Why “normal tests” do not always mean “normal fertility”

Many patients with endometriosis hear the same thing:

• “Your tubes are open.”
• “Your AMH is fine.”
• “Your hormones look normal.”

Yet month after month, there is no pregnancy.

This is not a contradiction. It is how endometriosis can behave.

1. Endometriosis changes the pelvic environment

Even with open tubes and normal hormones, endometriosis can change the space where eggs, sperm and embryos have to work.

It can:

• Release inflammatory chemicals into the pelvis
• Alter the peritoneal fluid around eggs and sperm
• Increase oxidative stress (a kind of “rusting” effect) around the ovaries and tubes

This can:

• Reduce sperm function
• Affect how eggs mature and are picked up by the tube
• Make it harder for an early embryo to survive

So tubes can be “open” but not working at their best.

2. Eggs can be affected even when AMH is “normal”

AMH tells you about egg number, not egg quality.

With endometriosis, especially ovarian endometriomas:

• Inflammation and oxidative stress can affect nearby ovarian tissue
• Surgery on endometriomas, if not done carefully, can reduce ovarian reserve

So:

• You can have a normal AMH and still have eggs under stress
• AMH can drop faster if there are large cysts or repeated surgery

A “good” AMH does not rule out endometriosis related fertility problems.

3. Tubes can be “open” but not working perfectly

A dye test (HSG or HyCoSy) only checks whether fluid passes through the tube.

Endometriosis can still:

• Distort the anatomy around tubes and ovaries
• Affect how well the tube picks up the egg
• Disrupt the tiny hair like structures that move the egg and embryo along

The report may say “tubes patent”, but:

• Egg pick up may be less efficient
• The journey to the uterus may be less smooth

“Open” does not always mean “optimally working”.

4. Implantation can be affected even with a normal looking lining

Endometriosis outside the uterus can influence what happens inside.

In some patients:

• The lining may be less receptive at certain times
• Inflammatory and immune changes can affect how well an embryo attaches and grows

The scan may look fine, but the microscopic “welcome mat” for the embryo is not ideal.

5. Pain, timing and sex itself can be disrupted

Fertility is also about timing and intercourse.

Endometriosis pain can:

• Reduce how often or when intercourse happens around ovulation
• Make sex painful enough that it is avoided
• Increase stress, which can affect cycles and libido

None of this shows up on an AMH, HSG or hormone report.

6. What to do if your tests are “normal” but you have endometriosis and no pregnancy

1. Get a clear picture of your endometriosis pattern

Ask for:

• Exact sites of disease (ovaries, peritoneum, deep nodules)
• Whether there are endometriomas
• Any distortion around tubes and ovaries on ultrasound or MRI

“Endometriosis present/absent” is not enough detail.

2. Match your plan to age and severity

• Milder disease, younger age, shorter time trying:

Timed intercourse, medical management and structured follow up may be reasonable.

• More severe disease, endometriomas, deep lesions, older age or longer duration:

You may need a more active plan: IVF, careful surgery, or both.

3. Think carefully about surgery

Surgery can:

• Improve pain
• Restore anatomy
• Sometimes improve natural conception rates

But ovarian surgery can lower AMH and egg reserve if not done carefully.

This decision is best made with someone who understands both endometriosis and fertility.

4. Consider a true endometriosis surgeon

Consider seeing a surgeon who regularly:

• Excises advanced endometriosis
• Works closely with fertility specialists
• Plans surgery around pain, fertility goals and previous procedures

Quick FAQs

Can endometriosis cause infertility even if my AMH and tubes are normal?

Yes. Endometriosis can affect egg quality, tubal function, the pelvic environment and implantation, even when standard tests look normal.

Do I always need surgery to improve fertility with endometriosis?

No. The best approach depends on age, pain, duration of trying and scan findings. Some people do well with medical treatment and IVF, others benefit from carefully planned surgery, and some need a combination.

The key message

With endometriosis, it is completely possible to:

• Have “normal” tubes on a test
• Have “normal” AMH and hormones
• Still struggle to get pregnant

That does not mean your concerns are “in your head”.

It means standard tests do not capture everything this disease is doing.

Often, the next best step is not another isolated test, but a joined up consultation that brings your symptoms, scans, blood tests, past surgeries and future plans into one clear, realistic strategy.

About Dr. Vivek Salunke

Dr. Vivek Salunke is a senior laparoscopic surgeon based in Mumbai, India, with over 25 years of experience in endometriosis and fertility-preserving surgery.

He leads the Endometriosis & Pelvic Pain Centre and is known for his ethical, patient-centered care and advanced excision techniques.