Deborah Howell (Host): Endometriosis is an often frustrating and painful condition for many women, and in some cases, it can be linked to infertility. With us today to help us unravel the mysteries around endometriosis is Dr. Allison K. Rodgers, a Reproductive Endocrinologist at Fertility Centers of Illinois. This is the Time to Talk Fertility Podcast. I'm your host, Deborah Howell. Dr. Rodgers, so nice to have you with us today.

Allison K. Rodgers, MD: Thank you so much. I'm happy to be here.

Host: Let's dive right in. What is endometriosis and how is it commonly linked to infertility in women?

Allison K. Rodgers, MD: Endometriosis is a condition where the lining of the uterus, instead of coming out through the vagina with your period, can actually go backwards through your fallopian tubes. And for everyone has this, it's called retrograde menstruation. The menstrual fluid can go backwards, but for most people, the fluid and the glands, it just gets absorbed by the body.

But for people with endometriosis, those glands are very sticky and they can stick to the fallopian tubes. They can stick to the ovary and all of the ligaments sort of behind the uterus. And every month when your hormones change, those transplanted glands that are stuck where they're not supposed to be, cause bleeding, pain, scar tissue.

And that is really what endometriosis is. And it can cause issues with the way the ovaries function. It can cause issues with the way the fallopian tubes function. And that is why it is so common patients who have trouble with infertility. So if you look at infertility patients as a whole, about 25 to 50 percent actually have endometriosis. In the whole population, it affects about 10 percent of women.

Host: And what are the typical signs and symptoms of endometriosis that infertility patients should be aware of? And of course, when should someone seek medical advice for those symptoms?

Allison K. Rodgers, MD: The two main symptoms are pain and infertility. So infertility as diagnosed if you are under 35 years old and you've been trying for a year, or if you are 35 and over, and you've been trying for at least six months, you should get evaluated. From a pain perspective, a lot of people have pain with their periods.

So sometimes it's hard to try to tease that out. A lot of times people will get pain around ovulation, with intercourse, and if you're someone whose pain starts before the actual bleeding starts, you'll hear people say, my period starts, but a few days before, I know I'm going to get it because I have serious cramping; those are people who are likely to have endometriosis and it's a good idea to get evaluated.

Host: And does endometriosis ever go away just on its own?

Allison K. Rodgers, MD: Yeah, usually it goes away at the time of menopause. So as soon as the ovaries sort of go to sleep and shut down, that is a time where we can see the endometriosis go away on its own.

Host: Oh, that's a good thing anyway. Now, how does the diagnosis process for endometriosis work, especially within the context of infertility treatment?

Allison K. Rodgers, MD: I think this is truly one of the most frustrating parts of endometriosis. This is one of the things that make it so difficult to diagnose and so difficult for patients because a lot of the symptoms they're having of pain and infertility can be caused by lots of different things and it's not such an easy thing to diagnose.

So the true way we diagnose endometriosis is a surgery called a laparoscopy, where we make an incision in your belly button, put a camera through, and take a look at your insides. Now obviously that's invasive. There's risks with surgery. And so, that is something that we don't do for everybody anymore.

So we used to do that a lot more than we do now. So I think that a lot of times we have presumed endometriosis. If you are coming to see me and you have pain with your periods, if you have infertility, that may be something that we're on the lookout for. Now, sometimes people can have significant or severe endometriosis that we can see on ultrasound.

We call this an endometrioma, where they have a endometriotic cyst that's forming on their ovary. And that is definitely advanced stages, but a lot of people have endometriosis that we can't see. There are some less invasive ways. So there is a test that's relatively new, it's probably been around 5 to 10 years, and it's a biopsy of the uterus, the brand that produces it is called Receptiva DX, and we do a biopsy of the uterus and send it out for some special staining called BCL 6, and it will tell us if you're at increased risk for endometriosis, or inflammation associated with endometriosis.

So it's not the same as having a laparoscopy, but it's a less invasive. You can have a biopsy done right in your doctor's office. And it's a lot less invasive and can give us some clues sometimes. So I think that the question really becomes of what do you do with those results? Because, I don't necessarily recommend that test for everybody who has infertility, right? Because if you have infertility and you have endometriosis, fertility treatment is the cure.

Not for the endometriosis, but for the infertility. And so, working through fertility treatments is often all we need to do to help people find success. So it's not always necessary that we give it a title and a diagnosis.

Host: Now, regarding, since we're talking about surgical intervention for endometriosis, there's recent research that suggests it might not be the best option for all patients because of its potential effects on fertility. Can you elaborate on these findings and their implications?

Allison K. Rodgers, MD: This is a really interesting balancing act. So, endometriosis lands on the outside of the ovary and it can cause destruction and damage to the eggs that are sitting on the outside edge of the ovary, and it can cause significant decrease in the number of eggs or what we call ovarian reserve, both in quantity and quality.

And when we think about having surgery where we remove this endometrioma from the ovary, we're actually having to remove part of the ovary. Even in the best of surgical hands, removing part of the ovary, and that is going to decrease the egg count further. So, obviously, every case is an individual.

If the endometriomas are small enough, and we can get to the eggs, a lot of times we'll consider doing something like IVF and leaving the endometriomas in place. And so we're not removing part of the ovary, which can further decrease the number of eggs we have access to.

Host: Very complicated. So for patients considering assisted reproductive technologies like IVF, how does endometriosis affect their treatment plan and success rates?

Allison K. Rodgers, MD: So it's so interesting. Of people who have endometriosis, only 30 to 50 percent of them have infertility. So just because you've been given this diagnosis of endometriosis, doesn't mean for sure you're going to be infertile. So, we often put a whole picture together of how old is the patient, how many more children do they want, do we think their fallopian tubes are functioning, what's the sperm quality, there's a lot that goes into being fertile, right, and we have to take all of that as a whole picture, not just this one aspect. I think that we might be more tempted to do IVF if we think there's damage to the fallopian tubes or other treatments aren't working as well; if we know somebody has endometriosis or if their egg count starting to drop, it might be dropping quicker. But I think that we, in general, treat patients with endometriosis like we would treat any infertile patients. We work through treatment, but we obviously keep that in mind when we're doing treatment planning.

Host: And now I'm curious, how does endometriosis affect egg quality and quantity, and how can egg freezing be a beneficial option for those affected?

Allison K. Rodgers, MD: Endometriosis can absolutely damage and cause destruction to the eggs that are sitting on the ovary. We see that it can affect both egg quantity and quality. So there was this really interesting kind of landmark study that was done years and years ago.

And they took people who were egg donors that had endometriosis and they took these egg donors with endometriosis and put them into recipients, intended parents that did not have endometriosis. And the eggs from that person with endometriosis, even though they were young and stuff, did not do as well in the person without endometriosis as the donor without endometriosis. So, if you compared egg donors with and without endometriosis, we had better pregnancies from people without endometriosis. So, that study sort of showed that it's not just, toxins or the environment of the endometriosis causing all this like scarring and other things.

There's something about the fact that it affects the actual egg quality. Now I don't want to scare anyone with that because obviously IVF is the treatment that can really help and lots and lots of my patients who have endometriosis go on to have super super successful pregnancies. But I think it's something that we just need to keep in mind.

Host: Absolutely. Now, how do the stages of endometriosis affect decisions around egg freezing and fertility treatments? And Dr. Rogers, is there an optimal time for patients to freeze their eggs?

Allison K. Rodgers, MD: So let's get into that a little further. So endometriosis is staged, stages one through four, and this is purely staged on how much endometriosis is seen at time of surgery. So you cannot officially be staged with endometriosis unless you've had surgery and most people don't have surgery. So, if we see the endometrioma on ultrasound, it's at least a stage three or four, so we can kind of guess.

I think that if you have minimal endometriosis, then the question is, is how many eggs does somebody have And what is their long term goals? So it really depends on that. Obviously, if you have advanced stages of endometriosis, we're more worried about fast destruction to the eggs, destruction of the fallopian tubes, that may cause your pelvic organs to not function the way we want. So that being said, in terms of egg freezing, if you are not ready to have a family yet and you're in your twenties and thirties as the sort of ideal range, the sooner, the better. Your eggs will never be as healthy as they are now. And we know that not all, but a lot of women with endometriosis lose their eggs quicker.

Host: Got it. Now, I'm hoping we can discuss the advancements in technology and medicine that have improved egg freezing outcomes, including those with endometriosis.

Allison K. Rodgers, MD: So the great thing about egg freezing is that it is a very successful tool that we have to preserve your fertility. Both egg freezing and, if you have a partner, possibly embryo freezing. And with this technology, the more eggs you get at the younger age you are, the better your chances of success.

But egg freezing is not experimental anymore. Not every single egg survives the thaw, but a lot survive the thaw. If you look at nationwide, it's about 80 to 85 percent of eggs will survive the thaw. This is very clinic dependent though. So at our clinic, it's much higher than that at Fertility Centers of Illinois.

It's probably in the 90 to 95 percent range. And this is why it's really important to choose the right fertility clinic to freeze your eggs when you're thinking about it. You really want to choose a clinic who does a lot of egg freezing and thawing.

So if you find a clinic who freezes eggs for an egg bank, those are clinics that have proven success if they're working with an egg bank to freeze eggs. We know that they can freeze and thaw those eggs. And that's one thing that you can look at. I've been at FCI for 10 years and we've been freezing eggs that whole time.

So certainly we're one of the leaders in the field in terms of egg freezing, but wherever you are, it's important to choose a clinic that does a good job.

Host: And you can ask them what percentage of their eggs survive the thaw, correct?

Allison K. Rodgers, MD: Absolutely. And a clinic should be able to let you know that.

Host: And for patients with endometriosis, considering egg freezing, what are the critical factors they should consider when choosing that fertility clinic other than those that we've talked about already?

Allison K. Rodgers, MD: Obviously the lab is number one. I also think that it's important you find a provider that you feel comfortable with, that you feel like you can have a conversation with that explains things well. And also certainly like looking at, when we do egg freezing treatment, you do need to get ultrasounds and blood work.

And is that a clinic that is convenient for you? Is that a clinic that's in your insurance network? And so those are all things that are important to think about. But first and foremost, this is something that you don't want to have to do again. While there's never a guarantee, the better the eggs are at freezing, the better they will come out of the thaw. And so picking the best lab that you can be in, is definitely the number one thing I would look at.

Host: Yeah. That just makes sense. Is there anything else you'd like to add to our conversation?

Allison K. Rodgers, MD: I wanted to just say, a lot of women have endometriosis. And a lot of women who see me as a fertility doctor have endometriosis. And I actually had a patient today who felt like, she just felt like this was taking over her life, in terms of pain and fertility that she had no control.

And what I will tell you is you should have hope. Endometriosis can be very painful and I think a lot of women go to doctors and report pain and are not always diagnosed appropriately or in a timely way. But it's important you find a doctor that is listening to you and taking your concerns seriously and there is a lot of hope and if you want to be a mom, you will be.

Host: That is just such solid and hopeful advice and excellent information, Dr. Rodgers. Thank you so much for being with us today to share your expertise.

Allison K. Rodgers, MD: Thank you so much.

Host: That was Dr. Allison K. Rodgers, a Reproductive Endocrinologist here at FCI. You can schedule an appointment to talk to a fertility specialist at 877-324-4483, or visit fcionline.com for more info. And if you enjoyed this podcast, you can find more like it in our podcast library, and make sure to give us a like and a follow if you do. That's all for this time. I'm Deborah Howell. Have yourself a terrific day.