Pelvic Pain, Endometriosis, and Fertility
Dr. Alan Martinez discusses the many contraception choices available, the right way to use them, and whether they'll affect your ability to get pregnant in the future.
Featured Speaker:
After graduating with distinction with a B.S in biology and B.A. in psychology from San Diego State University, Dr. Martinez received his medical degree from the David Geffen School of Medicine at the University of California, Los Angeles. He completed his obstetrics and gynecology residency training at Saint Barnabas Medical Center, an affiliate teaching institution with Rutgers New Jersey Medical School. He completed his fellowship training at the University of Cincinnati Medical Center.
Alan Martinez, MD
Dr. Alan Martinez is a specialist in reproductive endocrinology and infertility. He was drawn to this specialty because it is an ever-evolving field of medicine that allows him to partner with patients and provide personalized treatment plans. He also appreciates that the field is filled with the latest laboratory technology, which continues to advance success rates.After graduating with distinction with a B.S in biology and B.A. in psychology from San Diego State University, Dr. Martinez received his medical degree from the David Geffen School of Medicine at the University of California, Los Angeles. He completed his obstetrics and gynecology residency training at Saint Barnabas Medical Center, an affiliate teaching institution with Rutgers New Jersey Medical School. He completed his fellowship training at the University of Cincinnati Medical Center.
Transcription:
Pelvic Pain, Endometriosis, and Fertility
Melanie Cole (Host): Welcome to Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. I'm Melanie Cole. And joining me is Dr. Alan Martinez. He's a specialist in Reproductive Endocrinology and Infertility at the Reproductive Science Center of New Jersey. We're talking about pelvic pain, endometriosis and fertility.
Dr. Martinez, always a pleasure. I'd like you to just start with a working definition. Tell the listeners what is endometriosis and who does it generally affect?
Dr Alan Martinez: Thank you for having me on today. So endometriosis is defined as endometrial glands and stroma that normally line the inside of the uterus that are found simply outside of the uterus. So it could be anywhere. It could be on the fallopian tube. It could be on the ovary, outside of the uterus, in the intestines, anywhere in the abdominal cavity. So that's the definition of endometriosis and it affects about 7 million women in the United States, it's pretty common. And it affects generally reproductive age women, which is anybody who's having menses in their adolescent, late adolescent years, up to the age of menopause.
Melanie Cole (Host): So let's get into the big question. Does endometriosis cause infertility can a woman still get pregnant if she has been diagnosed?
Dr Alan Martinez: Yes. So for endometriosis, definitely we know that there's an impact on infertility. And there is mild, there's moderate, there's severe endometriosis. And each one of those has increasing pathology, and it can lead to decreased pregnancy rates. So we think it may affect potentially the egg quality, the embryo quality. It may be structural, so the egg and the sperm can not meet. And there may be scarring or adhesions in the abdomen. And it's just an overall dysregulation of the immune system that is thought to, when you compare a patient that has endometriosis to the same age matched patient that doesn't, they will have a little lower pregnancy rates. Overall, you can oftentimes still get pregnant, but it just may be more of a hurdle for that patient.
Melanie Cole (Host): So is it still worth it for couples to try and conceive on their own before they seek treatment? And when is treatment advised?
Dr Alan Martinez: So for young couples less than 35 without any other identifiable issues, it's appropriate to attempt naturally. However, if you have the diagnosis of endometriosis, especially if you know the stage, like they've needed a surgery in the past, and you kind of know is it more mild or is it more severe, then in those cases, it may make more sense to proceed with infertility treatment. And it can start with something as easy as the intrauterine insemination at a lower level with oral medications. But in more advanced endometriosis or the older patient above 35, it may be an indication to become more aggressive and immediately begin with the advanced procedures or treatments such as in vitro fertilization.
Melanie Cole (Host): So I'd like you to talk about those treatment considerations for mild, moderate, and severe endometriosis, as you've just said. But before you do that, birth control is considered one of the modalities, one of the therapies for endometriosis. So if a woman has been using birth control, how long should she be off it before she tries to get pregnant?
Dr Alan Martinez: Well, most of the birth control that you use, it can be either an oral combined hormonal contraceptive, which will include estrogen and progesterone. Sometimes a patient will be placed on an IUD, which helps out with the pain. In theory, when you stop these medications, you should start to ovulate within that following month. So a woman does not have to wait any length of time for those specific birth control options. If it's a Depo-Provera shot, which a lot of patients will use, then sometimes it delays the resumption of your menses overall.
Melanie Cole (Host): But then can she expect the pain to come back, pelvic pain, issues that she had before that therapy was initiated?
Dr Alan Martinez: Unfortunately and more commonly, yes, it has resumption of those symptoms. So the birth control pill quiets down the hormonal activity of the ovaries and it allows that patient to kind of go in a quiescent stage and their symptoms can really be alleviated or even sometimes completely disappear. However, when a patient wants to conceive, obviously that's contrary to our efforts of getting the ovaries to respond and grow eggs that can get the patient pregnant. So we have a discussion and I explain to my patients that you may have a resumption of your pain issues and your symptoms. However, if you really want to conceive, that may be an argument of why we go into fertility treatment sooner, give you a higher chance of conceiving, you have a child, and then you go back on the hormonal contraceptives after your pregnancy.
Melanie Cole (Host): So then speak about what you do for patients, Dr. Martinez, when they're going through this and they come to you for counseling. Tell us about this process.
Dr Alan Martinez: Yeah. So I sit down with the patient who is suspected of having endometriosis or has been diagnosed. We discuss the level of symptoms and we do laboratory testing to see how the ovaries are behaving or functioning for the patient's given age. And we do a risk-benefit analysis if we're going to treat symptoms, and one of the ways we could treat symptoms besides being on medications is sometimes patients will say, "Well, why don't we do a surgery?" And we have to weigh, okay, if we do a surgery and we take out some scarring or we take a cyst out of the ovaries that patients often have, it may compromise their reserve or their function of their ovaries. And it may actually decrease potentially their response to future treatment, medications. And so we have that discussion. It's shared decision-making. And oftentimes, patients will defer any surgical means and we talk about proceeding into the fertility treatments, either oral medications, injections of medication, or with the IVF in the more advanced stage endometriosis patient.
Melanie Cole (Host): So tell us a little bit about your outcomes and how this works for couples when the woman does have endometriosis and maybe has to go off of her medications as you've discussed and how do you work with them so that it's a whole picture, so she feels well enough to even have a happy pregnancy?
Dr Alan Martinez: It's a tough situation and it's on individualized case by case basis. So sometimes we will use NSAIDs, ibuprofen, Aleve, right before they start cycles or at the beginning of a period while we're preparing for the treatment cycle. And in other times, patients will just realize that this is a transient pain symptom and they're willing to go through this, but it can be difficult. So the patients, I explained to them that, you know, "if you want to increase your chances of getting pregnant, let's do this as quick as we can. Let's enter into the treatment regimen, so then we can get you pregnant faster." A lot of times patients do very well in pregnancy. And then after delivery, then we kind of go back to addressing their pelvic pain.
Melanie Cole (Host): Well, what a good point. And what about this multidisciplinary approach? While they're working with you, Dr. Martinez, is there still their gynecologist involved, any other physicians, their primary care, anybody who has been helping them with their endometriosis?
Dr Alan Martinez: Oh, yes. If they have a physician outside of our infertility practice, then absolutely they can continue the care with that individual. Sometimes they're seeing pelvic pain specialist, a urologist if they have urologic symptoms And we work in concert with those physicians. They understand that they can go on medicines that suppress the ovaries to any sort of degree, but there's ancillary things that the patients may use that may be beneficial to them. So we just discuss it and we make the best decision for that individual patient.
Melanie Cole (Host): And what else would you like to let couples know that are exploring fertility treatments and one of the partners does have endometriosis? Wrap it up for us and tell us anything we might've missed in this episode.
Dr Alan Martinez: I would say that if you've been diagnosed with endometriosis, it's a moderate or advanced stage severe endometriosis, then the consideration would be to visit your reproductive endocrinologist and fertility specialist like myself to discuss whether potentially higher level treatments. We still have an excellent option even with advanced stage of in vitro fertilization. And we have the ability to really kind of drive the pregnancies rate up at a very high level. And so don't hesitate, don't be afraid of obtaining the information, but sit down, discuss it with your infertility specialist and make the best decision for yourself, because you may be surprised that there's some good treatment modalities out there that you may think may not be an option for you.
Melanie Cole (Host): What great information. That was really informative. Dr. Martinez, as always, what a great guest you are. Thank you so much for your help today. And for more information, please visit fertilitynj.com to get connected with one of our providers. That concludes this episode of Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. I'm Melanie Cole. Thanks so much for joining us.
Pelvic Pain, Endometriosis, and Fertility
Melanie Cole (Host): Welcome to Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. I'm Melanie Cole. And joining me is Dr. Alan Martinez. He's a specialist in Reproductive Endocrinology and Infertility at the Reproductive Science Center of New Jersey. We're talking about pelvic pain, endometriosis and fertility.
Dr. Martinez, always a pleasure. I'd like you to just start with a working definition. Tell the listeners what is endometriosis and who does it generally affect?
Dr Alan Martinez: Thank you for having me on today. So endometriosis is defined as endometrial glands and stroma that normally line the inside of the uterus that are found simply outside of the uterus. So it could be anywhere. It could be on the fallopian tube. It could be on the ovary, outside of the uterus, in the intestines, anywhere in the abdominal cavity. So that's the definition of endometriosis and it affects about 7 million women in the United States, it's pretty common. And it affects generally reproductive age women, which is anybody who's having menses in their adolescent, late adolescent years, up to the age of menopause.
Melanie Cole (Host): So let's get into the big question. Does endometriosis cause infertility can a woman still get pregnant if she has been diagnosed?
Dr Alan Martinez: Yes. So for endometriosis, definitely we know that there's an impact on infertility. And there is mild, there's moderate, there's severe endometriosis. And each one of those has increasing pathology, and it can lead to decreased pregnancy rates. So we think it may affect potentially the egg quality, the embryo quality. It may be structural, so the egg and the sperm can not meet. And there may be scarring or adhesions in the abdomen. And it's just an overall dysregulation of the immune system that is thought to, when you compare a patient that has endometriosis to the same age matched patient that doesn't, they will have a little lower pregnancy rates. Overall, you can oftentimes still get pregnant, but it just may be more of a hurdle for that patient.
Melanie Cole (Host): So is it still worth it for couples to try and conceive on their own before they seek treatment? And when is treatment advised?
Dr Alan Martinez: So for young couples less than 35 without any other identifiable issues, it's appropriate to attempt naturally. However, if you have the diagnosis of endometriosis, especially if you know the stage, like they've needed a surgery in the past, and you kind of know is it more mild or is it more severe, then in those cases, it may make more sense to proceed with infertility treatment. And it can start with something as easy as the intrauterine insemination at a lower level with oral medications. But in more advanced endometriosis or the older patient above 35, it may be an indication to become more aggressive and immediately begin with the advanced procedures or treatments such as in vitro fertilization.
Melanie Cole (Host): So I'd like you to talk about those treatment considerations for mild, moderate, and severe endometriosis, as you've just said. But before you do that, birth control is considered one of the modalities, one of the therapies for endometriosis. So if a woman has been using birth control, how long should she be off it before she tries to get pregnant?
Dr Alan Martinez: Well, most of the birth control that you use, it can be either an oral combined hormonal contraceptive, which will include estrogen and progesterone. Sometimes a patient will be placed on an IUD, which helps out with the pain. In theory, when you stop these medications, you should start to ovulate within that following month. So a woman does not have to wait any length of time for those specific birth control options. If it's a Depo-Provera shot, which a lot of patients will use, then sometimes it delays the resumption of your menses overall.
Melanie Cole (Host): But then can she expect the pain to come back, pelvic pain, issues that she had before that therapy was initiated?
Dr Alan Martinez: Unfortunately and more commonly, yes, it has resumption of those symptoms. So the birth control pill quiets down the hormonal activity of the ovaries and it allows that patient to kind of go in a quiescent stage and their symptoms can really be alleviated or even sometimes completely disappear. However, when a patient wants to conceive, obviously that's contrary to our efforts of getting the ovaries to respond and grow eggs that can get the patient pregnant. So we have a discussion and I explain to my patients that you may have a resumption of your pain issues and your symptoms. However, if you really want to conceive, that may be an argument of why we go into fertility treatment sooner, give you a higher chance of conceiving, you have a child, and then you go back on the hormonal contraceptives after your pregnancy.
Melanie Cole (Host): So then speak about what you do for patients, Dr. Martinez, when they're going through this and they come to you for counseling. Tell us about this process.
Dr Alan Martinez: Yeah. So I sit down with the patient who is suspected of having endometriosis or has been diagnosed. We discuss the level of symptoms and we do laboratory testing to see how the ovaries are behaving or functioning for the patient's given age. And we do a risk-benefit analysis if we're going to treat symptoms, and one of the ways we could treat symptoms besides being on medications is sometimes patients will say, "Well, why don't we do a surgery?" And we have to weigh, okay, if we do a surgery and we take out some scarring or we take a cyst out of the ovaries that patients often have, it may compromise their reserve or their function of their ovaries. And it may actually decrease potentially their response to future treatment, medications. And so we have that discussion. It's shared decision-making. And oftentimes, patients will defer any surgical means and we talk about proceeding into the fertility treatments, either oral medications, injections of medication, or with the IVF in the more advanced stage endometriosis patient.
Melanie Cole (Host): So tell us a little bit about your outcomes and how this works for couples when the woman does have endometriosis and maybe has to go off of her medications as you've discussed and how do you work with them so that it's a whole picture, so she feels well enough to even have a happy pregnancy?
Dr Alan Martinez: It's a tough situation and it's on individualized case by case basis. So sometimes we will use NSAIDs, ibuprofen, Aleve, right before they start cycles or at the beginning of a period while we're preparing for the treatment cycle. And in other times, patients will just realize that this is a transient pain symptom and they're willing to go through this, but it can be difficult. So the patients, I explained to them that, you know, "if you want to increase your chances of getting pregnant, let's do this as quick as we can. Let's enter into the treatment regimen, so then we can get you pregnant faster." A lot of times patients do very well in pregnancy. And then after delivery, then we kind of go back to addressing their pelvic pain.
Melanie Cole (Host): Well, what a good point. And what about this multidisciplinary approach? While they're working with you, Dr. Martinez, is there still their gynecologist involved, any other physicians, their primary care, anybody who has been helping them with their endometriosis?
Dr Alan Martinez: Oh, yes. If they have a physician outside of our infertility practice, then absolutely they can continue the care with that individual. Sometimes they're seeing pelvic pain specialist, a urologist if they have urologic symptoms And we work in concert with those physicians. They understand that they can go on medicines that suppress the ovaries to any sort of degree, but there's ancillary things that the patients may use that may be beneficial to them. So we just discuss it and we make the best decision for that individual patient.
Melanie Cole (Host): And what else would you like to let couples know that are exploring fertility treatments and one of the partners does have endometriosis? Wrap it up for us and tell us anything we might've missed in this episode.
Dr Alan Martinez: I would say that if you've been diagnosed with endometriosis, it's a moderate or advanced stage severe endometriosis, then the consideration would be to visit your reproductive endocrinologist and fertility specialist like myself to discuss whether potentially higher level treatments. We still have an excellent option even with advanced stage of in vitro fertilization. And we have the ability to really kind of drive the pregnancies rate up at a very high level. And so don't hesitate, don't be afraid of obtaining the information, but sit down, discuss it with your infertility specialist and make the best decision for yourself, because you may be surprised that there's some good treatment modalities out there that you may think may not be an option for you.
Melanie Cole (Host): What great information. That was really informative. Dr. Martinez, as always, what a great guest you are. Thank you so much for your help today. And for more information, please visit fertilitynj.com to get connected with one of our providers. That concludes this episode of Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. I'm Melanie Cole. Thanks so much for joining us.