For women with endometriosis, oocyte cryopreservation can help preserve future fertility, but the potential benefits do not always justify the procedure. Decisions about which patients should be offered fertility preservation and when should be made on a case-by-case basis. Ludovico Muzii, MD, PhD, professor of obstetrics and gynecology at Sapienza University of Rome and director of the Gynecological Surgical and Oncological Unit at Policlinico Umberto I in Rome, Italy, discussed the topic during the conference “Next-Generation Assisted Reproductive Technology (ART): Multidisciplinary Pathways, Artificial Intelligence and Legal Transparency,” held at the Italian Ministry of Health’s Auditorium “Cosimo Piccinno” in Rome, Italy, on September 22, 2026, on the occasion of Italy’s national Fertility Day.

“Even today, in our country, it takes between 4 and 11 years from the first appearance of endometriosis symptoms to diagnosis,” Muzii said. “This delay has a tangible impact on women’s health because a timely and accurate diagnosis allows the right choices to be made to manage pain and the risk for infertility associated with the disease. Today, there is a tendency to prioritize a pharmacologic approach over surgery, whenever possible, both to control pain and to halt the progression of lesions and preserve reproductive capacity.”

Ovarian Reserve

“Endometriosis is inherently associated with a decrease in ovarian reserve, even in the absence of surgery. The removal of ovarian cysts, when performed, can cause further damage,” Muzii said. Between 25% and 50% of women with infertility have endometriosis, although this condition is not always the primary cause of difficulty in conceiving. ART is the primary treatment option for infertility.

When a patient wishes to postpone trying to conceive, oocyte preservation should be considered on a case-by-case basis, taking into account age, clinical condition, previous surgeries, and the possibility of future surgery. Reproductive medicine specialists with expertise in endometriosis should perform this assessment. Ovarian stimulation to retrieve oocytes for cryopreservation or immediate use in ART does not worsen the course of endometriosis or increase the risk for associated pain.

Evidence supports a tailored approach to fertility preservation. A 2025 review noted that age, ovarian reserve, and previous ovarian surgery are the main factors affecting the success of fertility preservation and that specific indications for oocyte cryopreservation in endometriosis have not yet been established.

Cryopreservation Timing

The American Society for Reproductive Medicine classifies endometriosis into four stages. Stage I is characterized by a few superficial lesions with no or minimal adhesions. Stage II involves more extensive and deeper lesions but no significant anatomic involvement. Stage III is characterized by ovarian endometriomas, deeper lesions, and significant adhesions. Stage IV represents extensive disease with endometriomas and widespread adhesions that may involve several pelvic organs.

“If the patient is young, under 35 years of age, with stage I or II endometriosis, it is unlikely that the small, superficial lesions will progress to the point of compromising ovarian reserve or necessitating surgery,” Muzii said. “In this situation, which is very common in the general population, egg freezing is generally not warranted.

“On the other hand, if the patient is older than 35 years or has reduced ovarian reserve because of the disease or previous surgeries, the likelihood of retrieving an adequate number of eggs for a subsequent pregnancy with a single stimulation cycle is low. In fact, at least 10-12 oocytes retrieved from a young woman are needed to have a good chance of success and ideally more than 15 if she is older than 35 years. This limitation must be clearly explained during counseling so that the patient can objectively assess whether the financial investment is justified by the expected outcome. Cryopreservation would therefore be appropriate for a young patient with stage III or IV endometriosis.”

Funding Coverage

Oocyte cryopreservation for women with endometriosis is funded by public resources in some regions. In Tuscany, for example, the Regional Health Service (SSR) provides up to two oocyte retrieval cycles free of charge to residents younger than 40 years with severe endometriosis and a documented risk for impaired ovarian function, particularly in cases involving previous surgery or ovarian cysts. Oocyte preservation is also covered by the SSR until the age of 46 years.

The Regional Council of Lazio in Rome, Italy, approved a budget allocation of €300,000 for 2027 to support gamete cryopreservation for individuals aged 18-40 years, excluding those with cancer that may compromise fertility, for whom SSR reimbursement is already available. Subsidies for oocyte cryopreservation may reach €3000. The eligibility criteria will be defined by the Regional Executive Committee.

“When public resources, which are necessarily limited, are being used, it is even more important to carefully assess which patients might derive a tangible benefit from cryopreservation,” Muzii said. “The goal must be to optimize the balance between the expected health benefit for women and the cost to the health system, while avoiding offering the treatment when the probability of future benefit is too low.”

Treatment Before Pregnancy

“A useful approach to preserving ovarian reserve and protecting fertility until a patient is ready to try to conceive is pharmacologic therapy with progestins or gonadotropin-releasing hormone analogs, according to the specialist’s assessment. These treatments can halt the growth of endometriomas and sometimes even cause them to regress,” Muzii said.

“There is also another aspect to consider when evaluating a patient’s reproductive capacity. Endometriosis and adenomyosis, a related condition characterized by the presence of endometrium-like tissue within the muscular wall of the uterus, can alter the structure of the reproductive organs and increase the risk for reproductive failure and embryo implantation defects.

“In the past, ‘clearing’ surgery was once standard practice to optimize the pelvic environment before trying to conceive or undergoing ART. However, recent studies have shown that surgery does not increase the likelihood of a successful live birth. Surgery may instead be necessary to treat pain associated with endometriosis when medication alone is insufficient.”

This story was translated from Univadis Italy, part of the Medscape Professional Network.