INFERTILITY IN WOMEN WITH ENDOMETRIOSIS: MECHANISMS, BIOMARKERS AND CONTEMPORARY MANAGEMENT STRATEGIES – A REVIEW

Endometriosis is a chronic inflammatory disorder that affects approximately 6–10% of women of reproductive age and is found in up to 50% of those assessed for infertility. While advanced stages of the disease can compromise fertility through the formation of adhesions and anatomical distortions, clinically significant infertility can also occur in cases of minimal or mild endometriosis, highlighting the role of non-anatomical factors. Current evidence suggests that immune dysregulation, progesterone resistance, chronic endometrial inflammation, oxidative stress, and microbiome disturbances contribute to impaired implantation and diminished reproductive potential.

This narrative review synthesizes current mechanistic and clinical evidence regarding endometriosis-related infertility, focusing on molecular pathways, evolving diagnostic methodologies, and fertility-oriented treatment strategies.

We searched PubMed, Scopus, and Google Scholar for publications from 2018 to 2025 on endometriosis and infertility. Priority was given to international clinical guidelines, systematic reviews, meta-analyses, and original studies addressing pathophysiology, diagnostics, fertility interventions (including surgery and assisted reproduction), and quality-of-life outcomes. A narrative synthesis was performed.

Endometriosis shares key molecular and immunologic features with recurrent implantation failure, such as aberrant macrophage activation, T-cell imbalances, and impaired endometrial receptivity. Oral GnRH antagonists offer new options for symptom control while preserving flexibility in fertility planning. Emerging therapies target inflammation, immune pathways, and the endometrial microbiome. Ongoing trials (e.g., surgery-first vs. IVF-first) may identify optimal treatment sequences. However, delayed diagnosis and unequal access to fertility care remain major challenges worldwide.

Infertility associated with endometriosis is multifactorial and requires an individualized, multidisciplinary approach that integrates reproductive goals, symptom management, and psychosocial well-being. Further validation of biomarker panels and comparative-effectiveness studies is essential to refine clinical algorithms and enhance reproductive outcomes.

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