Ep 351: Endometriosis and IVF: When to Transfer, Suppress, or Use a Gestational Carrier

0:00Dr. Carrie Bedient: 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.

0:21Dr. Susan Hudson: This episode is brought to you by Receptiva DX. What if unexplained infertility isn't actually unexplained? For many women, hidden inflammation associated with endometriosis and other uterine conditions can go undetected for years, even when everything else appears normal. For more than a decade, fertility specialists have trusted Receptiva DX to provide deeper insight into the uterine environment, helping women and their physicians uncover answers and make more informed treatment decisions. Hello, everyone. This is Dr. Susan Hedson from Texas Fertility Center with another episode of Fertility Docs Uncensored.

0:59Dr. Susan Hudson: I am here with my fearless and ferocious co-host, Dr. Keri Bedient from the Fertility Center of Las Vegas. Hi, how are you doing? Come on, I can get a better roar than that.

1:11Dr. Carrie Bedient: You probably could, but it's not just a roar is not entertaining. I think I would have to come up with something more creative for it. And I am not prepared for that. And so it may erupt at some point mid-episode, but I will not cheapen your RAR with an unconsidered RAR.

1:30Dr. Susan Hudson: Okay. All right. That's fair. That's fair. Okay. So right now, before we started podcasting today, I am working on my daughter's homecoming mom, which we will get to in a second. Mom, you're a mom? No, not like mom, but M-U-M.

1:49Dr. Carrie Bedient: Chrysanthemum?

1:50Dr. Susan Hudson: Chrysanthemum, but we'll get to what it is because my question for you, Carrie, because I'm working on this, is because homecoming mums are a very Texas thing. What is something that embodies Nevada? What is something that you think of when you think Nevada is something that is relatively unique to Nevada?

2:14Dr. Carrie Bedient: The glitz. It's the casino and it's the strip. It's the lights, the sequins, the sparkles, the feathers, the velvet, the satin. All of it together in a way that you see all of those things individually other places, but it's relatively unusual to see them all in the same place. And I hesitate to say done well because that's very subjective, but done all together in a way that is cohesive and that fits. I mean, there is a reason. For example, we recently met with a rep who's coming in from out of state to talk to us about a new drug that they're developing and blah, blah, blah, all that stuff. And I wore vegan leather is the fancy way of saying it.

3:00Dr. Carrie Bedient: Really, it's leather pants, whatever they are. They're the ones that are the Spanx, the official ones. I didn't look like a cheap hooker. That was not the goal. But I was wearing that. And in Vegas, I don't think twice about it. And frankly, I am one of the most tame people dressing-wise, you can imagine. But this guy was like, oh, my God, Dr. Beattie, and I didn't know you were that whatever adjective, glitzy, fancy, wild, whatever you want to say. And I'm looking at him going like, what are you talking about? This is tame. This is nothing. But in Vegas, it's normal. And so I think I would have to say between that and the mob, those are the uniquely Vegas things.

3:40Dr. Carrie Bedient: Makes sense. That makes sense. What's the new Braunfels San Antonio Austin vibe? The vibe on glitz?

3:46Dr. Susan Hudson: Nothing compared to that.

3:47Dr. Carrie Bedient: Well, I know that nobody does glitz better than Vegas. What are the mums supposed to reflect?

3:54Dr. Susan Hudson: So the mums is a Texas thing. I would say all of Texas pretty much participates in this tradition. Obviously, Friday night football in Texas is huge. There's TV series, movies all about how big high school football is in Texas. And I know it's big in other states, but it's a special level of crazy at times in Texas. And this kind of feeds into that fervor and that there's a homecoming game. So we're alumni and they have the dance and they have a royal court and everything like this for that type of thing. But they have homecoming mums, which they used to just be probably when I was in high school, the smaller ones were probably like three, four inches.

4:44Dr. Susan Hudson: And then the bigger ones maybe got to be maybe seven or eight inches. Nowadays, they can be essentially almost covering the entire chest of a girl and they wear them over their neck because you can't actually pin them on anymore. But so you have a mum and it's a silk flower and then it has ribbon all around it on that's like on a cardboard thing that's behind it. So you have the mum surrounded by ribbon and then you have streamers that come off and the streamers often say like homecoming or what class year they are. And sometimes they have bells, which make them super obnoxious and this type of thing.

5:23Dr. Susan Hudson: and so the girls get mums guys get garters that have like a little mum on it sometimes so anyway it's a Texas thing and it's fun and I am not an artsy person and I find actually this is one of the only crafts I enjoy every year because it's very methodical in how to make them when I was in high school my aunt made them and so I kind of paid attention so I make my daughter's mums and it's fun. And like I said, for somebody who's not artsy, personally, it's a neat thing to do because it's something I can't accomplish.

5:58Dr. Carrie Bedient: So the Vegas version of that would be two six inch mums strung together, hung around your neck in a bra and nothing else.

6:07Dr. Susan Hudson: Yeah, no, not quite that way. Yeah. Yeah.

6:10Dr. Carrie Bedient: With a big 12 inch one in the loincloth area on front and behind, like Like, that's your Vegas version of the mumps.

6:18Dr. Susan Hudson: Yeah, no, ours is much more innocent.

6:21Dr. Carrie Bedient: Hmm. Okay. Well, I can't wait to see pictures of the mum as it develops. And I'm sure it's all color coordinated and there's elaborate everything on it.

6:32Dr. Susan Hudson: Yes, yes. We are decking it out to the hilt this year. So, all right. So today we are going to do a question episode. And I do want to extend to our listeners. Thank you so much for sending us these questions because when we sit there and talk about any particular subject, there's no way that we could dive into the little intricacies we do when you send in your questions. So keep on sending them in. We love them and we'd love to be able to give you some perspective and really give all of your cohorts out there a perspective of things that can be helpful. So today we're going to talk about things relating to endometriosis.

7:14Dr. Susan Hudson: So, Carrie, would you like to read our first question? Yes. Okay.

7:18Dr. Carrie Bedient: Thank you for everything you do. Oh, you're welcome. And seconding what Susan says, we love getting these questions because we want nothing more than to help you guys. And so knowing what your specific questions are really helps us direct that. I am an intended single mother by choice. 39 years old, severe diffuse adenomyosis and suspected superficial endo. AMH 0.04. Unsuccessful three IUI cycles with letrozole. chemical pregnancy lasting one week on the third attempt sis clear no uterine scarring moving on double donor IVF so donor egg and donor sperm with three months of ultra long lupron suppression beforehand i would like to conceive with my body how many FETs would you recommend capping at before moving on to a gestational carrier is there an immune protocol you would recommend adding to lining prep how would fertility treatment look if my body transitions to permanent menopause after lubron suppression?

8:08Dr. Carrie Bedient: Great question. Okay. All right. So there's so many questions in that one. All right, Susan, pick the part you want to talk about and let's start there. Okay.

8:15Dr. Susan Hudson: So first of all, I want to talk about what adenomyosis is versus superficial endometriosis. So superficial endometriosis we think of as smallish implants on the surface of an organ, your ovaries or your uterus. Now you can have deep infiltrating endometriosis that can go deep into the peritoneum, the lining of the abdomen. You can have endometriomas, which are collections of endometriosis within a follicle of the ovary. And adenomyosis is where the cells that are normally in the lining of the uterus, the endometrium, end up in little pockets in the muscle of the uterus. And that specifically is something that has come to bigger attention nowadays now that we have some testing for a chemical called BCL-6.

9:15Dr. Susan Hudson: BCL-6 has a relationship to endometriosis. However, not everybody with BCL-6 has endometriosis and everybody with endometriosis has BCL-6, But we know that if that particular chemical or hormone is present in the lining of the uterus, it can decrease implantation rates and it can also increase miscarriage rates. Now, in this listener's situation, she has been advised, because of the possibility of having this present, she's just prophylactically using Lupron, which is an injectable medication that essentially temporarily makes you menopausal for a few months prior to embryo transfer to make any of that chemical go away.

10:01Dr. Susan Hudson: And there's a number of ways you can accomplish it. This is one of the ways. And really, she's looking to see what should happen in the future. I think this is a great way to move forward. I think that considering her ovarian reserve, it's very low using donor egg and donor sperm or considering using donor embryos, very personal choice. but those are great ways to improve her chances of carrying a pregnancy herself, that I think she has a very good chance of being successful with embryo transfers. Now, how many embryo transfers do you stop before moving to a gestational carrier? I'm going to pause here and let Carrie state something, and then we'll kind of go back and forth on this.

10:48Okay.

10:50Dr. Carrie Bedient: So transitioning into how many you do before you move to a gestational carrier, that is an intensely personal decision that has about a dozen things factoring into it. And I oftentimes meet with people who are thinking about using a gestational carrier. And I had a consult relatively recently where it was a single mom by choice who was in a very similar situation that you were. And she was really worried about how her body was going to do in pregnancy because of her endohistory and because of the amalgamation of everything that was going on. And choosing to work with a gestational carrier, if you have to do it, is phenomenal.

11:28Dr. Carrie Bedient: These women are amazing. They are volunteering to carry a pregnancy for another person. And yes, they get paid for it. But the reason I say volunteering is that for the vast majority of women, there is no amount of money that you could give them that would make them go through pregnancy if they didn't have to to build their own family. This is a special person and a special kind of love that allows gestational carriers to go forward. And when you are working with one, there is a huge amount of not just logistics, but things you have to consider going into it. Because when someone is debating whether or not to move on to a gestational carrier, rather than being absolutely forced.

12:10Dr. Carrie Bedient: So for example, if you've had a hysterectomy, if you are a single dad or a male couple, you don't have a choice. You have to use a gestational carrier because you have no other way to achieve that goal using the embryos that you're desiring. When you do have a uterus, even if it is affected by endometriosis or adenomyosis, that's a little bit different criteria because most of the time someone would say, okay, one is probably too early. One failed transfer is too early to jump. Six or seven may be where someone starts to consider it. And there is a hell of a lot of gray area in between. And Susan and I have both had patients who gestational carrier is just period, not an option.

12:50Dr. Carrie Bedient: And so we've done far more than that to get it to work. But when you're thinking about using a gestational carrier, you have to think about the money. Because right now, the numbers that I'm hearing the agency's quotes, like$150 ,000 to$200 ,000 by the time you factor in all of the compensation, the IVF cycles, the legal, the medical, all of it coming together. What is more important to me is you need to make sure that you and your gestational carrier are on the same page because if you have a difference of opinion about reasons that you would terminate a pregnancy, when you would do a c-section or otherwise, there are contracts that are agreed upon ahead of time, but no one can force someone to do something with their body that they don't want to do.

13:30Dr. Carrie Bedient: And so really making sure that you and your GC are on the same page is important. And what I think is probably the biggest thing is that most people who are in fertility treatment are very driven. They are very much on top of their lives and they want control. And especially about your baby, you want every last measure of control. And you do not get that with a gestational carrier, no matter how amazing she is. You cannot reasonably say, I want you to have green peas, six slices of lettuce, 12 carrots, and a medallion of organic chicken that was baked at 325 for 26 minutes to an internal temperature of 167.

14:08Dr. Carrie Bedient: And that sounds kind of like, oh, she's being over the top. Well, there are things that you do when you're on pregnancy that may seem to be kind of crazy, but if they make sense to you, and that's what you want to do, that's what people do. And we see this all the time. And that is a level of control you do not have with a gestational carrier. It is a very intensely personal decision that is governed by so many factors. It is well worth a conversation with your doc, your family, or whoever is close to you to think about some of these logistics of what am I not considering? Because there's a lot that goes into it.

14:40Dr. Carrie Bedient: And I agree with Susan. Endo and adeno, usually with the meds, we can overcome that.

14:45Dr. Susan Hudson: So another thing to consider is not all clinics will allow you to use donor egg, donor sperm, or donor embryo in combination with a gestational carrier. And the reason is, is because we honestly like someone to literally have skin in the game. And it helps prevent situations of child abandonment. And it sounds absolutely terrible and people think, oh, it wouldn't happen. But weird things happen. And it really changes the dynamic when we are either using your uterus or we are using your egg or your sperm. It can make a difference in the legal standpoint. I can tell you, like, at our clinic, we don't permit somebody who's using donor egg, donor sperm, or you can use one or the other, but not together, or donor embryo in a gestational carrier.

15:45Dr. Susan Hudson: And that's going to vary from clinic to clinic, but it's a very real reality that you need to find out if that's available where you are seeking care or if you would have to seek care elsewhere. I've had patients who have had to transition to something like that, and I helped them find somewhere that they can do that, but it is more limited. The other thing I wanted to comment on, you asked about how does your fertility treatment look if you somehow transition into full menopause, so not having any periods after undergoing the Lupron suppression. Honestly, it really doesn't change things all that much.

16:22Dr. Susan Hudson: In fact, in some ways, it kind of makes it easier. And that's not something I would really worry about since you've already made that transition to using someone else's eggs.

16:33Dr. Carrie Bedient: And just to make sure it's clear, Lupron suppression will not make your body go into menopause. So Lupron is a temporary hormonal suppression. So it's a medical menopause, but your body doesn't stay there if it wasn't otherwise going to stay there. And so if you're not in menopause and you take Lupron for two, three months, that's not going to make you go into menopause. So don't worry about that. And much of the time that people are thinking about doing Lupron for treatment leading into a transfer, they read everything online. And what they're looking at online in the endometriosis forums tends to be discussions about long Lupron protocols for endometriosis suppression outside of fertility.

17:16Dr. Carrie Bedient: This is where you're using Depolupron for six months, 12 months, or longer at a time. And there's a lot of conversation about bone loss and how you feel on it and all of the effects of it and it is very scary to consider. That is different than in the setting of fertility where, yes, we are giving you the Lupron, but it's usually for a very limited two to three month interval. And then right after you are getting a hormonal jumpstart again. And this is not a situation where you're on Lupron for a year and then we are hoping that you don't have any hormonal expression. This is, you're on Lupron for two months, and then we're usually actively giving or encouraging hormones in your body.

18:00Dr. Carrie Bedient: It's a different scenario. Before you dive into that particular morass of chat rooms and information online, know that it's different. And the things that you want to achieve in treatment of plain endo are different than infertility endo.

18:15Dr. Susan Hudson: Absolutely. let's play a game how many tabs do you have open right now about IVF one says your chances are great another says they're terrible reddit has one opinion tiktok has another facebook is full of horror stories and somehow after two hours of searching you have more questions than answers sound familiar that's exactly why we wrote the IVF blueprint this isn't another fertility book filled with opinions or miracle cures. It's an evidence-based guide that walks you through every stage of IVF, from understanding your fertility evaluation and choosing a treatment plan to medications, egg retrieval, embryos, genetic testing, transfers, and the two-week wait and beyond.

19:02Dr. Susan Hudson: Because the last thing you need during IVF is more noise. Close the tabs, put down your phone, open the IVF Blueprint instead. Available now wherever books are sold.

19:16Dr. Susan Hudson: Okay, our next question. I've been trying to conceive for four years with zero positive tests. I've had three failed PDTA normal embryo transfers. I had stage 4 endometriosis excised last year, and the surgeon noted mild to moderate adenomyosis. Now I am on Lupron Depo suppression for my fourth transfer. I am suppressing for two months, but my doctor has my baseline scheduled for two weeks after my last Lupron depo shot. So I could start estrogen around the time Lupron has been in my system for only six weeks. Does that count as two months of suppression? I've heard of other patients who didn't have their baseline until after eight full weeks of Lupron instead of six for me.

19:59Dr. Susan Hudson: Is there a difference in terms of success?

20:02Dr. Carrie Bedient: That was a really interesting distinction. The studies that are out there show eight weeks is the optimal for suppression. But now that you ask this very deliberate question about when you start estrogen, my inclination is to say eight weeks before you start the estrogen is better. But I don't know that that's really been truly teased out. They found that more time doesn't necessarily give an improvement, two months versus three versus four, but that less time, for example, doing it only for a month has a lesser effect. And so for me, my patients, I make them go eight weeks before we'll start meds.

20:43Dr. Carrie Bedient: What do you do, Susan?

20:44Dr. Susan Hudson: I do exactly what you do, Carrie. I have eight weeks of full suppression, and then I introduce meds. I think what we're trying to say is there is no data that we can say that six is not as good as eight. We know that four is not as good as eight weeks. And we know that eight is as good as 12 weeks. So you're somewhere in a gray zone and it's not what we would personally do, but we can't say that it's wrong either.

21:14Dr. Carrie Bedient: I would suggest after you've been trying for this long, if there's something about it that after you think about it, you're uncomfortable and you're like, I really want those extra two weeks. I would talk to your clinic about it because much of the time as we're considering what do we do and how do we do it. Part of the consideration is what do we have data for? The other consideration is what decision making are we all going to feel good about after the fact? Because we don't control anything besides making the decisions. The rest of it is up to the universe, not up to us. And so if you really feel like I'm going to regret this if I only do six weeks of Lupron, push for the extra two.

21:48Dr. Carrie Bedient: If you feel like, okay, my clinic is doing this for a reason, they know that this works in their hands, then great, go with the six. So you can make an argument for that either way, but I would say that it's worth a conversation and it's worth you thinking about imagining the worst case scenario. Imagine you do it and you don't get pregnant. What decisions are you going to regret and wish you had done otherwise?

22:09Dr. Susan Hudson: Absolutely.

22:11Dr. Carrie Bedient: Next question. We, a 38-year-old female, 35-year-old male, have eight euploid embryos from three retrievals and want two to three kids. Suspected endometriosis and was on birth control for 10 years, but still spotted throughout. Had a biochemical three months after stopping birth control and had two failed IUIs. During stims, my lining was trilaminar in eight to nine millimeters, but five to seven days after each retrieval, I start spotting and bleeding. My REI thinks endo could be worse than we thought and says there might be more cause in this case to do testing and treatment before transfer.

22:40Dr. Carrie Bedient: Also spotted through progesterone suppositories during the IUIs. The REI is giving us a choice between transferring first, which seems like they lean towards, doing a receptiva first, or going straight to a 90-day loop run suppression. So many pros and cons. Do you have any recommendations? Thank you.

22:55Dr. Susan Hudson: Okay. I'm going to break down some of the things that I think are important and not important because these are all good pieces of information. I don't think that being on birth control hurt you. And if you do have endometriosis, it may have helped keep it at bay, which is a good thing. The fact that you had a biochemical knows that it can happen, but that you've also had a miscarriage. Important thing to put in there. Lining got nice and thick. And having bleeding five to seven days after retrieval, normal, normal, normal. So that's what we expect to happen. We don't expect it to happen two weeks out.

23:31Dr. Susan Hudson: So it's not like you ovulate and then we're expecting something to happen at two weeks. It's really at that one-week time period. So that's all good. some of the spotting through progesterone suppositories during IUI. A little hard to interpret how important that was. I'm assuming you've had a saline ultrasound or some other measure of making sure the lining of your uterus is without fibroids, polyps, those types of things. As there is a concern that you've had suspected endometriosis, I'm guessing maybe they've seen endometriomas on your ovaries, maybe concerns about some ultrasound findings on your uterus.

24:09Dr. Susan Hudson: Lupron is not necessarily a fun thing to go through. I think that doing Receptiva is a great way to say, hey, do I really need to spend two or three months on a suppressive medication? Number one. Number two, paying for Lupron, it's expensive. And so if you have a proven an indication like a positive receptiva test, a lot of insurances will now, not all, but a lot of them will cover the cost of the medication. So that gives you an additional reason to do that. Now, if you're just like, I want to cut to the chase, I want to do the suppression, do the suppression and go. It's not a wrong decision.

24:52Dr. Susan Hudson: Aeuploid embryos wanting two to three kids. I would say if you wanted to move forward with an embryo transfer, you don't have to do anything ahead of time. If you had two to three embryos and you had two to three kids and we had all this stuff going on, I'd probably be a lot more pushier. But I do think that you have choices. And I can say that in fertility care, it is always, always, always a good thing when we give you choices. Because there are a lot of times we don't give people choices or it really doesn't feel that way because the choices are something that is positive and the choice is something really negative, I think you have a lot of good things going for you.

25:32Dr. Carrie Bedient: I would agree with that. Again, it goes back to what decisions are you going to be most comfortable with? And I think if you said, I want to be conservative and go straight to Lupron, great. I think if you say, I want to avoid this at all costs, then you maybe do a transfer without any Lupron. You have enough embryos so that you've got a little bit more wiggle room than most people have, which is a great place to be in. And I think if you want to kind of cut your losses and hedge your bets, you say, all right, let's do the receptiva because if it's positive, then all right, fine, we just do the Lupron.

26:01Dr. Carrie Bedient: But if it's negative, then you feel a little bit better about doing a straight protocol. And then if it doesn't work once or twice, however long it takes for you and your REI to say we need to change plans, then maybe you do Lupron then. There is no one right way to do this because if there was, we would just be doing that. The fact that you have options, like Susan said, is phenomenal because it buys you a little bit more confidence that, okay, we can do anything. All right, what's our next question?

26:28Dr. Susan Hudson: Hello, I am 23 years old and just had a laparoscopy to remove stage 2 to 3 endometriosis. I also had a right salpingo-ooforectomy, meaning their right tube and ovary, removed due to damage, and my left tube was patent or open, but the fembre, the ends of the fallopian tube, were club. Do you recommend looking into IVF due to risk of ectopic or trying to conceive naturally? My husband has a semen analysis and it was mostly normal aside from low motility and morphology. Thank you.

27:03Dr. Carrie Bedient: Ooh, so this is interesting because we see these kind of questions a lot in our 33 to 38 year old crowd. We don't often get them in the 23 year old crowd. This means that just because of her age, she has a little bit more in terms of options. So things that I would think about here. Number one, what is your actual trying to conceive history? And what I mean by that is not when you guys decided you wanted kids, but when you were not doing anything to prevent them. So not using condoms, birth control pills, IUD, Depo, whatever it may be to block a pregnancy. When did you stop doing that? Because whether or not you were thinking you wanted a baby, at that point, you were starting to try for a baby.

27:49Dr. Carrie Bedient: And sometimes people look back at this and they go, no, it's very clear. I was on birth control until X point. And then I came off. And other times people think about it and said, oh, well, we've been trying to conceive since February, but I haven't used birth control pills in the five years we've been together. And that's a really important distinction. And so determining that is huge because if you have an answer that is, I haven't been on birth control for a longer period of time, time, that is you're trying to conceive naturally. You've already done that trial and you don't need to keep doing it if you're ready to have a baby and you want to move forward.

28:22Dr. Carrie Bedient: So that's one thing to think about. With looking into IVF due to the risk effect topic, that is half the question, but it's not the whole question because you also mentioned low motility in the sperm analysis. And low motility can mean anything from it's supposed to be 42 % and it's 40 % or it's supposed to be 42 % and it's 2%. And those are wildly different situations. Progressive motility is going to factor in as well because it's not enough to be moving. We're looking for the Olympic swimmers. And when you look at motility evaluations, you've got your Olympic swimmers, that's rapid progressive.

28:57Dr. Carrie Bedient: You've got your Sunday afternoon strollers, that's slope progressive. And then you've got your couch potatoes. These are twitching, so technically they're modal, but that's really all you can say for them. And so knowing more of those details is important because we want to make sure that if you've got one of those really low total modal counts, yeah, you probably do want to jump to IVF a little bit faster because you've got one tube that's gone and the other one is clubbed. And clubbed fimbriae mean that they can't just gently reach out over the ovary and draw in that egg. And so you are looking at a considerably higher risk of an ectopic and a considerably higher risk of just negative pregnancy tests.

29:37Dr. Carrie Bedient: Don't waste the fact that you're 23 years old. Use that to your advantage and get the good advantage of the high success rates you have. That said, if you say, okay, we want to go another six months, nine months, as long as you are tracking your pregnancy potential very carefully, track your periods religiously, take good notes, know when you have intercourse, check regularly for positive pregnancy tests. If you're supposed to get a period on the first of the month and it's the second or third and you haven't gotten it, You take a pregnancy test because that is how we check early and catch ectopic pregnancies and keep you out of trouble.

30:11Dr. Susan Hudson: Another thing I would comment on, and again, this is just reading between the lines. If you've had this entire initial evaluation with your general OB-GYN, I do think it's time for you to have a consultation with an RAI or reproductive endocrinologist. because a lot of people go and have surgery. They may get a basic semen analysis and have these basic findings and be kind of sent on their way. And I think this is the time that you need a higher level of care.

30:42Dr. Carrie Bedient: I would agree with that. Next question. Hi, I have been listening to fabulous experts. Oh, thank you very much. Since 2022 when I found out I have DOR, endometriosis and would need IVF. I look forward to each new episode every week. Oh, thank you. Thank you. All warm and fuzzy. My question. I'm turning 40, have two euploid frozen embryos. Yay. One day 5 for AB and one day 6 to 7 for BB. I have silent endometriosis with a tiny 14 millimeter endometrioma, but my MRI didn't show deep endo. I ended up getting spontaneously pregnant in 2023 and have a two year old. My RE doesn't think that I need to treat the endo with meds or surgery, but I have a mixed doc and laparoscopy lined up.

31:23Dr. Carrie Bedient: I'm scared of Lupron, had one trigger with it, had heart palps and DOR, and it might overly suppress my body. Do I have surgery or go straight to FET? I'm scared to lose my two precious embryos.

31:36Dr. Susan Hudson: Well, this is one of those times when it's good to have options. So we have been mainly talking about so far in this episode, surgery versus Depo-Lupron. for suppression of endometriosis. There are two other medications that can be used in this type of situation. I use one of them a lot. I have used the other one a handful of times in people who've had contraindications or multiple reasons why. One of the medications is something called Oralisa. And Oralisa is a pill that essentially kind of does the same thing as the Depo-Lupron, But the nice thing about it is you can stop taking the pill if you start having major side effects, which is a nice thing to do.

32:24Dr. Susan Hudson: I actually probably use Oralisa more often than I use Depolupron just because I offer both to my patients. And the idea of taking a pill at the point that you're at is a lot more palatable than having to take those two intramuscular injections. The other option is using letrozole. So yes, the same medication we use to help you get pregnant in ovulation induction cycles, if we use it in certain ways, can help suppress endometriosis. And I also have been very successful in the handful of times that I have gone to that option. Surgeons like to do surgery. And I think a lot of times people don't necessarily have to turn to surgery just to help get rid of endometriosis that's in the lining of the uterus.

33:16Dr. Susan Hudson: That is what's specifically affecting their chances of being successful with the FET. Your thoughts, Carrie?

33:23Dr. Carrie Bedient: So I think whether or not you're having other symptoms really plays a large part in this. And you mentioned it's silent endo. And so I tend to be very hesitant to go to surgery unless there's either a really clear indication that we're going to be getting a benefit or we really don't have any other choice. And so here, I would tend to go more with the Oralisa route just because if there truly is endo and you're not having any symptoms, then laparoscopy won't necessarily be able to get all of it. And you can get everything on a much cellular, microscopic level better with the medications than you can with surgery.

34:01Dr. Carrie Bedient: So that's how I would approach it. Depending on how many more kids you want, if you want two more kids, then you take the most conservative approach because you've got to maximize those embryos. I think if you just want one more, then you've got a little bit more flexibility. But the other thing with endos, I always worry about people getting surgery on their ovaries, even if that wasn't the original intent. Don't go after a 14-millimeter endometrioma when there's any possibility. You might need to do another egg retrieval in the future. That is doing surgery on the ovary that is unlikely to benefit you and has the real potential for decreasing your ovarian reserve when we don't want to do that any more than it already is.

34:39Dr. Susan Hudson: Absolutely.

34:40Dr. Carrie Bedient: All right.

34:41Dr. Susan Hudson: Our next one. Thanks, docs, for your insight and support. Thank you for listening. You are all being so much fun and calm in one of the worst of times. I just wrapped up my second egg retrieval after failed euploid transfers had one chemical pregnancy. I've been diagnosed with PMOS since early last year, but just had a Receptiva Emma Alice ERA that showed endometriosis. Are there any specific guidelines when PMOS and endometriosis are party to the equation? Do they play a role in each other at all? Thank you for your insight.

35:17Dr. Carrie Bedient: Endometriosis and PMOS are two distinctly different pathways. PMOS is more related to insulin resistance and endometriosis is more related to an inflammatory response. And so treatment guidelines, once you get to the point of having a transfer, we're past egg retrieval, which is really where these two things intersect, the PMOS and the endometriosis. Once you're past that point, when you get to transfer, it's a little bit more straightforward because I think the PMOS plays a lesser component of this. Because even if you don't get periods at all, once you bring on a period, you're in a pretty good place and your management doesn't necessarily differ from anybody else who does or does not have PMOS.

36:04Dr. Carrie Bedient: So I think at this point, it is much less important. I think whether or not you go ahead with those medication suppression protocols that we talked about, whether or not you decide I want to do surgery to try and chase this, which given that you didn't know about it until now is probably not high on the list of things to do. I think paying more attention to the endometriosis as you plan and transfer makes sense. With the PMOS, it is oftentimes accompanied by prediabetes and having a higher weight and BMI. Get those under control because those will have a negative impact on your transfer success rate.

36:40Dr. Carrie Bedient: But in general, the PMOS doesn't have as much of an impact on the transfer. What do you think, Susan?

36:47Dr. Susan Hudson: Yeah, honestly, PMOS, once we get to IVF, is what I consider a strategic advantage because you're more likely for us to get more eggs. And the more eggs we have, the more chances we have with the fewer number of retrievals. Honestly, I think it's something playing into your favor. Yes, make sure you have good blood sugar control. Make sure your weight's good. Make sure you don't have any uncontrolled high blood pressure, those types of things. But at the point that we have embryos, I would really focus on any endometriosis-related sequelae.

37:19Dr. Carrie Bedient: All right. Let's do one more question. I'm writing in for your opinions on transfer protocols for endo. Background on me. 36 years old, started IVF when I was 34, four IVF cycles with ICSI, resulting in one aneuploid, two low mosaic, and teneuploid. A husband's semen is low average count and low morphology, three transfers, found out I have endo during a mock cycle, two months of Depolupron, a modified natural cycle transfer with pepsid claritin, low-dose naltrexone, lovinox, baby aspirin, and neupogen wash. It worked, but we found out they were conjoined twins and there was no longer a heartbeat at 10 weeks.

37:53Dr. Carrie Bedient: Did another transfer and found out it didn't work with an HCG of 83 during the first check up to 110, up to 128. Might be a next topic. What do you recommend I do next for a transfer? Taking a break and trying naturally.

38:05Dr. Susan Hudson: So my first thought is you've been through a lot between those two cycles. Also, those cycles have taken some time. So it's good if you're just needing to take a moment, which is completely good, because you do need to be in the right headspace going into embryo transfer. I think the mental focus on this is going to work has a huge impact. The other thing is I generally consider any treatment you did to get rid of BCL-6. You did two months of Lupron, but you've had all of these events. And I imagine six plus months have gone by. I usually retreat once we get to six months. Now, that is not based on any specific evidence having to do with the treatments with either Lupron or Oralisa.

39:00Dr. Susan Hudson: It's really based on the fact that we know that if somebody has surgery for endometriosis, that if it's going to recur, it usually starts to recur around six months. That's what I do in my protocols. I think that there's a lot of things going on, but don't get lost and forget about the important things you were doing to improve your outcomes.

39:21Dr. Carrie Bedient: I think that the big thing to hang on to here is that you've had two transfers that have worked. You may not have ended the way you wanted, but they worked. And really taking a look at what were those protocols. And I would be rather inclined to say stick with those types of protocols because if it works for you, if it ain't broken, don't fix it. And while many people would make the argument, it is broken, I don't have a baby, the conjoined twins, that's got nothing to do with anybody. That is a random nephew from the universe. And I'm sorry that you got that, that one in particular. But the most important piece of information you're taking away from that is that the protocol worked.

39:58Dr. Carrie Bedient: The next transfer that didn't work, even though it didn't work, you still got implantation, you still got rising levels. I don't know if I hope it's in a topic for you or not. I don't because they're a pain to manage, but also that's a great reason. If something's not going to work, that is a reason you want because it doesn't say nearly as bad things about what might happen in the future. I think sticking with the types of protocols that you have used previously is probably reasonable. I don't know all the reasoning behind why they gave the pepsiclaritin, Naltrexan, Lovenox, Baby Aspirin, Nucan Dynolash.

40:31Dr. Carrie Bedient: That's an awful lot of adjunctive treatments, but I'm assuming your RE's got reasons for all of them. Knowing that you had a couple of positive pregnancy tests, even if they didn't end the way you wanted, I think it's reasonable to take a look at those protocols and say, OK, we want to keep at least the core factors of this similar and see what makes sense to do. The other thing to think about is what's changed between those first couple of transfers that didn't work versus the ones that did and seeing was there a big protocol change or were the protocols the same all the way through, in which case it's probably the embryos that related to this.

41:04Dr. Susan Hudson: Absolutely. I agree. anything to add, subtract, multiply or divide? No, just thank you so much for sending your questions to us. It's great to be able to dive into these different subjects and hopefully provide some perspective for other people out there. So thank you so much for spending a part of your day with us.

41:24Dr. Carrie Bedient: If you enjoyed the episode, subscribe, leave a review, and send us your questions at fertilitydocsuncensored.com.

41:30Dr. Susan Hudson: And if you want even more fertility information, pick up a copy of the IVF Blueprint, our practical guide to understanding fertility treatment, IVF, and the decisions you'll face along the way.

41:40Dr. Carrie Bedient: Before we go, remember this podcast is for education and entertainment only.

41:45Dr. Susan Hudson: While we are fertility doctors, we're not your fertility doctors.

41:48Dr. Carrie Bedient: Nothing we discuss should replace medical advice from your own physician who knows your individual history and circumstances.

41:54Dr. Susan Hudson: Thank you so much for listening. Bye. Bye. This podcast is sponsored by Receptiva DX. When fertility questions remain unanswered, Receptiva DX helps reveal why. Trusted by fertility specialists for over a decade, Receptiva DX identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, Receptiva DX helps women and their physicians make more informed treatment decisions and move forward with confidence. you