II peritoneal disease type known as “superficial endometriosis”, which generally can’t be seen with current imaging technologies like TVUS (transvaginal ultrasound) or MRI [9] 

-That is why the gold standard for diagnosis is a laparoscopic surgery, both invasive and expensive as a diagnostic tool, but able to see the disease directly 

-endometriosis can, but does not always, contribute to infertility 

-however, studies have found that a two-thirds majority of women with infertility accessing surgery have endometriosis [3] 

– ENDOSURE, a Tier 1 diagnostic test for endometriosis, with a 99% accuracy, detects endometriosis in 30-minutes at any disease stage, and is now available in Canadian gynecology clinics in Alberta and Ontario in 2025.[5] 

Natalie shared her endometriosis diagnosis experience with us: “I worked with a gynecologist for four years, and all they were able to come up with was “unexplained infertility”. It led me to ask what was going on with my body. ENDOSURE was able to diagnose that I had endometriosis which was just a miracle for me to finally get answers as to why we couldn’t get pregnant.” 

Couples without endometriosis have a 15-20% chance of conception each month (aka fecundity rate). This rate drops significantly to 2-10% for those with endometriosis [7]. A recent published literature from January 1974 to 2024 shows that while 10 to 15% of women have endometriosis, between 20-68% of women with endometriosis face fertility challenges [1]. There is a very real connection. 

Endometriosis affects your reproductive system in several ways and can contribute to infertility. The condition triggers inflammation and creates adhesions that can change pelvic anatomy, alter peritoneal environment, hormonal function and, cause ovulation disorders, amongst other confounders to fertiltiy [6,7]. The mechanism involved: 

• Inflammation causesscarring  →blocked fallopian tube prevents the sperm and egg from ever meeting [6]. 
• Inflammation causes adhesions → pelvic adhesions can distort pelvic an atomy, impairing egg transport [7]. 

• Creates hostile peritoneal environment → affects egg development and embryo implantation [6]

• Endometriomas (endometrial cysts) in yourovaries  →might reduce the number of healthy eggs available (ovarian reserve) [6].

• Ovarian function → reducingegg quality and quantityand ovulatory disorders [7] 

The ENDOSURE test, which looks for the GIMA biomarker (Gastrointestinal Myoelectrical Activity) for endometriosis, has emerged as a breakthrough tool for non-invasive, rapid and accurate endometriosis diagnosis. This innovative approach takes less than an hour and uses electroviscerography (EVG) to record specific GIMA biomarkers through three abdominal pads [5]. 

Specialized software detects the GIMA Biomarker of endometriosis, giving a near instant result. Your healthcare provider interprets ENDOSURE test results, in conjunction with your clinical symptoms and medical history, providing a diagnosis and care plan. While laparoscopy still remains the traditional gold standard for diagnosis the ENDOSURE test is a valuable clinical tool allowing for rapid, non-invasive diagnostic results that guide treatment decisions faster, playing a vital role in how fertility concerns are approached.  

Many women first encounter the symptoms of endometriosis in their teenage years with period pain that feels far worse than normal period cramps. Due to lack of awareness, they may have been told by parents, peers, or healthcare providers that these monthly episodes of debilitating pain were a normal part of womanhood. Now we know better. Debilitating period pain that isn’t controlled by over-the-counter painkillers (OTC NSAIDS) is an early clue pointing to a deeper underlying condition, endometriosis, in about 50% of sufferers. 

Take the opportunity to assess if you have any of the common symptoms of endometriosis.  

Think about your menstruation NOW. Do you have: 

 Debilitating menstrual pain that isn’t controlled with OTC NSAIDs 

1. Pain levels that cause you to miss work or social events
2. Heavy menstrual periods – so heavy you wear more than 1 layer of protection
3. Brown bleeding/spotting before or after menstruation, or bleeding/spotting between cycles
4. Bloating & other irritable bowel symptoms (IBS) 

 Think about your menstruation when you were younger. Did you have: 

1. Debilitating menstrual pain that caused you to miss school but seemed to get better as you got older
2. Heavy menstrual periods that needed multiple levels of protection – tampons, pads 
3. Bleeding between cycles so you could never wear light colored bottoms 
4. Bloating that caused you to go up a pant size or more 
5. Were these symptoms a catalyst for you to start birth control? 

Think about your day to day experience. Do you have: 

1. Pelvic pain or pressure 
2. Pain during or after intimate relations 
3. Painful bowel movements
4. Painful urination or recurring feeling of a UTI (urinary tract infection)
5. Lower abdominal or intestinal pain 
6. Irritable bowel symptoms (IBS) 
7. Mental Health challenges like depression, anxiety, ADHD or substance use to cope with pain
8. Difficulty falling or staying asleep, due to pain 

Anything linked to menstruation is worth tracking. Not by memory, but through using a tracking application every day. It is critical to be able to name and gauge pain and keep a record of it. While the severity of your symptoms don’t always reflect disease stage[10], tracking timing of symptoms helps your healthcare provider understand your situation, how symptoms impact on your life, and helps you gauge changes over time. 

Your tracking should include: 

• Timing and severity of pelvic pain 

• Menstrual flow, volume (measure with a menstrual cup) and cycle length 

• Pain patterns during ovulation 

• Unusual bleeding or spotting between periods or any brown bleeding 

• Cervical Mucus Tracking, either manually or using femmtech such as: 

• • • Wearable rings (Oura), watches(Eva) or arm bands (TempDrop) that measure basal body temperature (BBT) 

• • • Mira or Proov, which measures urinary metabolites of hormones 

• • • Kegg, measures changes to cervical mucus to identify ovulation  

• • • Ovul, measures saliva ferning to identify ovulation  

Regular monitoring reveals patterns that might affect your fertility and helps to monitor the effectiveness of treatments. This information becomes especially valuable if you choose restorative reproductive medicine to treat infertility. 

Managing endometriosis and protecting your fertility needs knowledge, advocacy, and access to proper testing and medical care. Your symptoms are vital indicators that you shouldn’t dismiss. Speeding things up are medical advances like Tier 1 testing for endometriosis, that have made early diagnosis faster than ever. If you’re experiencing unexplained fertility issues or suspect endometriosis, find a clinic that offers ENDOSURE Tier 1 testing, or join the waitlist for updates on diagnostic testing centers closer to you at endodiagnosis.com/find-a-clinic. 

Written by Carolyn Plican, FCP

References:  

[1] Moïse, Alice & Dzeitova, Milana & de Landsheere, Laurent & Nisolle, Michelle & Brichant, Géraldine. (2025). Endometriosis and Infertility: Gynecological Examination Practical Guide. Journal of Clinical Medicine. 14. 1904. 10.3390/jcm14061904 

[2] Van Gestel H, Bafort C, Meuleman C, Tomassetti C, Vanhie A. The prevalence of endometriosis in unexplained infertility: a systematic review. Reprod Biomed Online. 2024 Sep;49(3):103848. doi: 10.1016/j.rbmo.2024.103848. Epub 2024 Feb 2. PMID: 38943813. 

[3] Nicolaus K, Bräuer D, Sczesny R, Bühler K, Diebolder H, Runnebaum IB. A two-third majority of infertile women exhibit endometriosis in pre-ART diagnostic hysteroscopy and laparoscopic chromopertubation: only one-third have a tubal obstruction. Arch Gynecol Obstet. 2020 Apr;301(4):1081-1088. doi: 10.1007/s00404-020-05479-5. Epub 2020 Mar 14. PMID: 32170409. 

[4] Akande VA, Hunt LP, Cahill DJ, Jenkins JM. Differences in time to natural conception between women with unexplained infertility and infertile women with minor endometriosis. Hum Reprod. 2004 Jan;19(1):96-103. doi: 10.1093/humrep/deh045. PMID: 14688164. 

[5] Noar, M., Mathias, J., & Kolatkar, A. (2024). Gastrointestinal Myoelectrical Activity (GIMA)Biomarker for Noninvasive Diagnosis of Endometriosis. Journal of Clinical Medicine, 13(10), 2866. https://doi.org/10.3390/jcm13102866 

[6] Macer ML, Taylor HS. Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am. 2012 Dec;39(4):535-49. doi: 10.1016/j.ogc.2012.10.002. PMID: 23182559; PMCID: PMC3538128. 

[7] American Society for Reproductive Medicine (ASRM), Endometriosis and infertility: a committee opinion. Fertility and Sterility, Vol. 98, No. 3, September 2012., https://www.asrm.org/practice-guidance/practice-committee-documents/endometriosis-and-infertility-a-committee-opinion-2012/ 
 

[8] WHO. (2023, March 24). Endometriosis. https://www.who.int/news-room/fact-sheets/detail/endometriosis 

[9] Daly, S., & Lin, E. C. (2018). Imaging in Endometrioma/Endometriosis: Practice Essentials, Radiography, Computed Tomography. Medscape. Retrieved from https://emedicine.medscape.com/article/403435-overview 

[10] Demco, L. (2000). Review of pain associated with minimal endometriosis. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 4(1), 5. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/