In this episode, we dive into the nuances of adenomyosis and endometriosis in our listener questions. Join Dr. Carrie Bedient from the Fertility Center of Las Vegas</a>, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center as they spend time explaining how endometriosis and adenomyosis impact treatment decisions. Learn the differences between the conditions and how they impact your fertility. We discuss different modes of treatment and preparation for patients affected by endometriosis and adenomyosis. Whether you are living with these conditions or just want to learn more, tune in for this informative episode!

Episode Transcript:

Susan Hudson (00:01)

You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.

Susan Hudson MD (00:22)

This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test used to help detect inflammatory conditions on the uterine lining, most commonly associated with endometriosis and may be the cause of failed implantation or recurrent pregnancy loss. Take advantage by learning more about this condition at receptivadx.com and how you can get tested and treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx, because the journey is worth it.

Carrie Bedient  MD (00:53)

Hello and welcome to another episode of Fertility Docs Uncensored. I am Dr. Carrie Bedient from the Fertility Center of Las Vegas, one of your hosts, and I am joined by my kick-ass, crazy, kind, and cool-brained co-hosts, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (01:11)

Hello everyone.

Carrie Bedient  MD (01:12)

and Dr. Abby Eblen from Nashville Fertility Center.

Abby Eblen MD (01:15)

Hey everybody, kick ass crazy Carrie. That’s the first time you’ve ever used that one before I think. I guess that’s a compliment, I don’t know.

Carrie Bedient  MD (01:21)

I mean, coming from me, yes. Coming from any of our patients, questionable. But from me, yes. Yeah. How are you guys doing?

Abby Eblen MD (01:26)

Okay, good.

Susan Hudson MD (01:30)

We are good.

Carrie Bedient  MD (01:32)

Okay, so the deeply insightful fertility related question of the day is, you prefer dogs or cats?

Susan Hudson MD (01:40)

or other pets of any other type.

Carrie Bedient  MD (01:44)

Yes, or rodents, reptiles, feathered friends, any of those creatures.

Susan Hudson MD (01:48)

Let’s go.

Abby Eblen MD (01:49)

Hahaha

Susan Hudson MD (01:52)

I’m definitely a dog person. I’m actually scared of cats.

Carrie Bedient  MD (01:58)

Like legit scared or just don’t know.

Susan Hudson MD (02:01)

I’m literally scared of them. I can appreciate them from a distance and I appreciate, I can look at a cat and be that’s a beautiful cat or something like that. But I was around some really mean cats as a child. And so I do, I do, I innately don’t trust them. And so, and they sense it, they absolutely know it. 

Abby Eblen MD (02:12)

If PTSD could add a little bit.

Susan Hudson MD (02:25)

I don’t hate cats. I’m literally just scared of them. So I like my doggies.

Carrie Bedient  MD (02:32)

What about you, Abby?

Abby Eblen MD (02:33)

Well, we have two cats. When I met my husband, he had two beagles that we had. We love all animals, dogs and cats. But the reason we settled on cats is just because we both worked. And it’s just really hard to have a dog if you’re not really close by and can’t let your dog out in a reasonable amount of time. So we have cats. Cats, you have to get to know them, but they all have their own personality and their own little quirks. The funny thing I think about cats versus dogs is they just do goofy things like were sitting there eating dinner the other night and one of our cats, for the first time ever, just climbed up on the shelf next to us and just we looked over and we’re like, where’d you come from? And she’s just looking at us like, hey. So they just do quirky things, but I love dogs too.

Carrie Bedient  MD (03:13)

I’m totally a dog person. Cats make me sneeze in very prodigious amounts. And there is just not enough Kleenex in the world to handle me having a cat of my own. We have a very firm no rodent policy in our house because those little creatures are nocturnal and as soft and cute as they are. No.

And we’re anti-reptile. Not really all reptiles. I would rather have a snake than a gerbil or a hamster or any of those things, because at least snakes are quiet in the middle of the night and they just sit there. I would be okay with a gecko or a lizard of some type. We did try an experiment with that, but you have to feed them bugs and that did not go over well in our house. And so as a result, we have our little Chewini whose name is Gigi who runs the house without a doubt. So last night we had dinner and we’re sitting around the counter talking afterwards. And I look over and Gigi has her tiny little ears and her eyeballs just above the dining room table. Like she’s here looking at it. And I glanced away and when I looked back, she was full on, on top of the dining room table, trying to scavenge whatever was left of dinner, which totally cleared so there was nothing there for her but she definitely maintains that we have a very clean house. What questions do we have today because we’re going to focus on we’re going to do a question episode and we’re going to focus on like endometriosis, adenomyosis, things that travel in that particular diagnostic category. So Susan, I feel like you probably have a list as long as all of our arms put together.

Susan Hudson MD (04:52)

I do, I do.

Starting a family is one of life’s greatest adventures, but sometimes the path to parenthood isn’t as straightforward as expected. Shady Grove Fertility is there to guide hopeful parents every step of the way, offering compassionate care and advanced fertility treatments to help make parenthood possible. With their exclusive 100 % refund program for IVF and flexible monthly payment options, Shady Grove Fertility makes treatment more accessible.

Visit ShadyGrowFertility.com to schedule a consultation and take the first step, because the adventure of a lifetime starts at Shady Grow Fertility.

Susan Hudson MD (05:27)

All right, so our first question is from San Antonio. 40 year old female, two euploid embryos, no biological kids, one natural miscarriage prior to starting IVF. While prepping for FET transfer, doctor found spots in my uterus. The day before transfer, doctor canceled FET and said I have adenomyosis.

Doctor hadn’t noticed it during follicle stim cycle, although my body had a massive response to the meds and we needed to cut back. I’ve donated eggs in the past and it was not noticed. I’m disappointed this wasn’t found until now. My doctor thinks it could be brought on by estrogen. I’m in the process of detoxing from daily PIO injections, suppositories three times a day and estrogen shots. I’m hesitant to try Lupron suppression as we are trying a quote natural approach to getting lighting ready before resorting to Lupron.

Carrie Bedient  MD (06:18)

Hmm. What do think, Abby?

Abby Eblen MD (06:20)

Well, I think that falls in one of those categories where that’s where if you put 10 reproductive endocrinologists together, you get 10 different versions of what to do. I wonder if he noticed that she maybe had cystic areas, like near the endometrium or something. Just, adenomyosis by itself, I don’t know that I would cancel a transfer for that, but I suspect that there’s something more there that he was concerned about, that it was just a massive amount cystic areas and he was worried and couldn’t tell if it was in the endometrium or in the muscular part of the uterus. And when you do Lupron, Lupron helps shut that down because adenomyosis is really kind of where the lining of the uterus that normally should be there grows into the wall. And so he may be doing that somewhat diagnostically as well, but also to see if he could get rid of those cystic areas, basically just so that your embryo will have a better place to implant. So I think it’s one of those things that I have to see the pictures of the ultrasound to really figure out what the issue is.

Susan Hudson MD (07:15)

think it’s important to know that as we go through the IVF process, there’s lots of things that we’re paying attention to. And so just like Abby said, it may have been actually something within the endometrium that they were concerned about versus in the muscle of the uterus. But also, I understand the desire to do things naturally, but natural hasn’t necessarily worked in the past. Otherwise you wouldn’t have needed to do IVF and realize that things like endometriosis and adenomyosis do more than provide a physical blockade to getting pregnant, but it also can provide a chemical blockade. And so if there’s the concern that you do have adenomyosis, your doctor may be thinking about doing Lupron instead of doing additional testing like BCL6 testing to see if there’s a chemical response. In essence to maybe save time and perhaps a little money depending on how suspicious they are about the adenomyosis. I know we only have a couple of little embryos to be working with here and each of those are extremely extremely valuable and so that’s probably a reason your physician’s being a bit more cautious.

Carrie Bedient  MD (08:29)

The other thing to consider is that sometimes adenomyosis can make it much more difficult to thicken up the lining. And so it may have been something where your doc was like, okay, that lining is adequate, maybe not amazing, but is adequate. And then with an ultrasound, they were finally able to catch sight of something that really made an impact to say, I don’t want to risk this. I don’t want to go forward. And a lot of us with with a first attempt at an FET, it’s very different than if you’re on your third or fifth or whatever attempt, because the first one, the thought is, all right, this is how well we’ve done now. Can we get any better? And perfect is the enemy of good. Going after perfect is not always the best idea. But after a first one where you don’t really have a huge comparison, you’re a little bit more likely to say, okay, let’s cancel now and let’s see what we can get. Because if we’re on a second or a third cycle and this is just the best we get, this is the best we get and we go forward. If not, then you do better and you kind of know, all right, this was worth waiting for. And it’s something that’s very hard for patients because I think probably one of the most common questions that we get in our initial consultations is, how long before I get a positive pregnancy test?

And in walking through that and saying, okay, well, you’ve got a menstrual cycle worth of testing, a menstrual cycle worth of planning, a menstrual cycle worth of an egg retrieval and a uterine evaluation, and then a transfer. You can easily be several months into this before you get to the point where you’re actually able to attempt a positive pregnancy test. Patients hate waiting. I mean, they have waited long enough by the time they set foot in our office for the very first time. And so when you add to that, I think sometimes that is more upsetting to people than any one diagnosis. So, okay. What else do we have?

Susan Hudson MD (10:21)

All right. Hi there. You three and your guests having been so helpful through this process. I don’t know where I’d be without your podcast. Thank you. Thank you so much for listening. My husband and I have been trying for about a year and a half and during the time we’ve done three rounds of failed IUI with letrozole and injections. AMH 5.39, TSH 1.99, FSH 4.9, Estradiol 26, partner normal sperm.

I’ve also done the HSG and everything normal and not blocked. I’ve been diagnosed with unexplained infertility, but because my mom has endometriosis, they think that I could as well. My doc recommended doing a laparoscopy before we start IVF. I’ve also been doing acupuncture as the East Medicine doc thinks it’s poor circulation that’s the cause. What do y’all recommend I try next?

Carrie Bedient  MD (11:11)

We didn’t get an age on her, right?

Susan Hudson MD (11:14)

I do not have an age.

Carrie Bedient  MD (11:17)

Okay, so Abby, what do think?

Abby Eblen MD (11:20)

So I think if you’re a younger patient, younger being 36 or less, that might be reasonable. I think about 10 years ago, the pattern of practice for most reproductive endocrinologists was to do some treatment in the office. If that wasn’t successful, then look for endometriosis. And so I’ve done many of those laparoscopies before. We don’t jump to do those now, or at least most people don’t, unless we see something now that’s suspicious for more advanced endometriosis. We know that minor endometriosis can suppress your fertility. It doesn’t truly make you infertile, but it can take you longer to get pregnant than say a neighbor next door. So there’s nothing wrong with doing laparoscopy. Typically it takes you about a month to heal, but it is a surgery. And so to that end, that’s the reason most people don’t jump to do that because when you’re looking at risk versus benefits, risk of a surgery, versus benefits of maybe getting rid of some mild endometriosis, most people would say it’s probably more reasonable just to move on to something more aggressive like IVF. With IVF, by taking the embryo and putting it in the uterus, we created outside the petri dish when it’s not exposed to the endometriosis, and other than some inflammation in the endometrium, it doesn’t seem to appear to affect the embryo if you have more advanced endometriosis.

I’ve evolved now where I don’t necessarily do laparoscopy personally on my patients unless there’s something obviously there or somebody has really severe pain or some symptoms of endometriosis that can potentially be more improved by surgery than just treatment that we give medically. The exception to that is if we find that there’s a marker BCL6 in the endometrium that can be linked to endometriosis, those are times when I would consider treating somebody with lupron ahead of time, but not necessarily doing surgery ahead of time.

What do you think, Carrie?

Carrie Bedient  MD (13:07)

I’m always hesitant of surgery without a really clear clinical cause of pain or, we know that there’s a big hydrosalpinx, for example, that we need to take or a huge endometrioma, things like that. Mostly because I worry about the damage that surgery itself will do because once you’re in there, you kind of got to respond to anything you see and…there is a very high inclination no matter how restrained you are to, if you see stuff on the ovaries, to go get rid of it. And the act of getting rid of it can damage a variant tissue. No matter how amazing a surgeon you are, just by virtue of cutting or burning or even just poking around around the ovaries can limit the number of eggs that you have. And so before you go into doing that, you really want to know what you’re going for. And so if we’ve got a…an eight centimeter endometrioma that’s blocking our ability to access eggs, absolutely go get that sucker out. It is not doing anybody any favors. But if you’ve got a one to two centimeter endometrioma, sure, you can go in and get it out. But the act of getting it out will have collateral damage. And so I tend to be not super surgically, proactive, unless someone is really having an issue. Like if you’re having crazy pain, if there’s bunch of scar tissue, there’s stuff that’s actively interfering with your daily life, yeah, let’s go get rid of it. But I tend to be hesitant because I worry about collateral damage that you’re gonna find when you get in there that you just don’t know what the impact is gonna be down the road. What do you think, Susan?

Susan Hudson MD (14:43)

I I think we’ve got a lot of great ways to look at chemical ways endometriosis can affect implantation and IVF cycles with the Receptiva and BCL6 testing. I think we have some really good medical therapies for that, whether we’re looking at using Depo Lupron or Orlissa to help suppress any endometriosis and surgery as being a primary thing to do before going to IVF is something that is a little bit of an older practice and it doesn’t necessarily make it wrong, but especially if you’re wanting to avoid IVF, but if you’re just doing it before IVF for the sake of looking to be like, yes, we have a diagnosis of endometriosis, I don’t think it’s all that helpful.

Early in my career when I did a lot of diagnostic laparoscopies, really the big purpose of the diagnostic laparoscopy in addition to ablating endometriosis was to look to see how bad it was. And so if you had very advanced stage endometriosis, the recommendation at that point would be go directly to IVF. So one, if you’ve already gone through the treatments you would do prior to IVF and you’re going to IVF anyway, that doesn’t make a lot of sense. And number two, one reason I stopped doing as many is because a lot of people who hadn’t done any treatment and were starting off with laparoscopy, even if they had severe endometriosis, they declined doing IVF because they didn’t have coverage and that type of thing. Regardless of what they knew success rates were going to be, they still wanted to try something less invasive before moving on to IVF. So it really lost a lot of its meaning in that timeframe.

Carrie Bedient  MD (16:25)

Absolutely. Okay, what else you got?

Susan Hudson MD (16:29)

Okay, so our next one is I have a question about a recent diagnosis. I’m 33. My husband also 33 has been struggling for infertility for seven years with male factor. I’ve had five IUIs, three rounds of IVF. My first transfer was an ectopic pregnancy that required laparoscopy, D&C, and two doses of methotrexate. My second single embryo transfer led to mono di-twins that miscarried at 14 weeks. I had a D&E and retained placenta for three to four months afterwards, which passed on its own.

I just got diagnosed with mild adenomyosis and I’m on Lupron suppression for two months prior to my next transfer. Can you provide insight into this diagnosis and if I’ve always had it or has likely been caused by my history?

Carrie Bedient  MD (17:17)

That’s a good question. There are lots of layers to that question. OK, Susan, which layer do you want?

Susan Hudson MD (17:19)

Mm-hmm.

Well, I’d like to say that the diagnosis of adenomyosis is more common in people who have had some sort of pregnancy before. So I think that there may be a relationship to it. No one’s going to ever be able to absolutely say for sure, but I think, you may not have had ultrasound evidence suggestive of adenomyosis prior to your pregnancies and especially prior to instrumentation of your uterus. So I’ll start with that part.

Carrie Bedient  MD (18:02)

Okay, Abby.

Abby Eblen MD (18:03)

Well, one thing I would say about adenomyosis, we’re throwing it around like it’s a real cut and dried thing and it’s not. You the diagnosis of adenomyosis is a subjective thing. If you ask a pathologist, a person who deals with tissues in the lab, how you make that diagnosis, they’d say, well, we make that diagnosis after somebody’s uterus is out and we look at it in the lab. So what I’m assuming they’re calling adenomyosis are cystic areas in the myometrium, the muscle of the uterus again, because endometriosis grows in there and looks cystic.

I agree with Susan. My first thought was, the more pregnancies that you have, the more chances you have of getting adenomyosis. Now, your pregnancies didn’t go very far along. The first one was a tubal pregnancy, and gosh, that sounds horrific. You had to have a laparoscopy, and a D&C, and methotrexate. You got all three treatments. So that, I don’t know, would really contribute, maybe from a hormonal standpoint, possibly. But sometimes we think it’s from the stretch of the uterus. The uterus stretches out and allows little crevices and allows the the endometrium to grow in the wall. And with your twins that you had, it’s possible that that could have played some role. Certainly if they did a D&C, that could have breached that barrier. But in terms of it really impacting your fertility, I think it’s more, if I had to guess, and this is a crystal ball kind of thing, I think it’s more related to your pregnancies rather than it being a cause for your infertility, if I had to guess.

Carrie Bedient  MD (19:21)

One of the things that popped out at me was just the amount of work that has had to be done on the uterus and by the uterus. Whenever I see someone who’s had to have multiple layers of treatment for an ectopic, including multiple doses of methotrexate and had another pregnancy that had retained products, and even if they came out on their own, that really makes me wonder what’s going on inside the uterus itself. And that’s, that’s not necessarily related to adeno. That’s more just what, what is going on with the lining of the uterus, the basement membrane that separates the muscle from the glandular part of the endometrium that grows and comes off every month and that pregnancy’s implanted. And, and I start to worry about, okay, with a future pregnancy.

Are we going to see number one, any difficulties in the line thickening up? And number two, any abnormalities of implantation that don’t necessarily impact your ability to get pregnant, but they do have a big impact when it’s time for the uterus to clear out, clean up shop and reset itself. Because when you’ve got retained products, when you’ve got the need for additional doses of methotrexate after a laparoscopy, all of those things, It just makes me wonder how is that implantation going? Is it locking in much more thoroughly than really it needs to or it should? And so I start to think about like, what about doing a hysteroscopy before your next attempt just to make sure that everything is as clear as possible and if there’s not scar tissue that is obvious, there can be scar tissue that’s not obvious.

Is there scar tissue that’s obvious? Is there inflammation in there? Is there anything else that really needs to be dealt with before you go ahead and transfer? So that’s one thing that pops into my mind, just hearing that whole story.

Susan Hudson MD (21:09)

Good deal. All right, our next one. Hi, docs. Thanks for the fantastic informative podcast. We appreciate it. From Hungary, thank you for listening from abroad I was diagnosed a stage four deep infiltrating endometriosis and adenomyosis. Had laparoscopic excision surgery with bowel resection. I turned out my fallopian tubes were completely blocked, so my doctor directed me to IVF.

My fiance and I are starting our fertility journey to freeze our embryos before implantation. My AMH is 0.79 and then it was 0.65 about three weeks later. FSH 13.7. My AFC was two. I am very nervous to begin IVF treatment and the prospect of donor eggs has been brought up already. Is it normal for AMH to fluctuate? Is there hope to use my own eggs? Thank you.

Abby Eblen MD (22:03)

How old is she?

Susan Hudson MD (22:04)

We do not have an age.

Carrie Bedient  MD (22:05)

Why do you care about how old she is, Abby?

Abby Eblen MD (22:07)

Well, because I’m worried, I am worried about her numbers. I don’t think the difference between 0.79 and 0.65 is a real difference. With just a few weeks apart, it’s like if we check your blood pressure today, tomorrow, the next day, it’s gonna be a little bit different, but it’s gonna fluctuate up and down around the baseline. I think that’s just the error that we sometimes see if we do a test over and over and over again, one right after the other, we’re not gonna get the exact same number. To me, whether it’s 0.7 or 0.6, doesn’t really matter, it’s not gonna change what I’m gonna do in terms of how it would stimulate you. But I do know that based on your elevated FSH, so the FSH is the hormone from the brain that goes down and stimulates the eggs to develop, it’s a little bit higher than what we would like to see. The number’s less than 10, that’s kind of a better number. It suggests that the brain has sort of caught up with the fact that your egg reserve is not very good. It worries me a little bit that when we go to stimulate you with the FSH medicine for IVF, that more of the same is not gonna make a tremendous difference if there’s not very many eggs there. And so, but it’s one of those things we don’t know until we try. And I’ve definitely seen situations where women with an egg reserve that’s suboptimal still do very, very well. The reason I was wondering about your age is because younger women with a lower amount of eggs tend to do better and younger would be under 35 tend to do better than women that are 39 or 40 with a lower number of eggs. It just means that those eggs are more likely to be genetically normal, even if there’s a small number, and we’re more likely to have one that would be a really healthy embryo.

Carrie Bedient  MD (23:37)

Okay.

Susan Hudson MD (23:37)

I think that the consideration of donor eggs in the future is maybe something that you’ll need to start having some conversations about, but it doesn’t necessarily mean you have to start off there. We’ve all seen people with these type of parameters who have ended up with pregnancies using their own eggs. So I would say give it a good shot, go with gusto and really hope for the best and positive mentality going into it.

But also balancing that with there are other options if you need them to complete your family building.

Carrie Bedient  MD (24:10)

I’d say that mentally planning on, right, this is probably going to take me more than one cycle is helpful. And not getting tied to any one cycle’s results because we see variation in every single cycle. The variation that you get when somebody’s got, say, a follicle count of 15 and maybe you get 17, maybe you get 13, there’s there’s a difference that feel, but you don’t feel it nearly as sharply as the variation between two eggs versus three versus one. And so it is a very different feel. Doing one cycle where you get one egg and the next cycle you get three, you may feel like they are drastically different, but in reality they’re not. It’s the same variation of one to two eggs. It’s just the percentages feel different and the emotional impact of it feels different. And so…I think it’s very helpful to be aware of that and of approaching it with the long haul of this is probably not going to be a one and done situation. This is probably going to be something that stretches over a much longer period of time. And that will require you and your other half to have a lot of conversations about what, what do we hold dear? What are our values? Because if you value getting pregnant really fast, that may push you into a donor cycle much sooner than if you value trying to extend every possibility in using your own eggs. And so having a lot of those conversations and being open with your partner and thinking about some of the difficult things and what it means and avoiding the temptation to rush into anything are all really helpful as you’re approaching this because it means that you’re happy with what you’re doing not just now, but five, 10 years down the line, you’re like, yeah, we made the right decisions. Whether it works out the way you want it or not, that you made the right decisions.

Susan Hudson MD (25:58)

Absolutely.

Carrie Bedient  MD (26:00)

Hey, what else?

Susan Hudson MD (26:02)

Okay, we have another listener from overseas. Hi to all my favorite doctors. I’m an American living in Ireland. My husband and I have been casually trying to conceive for two and a half years, no medications or IVF attempts. I’m 37 with endometriosis. I had a laparoscopy almost a year ago for endo excision. And while in surgery, they cleared out my fallopian tubes. My AMH is 0.7, although I’m not interested in IVF.

Lab work has been normal. Ironically, my husband and I are both fraternal twins, so we haven’t been super excited to try ovulation induction. Would this dramatically increase our odds of having twins? What would you expect to achieve from a fertility specialist outside of IVF? I’m just nervous to make that leap. Thanks so much. I appreciate you all. That’s a great question.

Abby Eblen MD (26:57)

So I would say with our fertility medicines, our oral fertility medicines, the chances of fraternal twins, we quote, is generally about five to 10%. And I really believe now that we don’t do transfers and we just don’t see many multiples anymore now that we don’t transfer an excess number with IVF, that the excess number of embryos and babies tended to come more from more powerful IVF drugs that we would use and sometimes pair that with IUI.

So we’d use the powerful drugs and we couldn’t control the number and people would end up with twins, triplets, and sometimes beyond. We rarely see that anymore and I guess Carrie and Susan, you can speak to that as well, but I honestly can’t remember the last time I’ve seen twins. It’s been a while. I mean, we see them sporadically, but it doesn’t seem like there’s a real high incidence even in people who have family histories of twins. So about a five to 10 % chance that you could have twins. And if we do just IUI without doing, so intrauterine insemination where we take your partner’s sperm, put it up inside the uterine cavity, that can increase your odds a little bit as opposed to doing it with oral medicine and insemination. That doubles your chance to about 10 % chance of success, but it also would increase your risk of more than one baby. So if you’re really worried about that, you could just try IUI first if you wanted to do treatment.

Susan Hudson MD (28:07)

I think an important thing is to really understand when we’re throwing out these statistics that first of all, baseline, you try on your own, you have about a 1 % chance of twins. Okay. Now, if you have infertility, which you guys have been having unprotected intercourse for over a year and have not had a pregnancy. So by definition, you have infertility without help, you have about a 1 to 2 % chance of pregnancy without help. If you do something, like letrozole with insemination, chances are going to be maybe around 15 % depending on age, different things like that. And if you achieve pregnancy, then you’re looking at that five to 10 % chance of multiples, which gets you back down to if you’re just sitting here listening, you’re back to that one to 2 % chance we were talking about if you were trying on your own. And so I wouldn’t avoid fertility treatment because of a fear of multiples.

Age in some ways is protective in some ways it’s not protective and that if you’re I believe we said you’re 37 risk of miscarriage is getting upwards of around 20 % at that point for each pregnancy and so you can only make that decision for yourself on whether or not you want to take that risk.

But if you don’t push things a little bit, I’m concerned about your success rates in the future.

Carrie Bedient  MD (29:31)

Mm-hmm. Agree with all of those. And one thing to remember about statistics is that they’re great for a football stadium worth of women or in Ireland. I don’t know if cricket is a little bit better, but they’re good for a huge number of women. They mean very little in response to one woman or one couple’s experience because you are not going to have 1 % of a twin pregnancy. You either do or do not. There is no try.

Abby Eblen MD (29:43)

Yeah.

Carrie Bedient  MD (30:00)

And so that’s something that a lot of people forget in that they spend a lot of time looking at all these percentages. And these percentages are great when we’re talking about, on average, if we try this, this is more likely to work than that. But for you, you really don’t care what happens except what happens to you. So the percentages are relevant. You don’t want to spend a ton of money on something that’s got a 1 % success rate, but also you get what you get and it’s an all or nothing kind of experience. And so, when I look at the percentages of twins that I see in my IVF population, it’s very, very rare that we do anything other than a single embryo transfer because that’s what’s better for babies and for moms. I’ve had in the past, what, 11 years of practice plus an extra several years of training before that. I have had one pregnancy where I transferred one embryo and ended up with triplets. And all the rest are, you know, are singletons. And you do get that up to, one, 1.5 % chance of twins. But I don’t think that’s a reason not to do anything because you’ve got that chance no matter how you get pregnant. And it’s, are, what are your values? What do you…what do you want the most and how are you gonna go about getting that? Knowing that there’s always some collateral, I don’t wanna say damage, because that’s not really right the word, but collateral things that can happen that you just may have to accept based on what’s going on.

Susan Hudson MD (31:29)

We have one more international listener who has a question about endometriosis. So we’ll we’ll finish with this one Hello. First of all, I love your show informative and fun. It’s easy to listen to. I’m 39 and from Germany. Over the last couple of years. I’ve had seven failed embryo transfers six failed to implant plus one miscarriage at nine weeks. Recently endometriosis was discovered through laparoscopy. I want to do GnRH suppression with Lupron but this is not common here. How can I convince my RE to give it a try? Unfortunately, PGT testing is not allowed here. We do have five untested embryos left. We can’t try naturally because of my husband’s cancer battle. Thanks so much for your help.

Abby Eblen MD (32:15)

So I think the one positive thing for her is depending on when she had the laparoscopy and I assume it was after she had her seven failed transfers, One of the treatments for, I mean, a really good treatment for endometriosis is to go in and do surgery and remove it. And so, I don’t know exactly what they found at surgery, what they did, but if that’s been within a year or so, that’s kind of the treatment that really replaces Lupron. You don’t need to do both of those things.

If it’s been a couple years, then yeah, maybe that would be beneficial. What you could do if it’s available in Europe is do the Receptiva assay. And I can’t remember the number of our episode that we did. It’s been a while now, but we talked to Bruce Lessey and we keep mentioning the Receptiva assay. It’s an assay to look at an inflammatory marker in the uterus. And so as far as failed transfers go, if the Receptiva assay is done and reveals that there’s a marker that’s positive, that’s bad. That means that there’s inflammation there.

And in that situation, I do think Lupron would be beneficial. And so you certainly can pull that up on the Receptiva website. It talks about it talks about why Lupron may be beneficial. And it may be worthwhile to show your physician if he or she is not aware of that information.

Susan Hudson MD (33:23)

Other medications are also useful. And I would say if it’s been over six months from your surgery, it might be worthwhile doing some sort of suppression. In the US, we have a newer medication called Orlissa And there is actually some newer data out as well that you can use letrozole, which is much less expensive than Lupron or Orlissa to potentially help suppress any expression of BCL6 in the endometrium, it may not be quite as effective, but maybe on top of your surgery suppression, letrozole might be a good thing to add for a couple of months prior to embryo transfer to help squelch out any of that expression.

Carrie Bedient  MD (34:08)

Oftentimes the European countries have a little bit different approach because so much of your care is covered by national health plans. So I think approaching in a couple different ways can be helpful. I think the idea that Abby had of showing kind of the receptiva data and all of that is helpful. I think Susan’s idea of letrozole.

I know that there’s some supporting data on the Receptiva site about that. It’s not quite as good as, GnRH agonist suppression, but if you can get that versus nothing, it’s totally worth it. I think some of those approaches are better, knowing that it’s coming from a national healthcare plan, being mindful of the cost of it can be very helpful and other sources to get the drugs like that may be a useful thing to consider. And also talking with someone who’s willing to think outside the box a little bit, sometimes going to a university program where their goal is to stretch boundaries and the boundaries that they may have may be different than the boundaries of somebody just out in private practice. And that’s true in many places. So, those are all things to think about that may be helpful for you as you were going through this and trying to figure out, all right, what’s the next step? What’s the best place for us to go from here?

Susan Hudson MD (35:24)

Lots of questions from around the world. It’s great!

Carrie Bedient  MD (35:28)

Germany, Hungary, Ireland. Let’s see where else we can get from. It’s fun to have people from other places weigh in and everybody’s experience, especially in the infertility world is so different because all these countries have very different rules and laws and regulations and values and all of it. So it’s fun to hear from other places.

All right, so to our listeners, thank you so much for listening. Subscribe to Apple Podcasts to have next Tuesday’s episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible. And as we’re learning all around the world.

Abby Eblen MD (36:02)

And you can also visit fertilitydocsuncensored.com to submit specific questions you have and sign up for our email list.

Susan Hudson MD (36:09)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye!

Carrie Bedient  MD (36:19)

Bye.

Carrie Bedient  MD (36:20)

This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test that can help detect inflammatory conditions on the uterine lining that might be preventing you from becoming pregnant or staying pregnant. If you have experienced implantation failure or recurrent pregnancy loss, ask your doctor about ReceptivaDx testing. If found, uterine inflammation can be treated, providing a new pathway to achieving a successful pregnancy.

ReceptivaDx because the journey is worth it.