Written by: Dr. Merritt Jones, LAc, DAIM, FABORM
With National Infertility Awareness Week around the corner (April 19-25, 2026), this year’s theme, “MoreThan”, reminds us that infertility doesn’t look one way, and neither does the disease that may be driving it.
There’s a version of endometriosis that doesn’t announce itself.
No debilitating cramps. No obvious red flags on imaging. No textbook presentation that prompts a referral. The disease is active, driving inflammation, disrupting immune function, and quietly reshaping the pelvic environment. But from the outside, everything looks fine.
This is what clinicians call “silent” endometriosis. And for many people, the first sign that something is wrong isn’t pain. It’s infertility.
What Is Silent Endometriosis?
An estimated 20-25% of people with endometriosis have no classic pain symptoms. That doesn’t mean nothing is happening. Endometriotic lesions still generate an inflammatory cascade, promote adhesion formation, and can impair reproductive function even when pain is absent. The disease may grow in areas that don’t produce pain signals, or it may develop so gradually that symptoms are normalized or dismissed as something else entirely.
This is the paradox of endometriosis staging: the severity of disease doesn’t correlate with the severity of pain. A person can have extensive disease and minimal symptoms, or minimal disease and debilitating pain. Pain is not a reliable indicator of what’s happening inside the pelvis.
The Symptom Shuffle
For people who do have symptoms, the presentation often doesn’t look like the textbook version of endo. Bloating gets labeled IBS. Fatigue gets attributed to stress or poor sleep. Bladder pain gets diagnosed as interstitial cystitis. Painful sex gets normalized. Each symptom lands in a different specialist’s office, and no one connects them.
The gastrointestinal overlap alone is striking. Research published in Clinical Gastroenterology and Hepatology found that up to 90% of people with endometriosis experience GI symptoms, including constipation, bloating, and nausea. People with endometriosis are 3-5 times more likely to receive an IBS diagnosis than those without the disease. And this isn’t just a bowel endometriosis problem. GI symptoms occur regardless of whether lesions are directly on the bowel, likely driven by systemic inflammation and the cross-talk between the pelvic and gastrointestinal nervous systems.
So when a patient has been bouncing between a gastroenterologist, a urologist, and a primary care provider for years, each treating a fragment of the picture, it’s worth asking: what if this is one disease, not five?
The Unexplained Infertility Connection
Here’s where things get especially important during a week dedicated to infertility awareness.
For many people with silent endometriosis, infertility is the first and only clinical sign. Standard fertility workups may come back normal. Ovulation is regular. Semen analysis looks fine. Tubes appear patent on imaging. And yet, pregnancy doesn’t happen. The diagnosis: unexplained infertility.
But “unexplained” may not mean “without cause.” A 2024 systematic review published in Reproductive BioMedicine Online found that when patients with unexplained infertility underwent diagnostic laparoscopy, 44% were found to have endometriosis. The vast majority of those lesions, about 74%, were classified as minimal or mild.
A separate retrospective study found even more striking numbers: among patients with unexplained infertility who had failed prior fertility treatments and subsequently underwent laparoscopy, pathology confirmed endometriosis in over 90% of cases.
That means for a significant number of people sitting in fertility clinics right now, the inflammation, the immune disruption, the subtle changes to egg quality and implantation potential may have a name. It just hasn’t been found yet.
How Silent Endo Affects Fertility
Even without pain, endometriosis creates an inflammatory pelvic environment that can interfere with reproduction at multiple levels. The inflammatory milieu can impair oocyte quality and follicular development. Adhesions and scar tissue can distort tubal anatomy, even when imaging appears normal. Peritoneal fluid changes may affect sperm function and embryo transport. And increasingly, research points to endometrial receptivity as a key factor: the progesterone resistance and immune dysregulation associated with endometriosis can compromise the implantation window, even when embryos are chromosomally normal.
In other words, the problem isn’t always the egg or the sperm. Sometimes the environment is working against conception in ways that standard testing doesn’t capture.
Why Diagnosis Takes So Long
The average time from symptom onset to endometriosis diagnosis is still estimated at 7-10 years, and that figure may be even longer for people without classic pain. Several factors contribute to this delay.
First, current guidelines generally recommend against routine diagnostic laparoscopy for unexplained infertility, citing insufficient evidence that it changes outcomes. This means many people move through rounds of ovarian stimulation, IUI, and IVF without anyone surgically evaluating the pelvis.
Second, imaging has improved significantly, particularly for endometriomas and deep infiltrating endometriosis. But minimal and mild disease, the type most commonly found in unexplained infertility, often doesn’t show on ultrasound or MRI. These are peritoneal lesions, subtle implants on the lining of the pelvic cavity, and they’re effectively invisible to non-surgical assessment.
Third, and perhaps most importantly, the medical system is still largely looking for one version of this disease: the patient with severe dysmenorrhea. When someone presents with bloating, fatigue, and difficulty conceiving but no dramatic period pain, endometriosis may not even make the differential.
What Whole-Person Assessment Looks Like
This is where integrative care has something meaningful to offer, and it’s the lens we use every day at Natural Harmony.
When you look at the bloating, the fatigue, the bladder symptoms, the cycle irregularities, and the fertility struggles together, a pattern often emerges. In Traditional Chinese Medicine, we’ve been connecting these dots for a long time: gut function, reproductive health, immune regulation, and systemic inflammation aren’t separate categories. They’re one picture.
That doesn’t mean acupuncture replaces surgical diagnosis or fertility treatment. It means that whole-person assessment can help identify the patients who need further investigation, support the body’s capacity to respond to treatment, and address the inflammatory and nervous system components of the disease that medical interventions alone may not reach.
For patients navigating unexplained infertility, this kind of care can be the difference between feeling dismissed and feeling seen.
If This Resonates
If you’ve been told your fertility workup is “normal” but something still feels off, trust that instinct.
If you’ve been carrying a handful of diagnoses, IBS, IC, chronic fatigue, painful sex, that no one has put together, it may be worth asking whether endometriosis could be the thread that connects them.
If you’re in a fertility clinic and no one has discussed endometriosis as a possibility, bring it up. Ask about your options. You deserve a provider who zooms out.
National Infertility Awareness Week exists because infertility is still one of the most isolating experiences a person can go through. This year’s #MoreThan theme is a reminder that infertility doesn’t look one way, that the paths people walk to build families are as diverse as the people walking them, and that no one should have to navigate this alone.
You are more than a diagnosis. More than a lab value. More than “unexplained.”
Medically reviewed by the author 4/14/26
Dr. Merritt Jones is a board-certified reproductive acupuncturist (FABORM) and the founder of Natural Harmony Reproductive Health in San Diego. She has lived with stage 4 endometriosis and adenomyosis and has been helping others navigate this disease with integrative, whole-person care since 2015.
References
[^1]: Metz CN. ‘Silent’ Endometriosis Isn’t Silent: We Just Aren’t Listening. U.S. News & World Report. March 23, 2023. The 20-25% estimate is widely cited, though the original data source is a 2010 study; prevalence in asymptomatic women undergoing laparoscopy for other indications has ranged from 20-45% depending on population studied.
[^2]: Maroun P, Cooper MJW, Reid GD, Keirse MJNC. Relevance of gastrointestinal symptoms in endometriosis. Aust N Z J Obstet Gynaecol. 2009;49(4):411-414. Cited in: Simons M et al. Endometriosis Is Associated With Higher Healthcare Utilization and Upper Gastrointestinal Symptoms. Clin Gastroenterol Hepatol. 2024.
[^3]: Chiaffarino F et al. Endometriosis and irritable bowel syndrome: a systematic review and meta-analysis. Arch Gynecol Obstet. 2021;303:17-25. The 3-5x increased risk of IBS diagnosis in endometriosis patients is reported across multiple studies.
[^4]: 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;49(3):103848.
[^5]: Salama M et al. The Prevalence of Endometriosis in Patients with Unexplained Infertility. J Clin Med. 2024;13(2):580. Note: This study examined a specific cohort of patients who had failed prior fertility treatment, which may represent a higher-risk population than the general unexplained infertility population.
[^6]: Diagnostic delay estimates vary across studies and populations. WHO reports an average of 4-12 years; other sources commonly cite 7-10 years. Delay may be longer in patients without classic pain symptoms.