Bill Klaproth (Host): This is Fertile Edge, a podcast by the Reproductive Science Center of San Francisco Bay. I'm Bill Klaproth. And with me is Dr. Michael Homer, a reproductive endocrinologist. Hello, Dr. Homer.

Michael Homer, MD: Hi. Thank you for having me.

Host: It's so great to have you, and looking forward to our discussion today. So, Dr. Homer, let us start with this. Can you provide us with a brief overview of what endometriosis is and how it can affect fertility?

Michael Homer, MD: Absolutely. Endometriosis is not a fun topic for patients. Endometriosis, or endo for short, is a condition where the tissue that is similar to the lining of the uterus, which is called the endometrium, grows outside the uterus. That's kind of the definition of it. This tissue can be found anywhere. The ovaries, fallopian tubes in the pelvis is the primary parts that we're concerned about. It can be found as far away as even the brain. It grows and spreads a little bit like a very scary word, cancer. It is not cancer, of course, but it causes problems by spreading to the different areas and places where it shouldn't be, and then disrupting the function and the biological processes there.

Many of those with endometriosis unfortunately can feel this, this is pain, with their periods or cycles. With fertility concerns, it can cause inflammation and scarring, which can lead to fertility challenges. I know it sounds like a lot, and it is, but endometriosis is fairly well understood. And I'm hoping with this type of conversation that you'll feel like you have a better grasp on it.

Host: So, you mentioned a woman might experience pain with her menstrual cycle. Are there any other signs or symptoms that indicate someone should get tested for endometriosis?

Michael Homer, MD: Yeah, there are a couple other ones that will show up and it's difficult to diagnose because there's a lot of crossovers with other symptoms that people can have as well. But primarily to answer your question is that you can also have pain with intercourse, sort of it feels deep in the pelvis, is what that pain. Some people who have really strong sort of heaviness in their pelvis on one side versus the other, and also, at times, pain with defecation or using the bathroom.

Host: Okay. So then, how does endometriosis impact egg quality specifically?

Michael Homer, MD: That's a major factor or focus for we as physicians and, of course, for you as patients. it can impact in a few ways, primarily through chronic inflammation and oxidative stress that's associated with this condition. Think of endometriosis as like a toxic factory by the road. It emits all of these toxins that can really hurt the environment. And endometriosis acts unfortunately very similarly by producing a lot of inflammatory factors that activate the immune system and disrupt the patterns around it. Also, endometriomas are physical manifestations of endometriosis in the ovaries, they're the cysts and they're in the ovary. And that can really affect the egg number as well as the function of the follicles, which supports the egg and the egg itself.

Host: So, I want to ask you a question about IUI versus IVF. First off, can you explain to us what IUI is?

Michael Homer, MD: Intrauterine insemination, or IUI, is the process of helping someone get pregnant through a less invasive means than IVF. Typically, this is where we track an ovulation in a patient, whether they've taken some oral medications to help induce that as well or naturally on their own. We time with ultrasounds and blood works, and one injection typically of a medicine to cause someone to ovate on a particular day that's right for them.

At that time, we then take the sperm sample; a collection; spun, washed and cleaned; and then, in the clinic, placed directly into the uterus to give a better chance for the sperm to meet the egg. So, it's the best sperm as close as possible to maybe more than one egg at the right time.

Host: So, IVF may have better outcomes, but it's not always the best method for everyone right away. So, who may benefit from IUI versus moving straight to IVF right away?  

Michael Homer, MD: Yeah, that's a good question. I think what we'd say is that, I would sort of reverse the question, say who would benefit more from IVF compared to IUI? I think with intrauterine inseminations, you have to have three things. You have to make sure the sperm is strong, the fallopian tubes are open, and that you're ovulating. And as long as all three of those criteria are met, then an IUI is an option.

Endometriosis specifically, however, can hurt the egg quality. And with an IUI, there's no way to really affect that or know exactly what that is. And endometriosis can also cause scarring, adhesions in the pelvis, or just a disruption in the function of the fallopian tubes. And since in IUI, you have to use the fallopian tubes to deliver the embryo to the uterus, that may be impacted by endometriosis.

When we think about what IVF offers is that IVF allows you to skip the fallopian tubes, right? And also to be able to look at the eggs more directly into lab to get a much better sense of egg health and then the embryo development.

Host: Okay. So, how do you counsel your patients between IUI and IVF? How do you say, "This one might be better for you. This one might be better for you"?

Michael Homer, MD: Yeah. We look at a couple of factors about that person. So, what is their history? Have they done IIS before? Of course, that would kind of make sense. We also look at their age. We also look at their ovarian reserve. How many eggs do they have in general? What are the other hormone values that we use to check the number of eggs that they have? We also would look at the sperm count to decide. All of those factors together, whether what are the chances of success with IUIs and IVF? So, kind of presenting what the time is needed and the effort is needed for both types of treatments, looking at the success rates for both of them, and then, the cost. Of course, the cost or the insurance coverage for those. That's generally how I take the picture or approach that I take to help my patients decide.

Host: So, there's a lot of factors involved, but it's good that you're there to counsel people through this. So when should someone consider scheduling an appointment with a reproductive endocrinologist like yourself for an endometriosis-related fertility issue?

Michael Homer, MD: the American Society for Reproductive Medicine or ASRM has guidelines, and we'll say less than 35 years old. You can try it for about a year and then go seek help if you're having trouble. Over the age of 35 is to say six months, and then go seek help. If you have endometriosis though, I would say that it's okay to try for about maybe three or four months. But after that, if not successful, if not super lucky, then I would go seek the help of an infertility specialist such as myself.

Endometriosis has a variable effect, and sometimes it can be devastating, or someone can spend a long time. The emotional impact of all that time trying not be successful can really burn people out. And the fertility journey for those endometriosis may not be the smoothest. And so, you don't want to be able to spend all of your resources, your emotional resources, your time, resources on something that has a lower chance of success. So, I would say after about three, four months of trying on your own, it's good to seek help. 

Host: Good advice. Well, this has really been interesting, Dr. Homer. I want to thank you for your time. Before we wrap up, is there anything else you wanna share with us today?

Michael Homer, MD: Yeah. I think that most patients also kind of want to know what can I do about this, and I would say that ways to help optimize your egg health-- Okay, so it's important to know this. We try to focus on ways to help optimize your egg health as well as the body around you. So, some things are kind of common sense, but I think it's also good to just reiterate it.

Dietary adjustments. We really want you to kind of focus on a diet that's rich in antioxidants, omega-3 fatty acids, and those whole foods that can help reduce inflammation. Lower, not no carb, lower carb though. So, speaking to a fertility specialist or a nutritionist can help give you more guidance on that.

Lifestyle factors, you've heard this before. Stress just for life. Stress management, adequate sleep, regular exercise, right? Those all play a significant role in hormone regulation and overall reproductive well-being. The problem is, though, is that you're just then going to stress about stress, and I don't want that. That's not fair. So, I want you to focus on those things as much as you can, but not every day is going to be perfect that way. And if there's not, that's okay. It's not crucial, but it can help. And so, just if one day doesn't work out, try the next day. Just kind of refocus yourself.

Supplements or vitamins. At RSC, Reproductive Science Center at the Bay Area, we always recommend patients to take CoQ10, vitamin D, omega-3s, or fish oil, as well as a prenatal vitamin. Those can help the mitochondrial sort of function of the eggs and which in theory should be helping the egg quality.

And then lastly, endometriosis, it's for different topic, I suppose, in a way, but medical interventions are available for endometriosis. Just as a big broad stroke, there is hormonal suppression of endometriosis, which is to have you stop producing estrogen in your body. That's typically a two or three-month treatment before you would try to conceive. There's also surgical intervention, which is just to cut it out. There's lots of pros and cons and require a couple of good, long, in-depth conversations with your medical provider, GYN doctors or reproductive endocrinology and fertility specialists such as myself.

So, just know that endometriosis is something that is decently well understood. It's cloudy. It's a little murky about which path you take, but those pathways are well laid out. And speaking to a provider like myself can really provide a lot more clarity probably for you during your fertility journey.

Host: Well, you are certainly clearing it up for us. You are parting the clouds and the murkiness and clearing this up for us, Dr. Homer. Thank you. You're doing a great job.

Michael Homer, MD: Thanks.

Host: Thank you so much for your time. We really appreciate it today. Thank you again.

Michael Homer, MD: All right. Thank you.

Host: And once again, that is Dr. Michael Homer. And for more information, you can visit rscbayarea.com. And if you found this podcast helpful, please share it on your social channels and check out our entire library for podcasts of interest to you. This is Fertile Edge by the Reproductive Science Center of the San Francisco Bay Area. Thanks for listening.