WEBVTT
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Hi everyone, we are Rena and Dara, and welcome to Fertility Ford.
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We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City.
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Our Fertility Ford podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
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I am so excited to welcome to Fertility for today, Dr.
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Zoran Pavlovich, or Dr.
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Zee, who is a physician under US Fertility working at IVF Florida.
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And in addition to being an accomplished REI, he is passionate about endometriosis.
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And I'm so excited to have you on because I know that I myself have so many patients who have endo or have the dual endoadno.
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And they just feel really alone, both in the diagnosis and the treatment.
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And then they feel a lot of fear about future implications in terms of reproduction and what that might mean for them.
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So I'm really excited to have you on to talk about this and hopefully alleviate some of that and just share all of your expertise and guidance.
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Of course, yeah.
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Thanks for having me on.
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It's great to have this opportunity to talk about this really, I think, important topic and how it interplays with fertility.
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So again, thanks for having me, and I'm excited to get our conversation going.
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Yeah.
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Well, so first let's tell our listeners who may not know the definition of both endometriosis and then a domiosis, because I think there's a lot of misinformation about both of those.
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There is, yeah.
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So the statement used to always be that endometriosis is endometrium or endometrial-like cells growing outside of the endometrium, so in the pelvis or elsewhere in the body in the abdominal cavity, and can even go to other places such as the lungs and the brain.
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That's a good basic definition.
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But now we're starting to find out that it's not just endometrial-like cells, but cells that are also highly involved in inflammatory processes, autoimmune processes, nerve, pelvic pelvimetry issues, and affecting the nerve structure in the pelvis.
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So altogether, it's kind of this hormonal, autoimmune, inflammatory, nerve-affecting disease that stems from endometriosis or endometrial-like cells in the pelvis.
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And then adenomyosis is really those same or similar cells, but now located in the muscle layer of the uterus and confined to the uterus rather than extra pelvic.
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Are these conditions genetic or are they random in appearance?
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How might you know that you're at higher risk for them?
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And then also that you may be having symptoms of them.
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So it's a little bit of both.
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There are some genetic components to it that we're starting to discover, but it's also there's patients that may not have any family history or that can develop it as well.
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One of the longtime older theories was that retrograde menstruation was a big part of it, where instead of having a period that flows forward, some of those cells would flow backwards through the tubes and then implant in the pelvis.
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Although we're starting to learn that that one mechanism is just one part of a much larger picture.
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And in fact, endometriosis can spread commonly through the vasculature, through the vessels, through the lymphatic system.
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There's a genetic component to it.
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There's either embryonic stem cells or bone marrow stem cells that can transform into endometriosis-like cells, as well as the cells of the lining of the abdomen and the pelvis, can then they themselves transform into endometriosis cells.
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So there's a large combination of theories of how a patient could get it.
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And no single one of them actually explains all the instances of how someone gets endometriosis, but they're all play a role.
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And really the first indication that endometriosis may be part of your picture is the clinical symptoms, which usually include chronic pelvic pain, pain with intercourse, very painful or heavy periods, issues with infertility, generalized pelvic pain or sciatic nerve pain that shoots down their legs, lower back pain, and then also fatigue, bloating, generalized feelings of inflammation that people can have in their abdomen.
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All of that can be a constellation to symptoms of endometriosis.
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Is this something that you're born with and is present your whole life, or could you develop it later in life?
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So both.
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You can either sometimes there's indications or instances where adolescents will have endometriosis even before the menstruation starts.
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And that is usually cells that come from an embryonic or stem cell origin that are present and then transform to endometriosis cells.
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And then patients can also develop it later in life, either where these cells travel through the vessels or post-surgically, some of these cells get implanted into the uterus.
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You can develop it later in life.
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So it's a combination of the two, actually.
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And how might you treat it?
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So treatment, it's a complex answer because endometriosis, adenomiosis is again a complex constellation of symptoms.
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And of course, there's the mainstay of surgery, which for endometriosis especially, patients will have to at some point get an endometriosis surgical treatment, whether that's excision or fulguration, which is burning.
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Although I personally believe in excision and removal of the endometriosis rather than burning.
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Okay, great.
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Let's break both of those down for our listeners.
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So when it comes to surgery, you can have either actually removal of an endometriosis lesion.
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So you go in and you surgically take out the tissue that contains the endometriosis, so it's removed from the patient's body.
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Whereas the fulguration or burning is where you go in and you just use uh cautery to zap and to burn off those little lesions.
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So physicians often do either or.
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Why I'm more of the school of thought of excision is because when you're burning the endometriosis, sometimes there are parts of that endometriosis that are deeper and you can't really burn too deep, and you don't even know how far deeply you need to burn to fully get rid of the lesion.
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And sometimes the endometriosis is on important structures, so on the ovaries or around the ureters, around the bladder, around the bowel, and you can't burn those lesions because you don't want to burn into the normal tissue and then cause other issues and complications.
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So that's where the two different schools of thought are.
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And I do believe in the field that the actual removal of the endometriosis is the right way to go.
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So, okay, and I don't want to get sidetracked from the initial question, but I think this is super important because I know so many of my clients then deal with this.
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So if you are someone that's having the surgery, right, okay, you find out, and I know a lot of people don't find out that they have endo or adeno until they start trying to conceive, right?
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And then it's not happening because maybe you're someone that you didn't ever present with heavy periods or abdominal pain.
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You had more of the silent endo or adeno, which means you didn't really experience these physical symptoms.
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And it's not until you go to try and conceive and it's not happening, you find out, oh, okay, I have endo or adeno or both.
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Okay, so next steps.
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Now we have to have a surgery to remove this.
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Now, what does this mean for your reproductive future?
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Can you carry?
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Can you conceive biologically?
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Can you still have a vaginal birth?
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Do you have to have a C-section?
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These are all things that I know come up for patients when they're delivered this news.
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Actually, I should step back and you asked me initially how do you treat the endometriosis, which even before you treat it, the first most important thing is how do you diagnose it?
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And that's where when we talked about the clinical symptoms are really important, listening to the patient, hearing their story, having that a high inner differential of chronic pelvic pain, physical exam that you do yourself with a bimanu exam, and then imaging becomes really important.
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Because a transvaginal ultrasound and MRI, those are the two mainstays of imaging.
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And if done correctly, in terms of a complex gyne ultrasound or an MRI, where either you were able to read it yourself or have a radiologist that's experienced and looking for endometriosis, will then tell you the level or stage of the disease.
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And then that can give you some indications of what a surgery would look like, what it would contain, and what could that mean for fertility future.
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So, for example, if the endometriosis is on one or both tubes and you may need to remove a tube, the implications of fertility for that are important to talk about with the patient.
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Because if both tubes need to be removed now, how do we bypass the tubes?
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We would have to do something such as IVF.
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But if the tubes are okay and it's it's removal of endometriosis in other areas of the pelvis, then they would have the ability to get spontaneously pregnant, vaginal delivery, all of that still stays the same.
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But if the ovary, for example, has a large cyst on it, we would then talk about how that could impact egg reserve and the changes in that.
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And when it comes to C-section, so mostly for endometriosis, even if it's bad endometriosis where there's cysts in the ovaries or on the bowel and needs to be removed from the bowel, etc., a pregnancy and vaginal delivery are still possible.
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Adenomiosis is a little different because when you're looking at diagnosing adenomiosis, if it's diffuse, meaning it's all around the uterus, you can't really treat that surgically.
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You have to manage the symptoms either hormonally with through something such as an IUD and then try to prepare the patient for pregnancy, which there's different caveats within that of how to do we do IVF right away and prepare embryos and then prepare the lining, or do we have a patient just have an IUD in place for a while for symptoms and then try naturally?
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Or if it's focal adenomyiosis, you can actually surgically remove that, similar to how you would remove a fibroid that's in the focal area.
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But once you cut into the uterus and remove the adenomyoma is what we would call it, and you stitch that back together, then that prevents the patient from having a vaginal delivery in the future.
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And that's where a C-section would be required between 37 to 38 weeks and six days or so.
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And so the fertility aspects of their future fertility and how they're going to deliver and the ability to get pregnant really depends on the degree of disease and what's present and what requirements are gonna have to happen within the surgery.
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Okay, so it's very patient and case dependent.
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Very patient and case-dependent, exactly.
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Yeah.
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And with both of these, both endo and adeno, is it something that once you quote unquote treat it, it's good, or it's ongoing treatment and ongoing maintenance?
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It's an ongoing treatment, ongoing maintenance.
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One thing that ACOC did well recently defining in their new document that they came out with was that it's a chronic pelvic pain disease and it's a chronic lifelong situation where it's all about removal of the lesions, management of the symptoms, helping with pregnancy, et cetera, up until hopefully you get to the age of menopause, which then without the hormones of the ovaries, that the disease should quiet down.
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However, there are instances of post-menopausal endometriosis as well, because again, it's it's a disease that's chronic, that's inflammatory, that affects the nerves, and it's not just hormonally active, which then complicates that picture a little bit, where you might have to manage a patient further and further.
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And I do tell patients that the recurrence risk, even for a full excision, is patient dependent, and depending on how much disease was there.
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And if you had a surgeon that was skilled enough to remove everything or was anything left over, that also plays into a factor of how fast a recurrence can be.
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But on average, sometimes it's up to 25 to 40 percent recurrence rate after a couple years after excision.
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So it really depends on the amount of disease that's there and then how much is able to be safely removed.
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But because it can come back, and it's either going to be microscopic disease that you couldn't see that activates itself, or the same way that the endometriosis and aomiosis spread the first time, let's say through the lymphatic system, can happen again, and then that endometriosis is back.
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So it really does become a management thing between the patient and the physicians that she's working with throughout the rest of their lives.
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So, what would your advice be for someone that say they're not even thinking about family building, but they're listening to this and they think, oh my gosh, wow, I really think I have endo.
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What type of physician would they call if they're not looking to family build?
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I would say so either someone that's at least comfortable with diagnosing and doing the initial workup with endometriosis, which could be either an OBGOIN that is well versed in recognizing the signs and symptoms of endo and knowing what imaging to get, or a step above that, if you have either a fertility specialist such as myself that does a lot of reproductive surgery, or a minimally invasive guidance surgeon that focuses on endometriosis and is able to also again do the diagnosis and then the imaging workup and then either the referral for the surgery yourself or to someone, a specialist.
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Those are the kinds of people that I would have the patient look to talk to.
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Because the biggest issue nowadays is there's about this, on average, seven to 10 year delay in diagnosis.
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The ACOG document says four to 11 years.
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And that's because for the longest time, so many people were thinking that, oh, this these painful periods are just how a patient's periods are, or these symptoms are something that they just have to get used to.
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And so the bucket gets kicked down the road.
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And after years and years of being told that the disease in that time gets worse and worse.
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And so I would say that patients really, if they're feeling that they're concerned that they may have symptoms of endometriosis, is to go talk to probably first year OBGIO and advocate for either a referral to the specialist or more imaging.
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And if they find like they're not getting the support there, then to either find locally through some of their own research or online groups just to see who locally in their area or a nearby city may be doing this kind of work and then go to that more specialized center because you don't want to delay your diagnosis if you truly feel like you're having these symptoms.
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And I think that's one of the things that a lot of people run into is being told previously, oh, you're fine, that's normal.
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And then people believe what their physician says and don't pursue it, and then those kind of suffer until they get to someone, usually when it's trying to conceive that recognizes it.
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And I know with that, certainly there's so much frustration, right?
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That, okay, I didn't have to live like this for the past 10 years or whatever.
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Because it's really quite debilitating, both of these diseases.
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Oh, absolutely.
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And I think that that's where a lot of patient frustration comes from and why there's a lot of anxiety around this.
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And I had a great mentor at Mayo Clinic once that just like had we were talking to a patient.
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He was basically took pieces of paper and he had the patient crumple the pieces of paper up and throw it in the trash to represent each person that told her that it was in her head.
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And that was like very cathartic for her.
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But it was just an example of how that happens so often.
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And this old school thought of thinking that we had decades ago needs to change, and luckily is changing with either physicians that are retraining themselves or younger physicians coming into the field now that are understanding and learning about chronic pelvic pain early on in med school and residency, fellowship, et cetera, and bringing that into their practices.
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I'm seeing noticing with the OBGONs that work around me that they are putting it higher in the differential.
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And I tell them all the time, I would rather you over-diagnose it and be really conservative and suspect it, and then also do either a lot of imaging or tests or even the surgery to then find that, oh, it's a low-level disease that we can take care of early rather than waiting for the patient to be diagnosed a decade down the road.
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And then now the disease is significantly advanced.
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So that's changing, I think, slowly but surely, and we're getting better at it, but it will take time, I think, until we have that perfect system of early diagnosis and early understanding and listening to the patient, good imaging, and then good referral for surgical and conservative care as well.
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Well, it's so heartening to hear that it's changing because I'm sure you as well, as myself, have seen so many people suffer.
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What about though?
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You know, so many women start a birth control pretty soon after they start menstruating.
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So, what if you're someone that's been on a birth control for most of your life and then you did not have the experience of these super heavy, painful periods because it was masked?
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I mean, is that possible?
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Is that what happens potentially with endocan being on birth control kind of your whole life until you decide that you want to conceive?
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It can be masked by that.
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It definitely can sometimes, although often there's usually something else that's going on.
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So they may not have these painful, debilitating periods, but they'll have a lot of pain with intercourse or a lot of pain with bowel movements or urination that gets misdiagnosed as a cystitis or constipation, something like that.
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And just none of those are giving the answer.
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And then the generalized fatigue and malaise and the bloating that is so significant every month, those are other signs that are softer signs that may indicate to a patient that there's something else going on, especially in terms of endometriosis and adenomiosis, and at least warrants them getting some imaging.
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But it definitely can be masked at times.
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And then when patients are ready to undergo fertility treatment, that's where they stop the birth control, and then a lot of these symptoms just come roaring in and they're get noticed on the imaging during a fertility workup, or there's just saying that, oh, I just thought of birth control a few months ago and I've had this really excruciating pelvic pain out of nowhere, and that's where we find out.
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Hopefully, we're catching those patients sooner rather than later.
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But it's a potential that sometimes the symptoms can be a little massed, and that can delay diagnosis as well.
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So I guess any final words of wisdom or thoughts for patients either that have already been diagnosed with either of these or someone that thinks that maybe they have one of these conditions?
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Yeah, I would say the most important thing is definitely advocate for yourself.
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And really, if you go online and you think your symptoms are part of this constellation, to really push for being seen and diagnosed and done imaging.
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And if whoever you're working with seems to be dismisses of that, to then seek a second opinion because I think that's important.
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I think some, as you said, patients trust their doctors, and so they'll just live with something because they believe what they're told.
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But if it doesn't feel right to you, then it likely isn't.
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So keep trying and looking until you find those people that can dive into it a little bit further for you and give you more answers.
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That'd be one thing.
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And then two, just look into what kind of either fertility or surgical expertise there is in your surrounding area because that's going to help also dictate where to go and where you could get the best possible care.
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I think that my dream would one day be that every single state has this multi-level tertiary system where you have uh general practitioners and OBGYNs initiating the initial diagnosis and the symptoms and then referring out to more complex guy imaging and endometriosis MRIs, and then the large, you know, at least one center per state where it's the multidisciplinary chronic pelvic team, where you have everything from the surgeon to the fertility doctor, the colorectal, the pelvic floor physical therapy, et cetera, to really tackle it all together.
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And so looking out for places in the states and institutions that may offer that endometriosis center of excellence would be an important thing for a patient to look into.
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And just not wait.
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You know, if you feel like something's wrong, again, just going early and going often to try to be seen and be diagnosed.
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Well, I mean, I hope that your dream becomes a reality because I think you just touched upon something that is part of the biggest stress for people, which is look at all those providers you just named, right?
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Down to a pelvic floor therapist.
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You know, I think that's where so many people get overwhelmed or come up with roadblocks that it's not about one provider is able to kind of one-stop shop this for you.
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And it takes a lot of time and patience and advocacy and navigating the healthcare system, which unfortunately is pretty daunting.
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And so I think a lot of people either kind of stop because they just get tired of it, or you know, they just get so overwhelmed dealing with it.
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And it's a lot for people to take on.
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And I think that's a broader conversation about our healthcare system, but that that's such an issue too.
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Piecing it all together is quite stressful.
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Yeah, it's it's definitely hard and it does take a lot of time.
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And I think that's, as you were saying, a broader part of our healthcare system where I can see how when a provider, say no BG Wayne has only 15 minutes with a patient to be able to go through all that and talk it through, it's gonna be really hard.
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I'm lucky I get to spend 45 minutes to an hour sometimes in my consults when I talk about endometriosis and the plan to diagnose an image.
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That's a long visit that not everyone has a luxury for.
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And so those are things that need to change in our system for sure.
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But at the very least, what can be done even in a short visit is just acknowledging that pain and that patient's vulnerability, realizing that they're telling you something important and keep keeping it high in your differential just to be able to then go try to tackle it earlier rather than later.
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I think will help a lot.
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That that's going to maybe catch a lot more people sooner.
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And especially as ACOG is saying that you can use imaging to help initiate treatment, then we don't have to wait for a long period of time for someone to finally get a surgery to then get the diagnosis.
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We can actually start examining them and treating them earlier on and then get them to surgery in a safer way.
00:21:16.319 --> 00:21:19.119
So it'd be nice, yeah, for one day to we're we're getting there.
00:21:19.200 --> 00:21:21.200
There's some countries in the world that do it really well.
00:21:21.440 --> 00:21:24.400
Europe is a good one, Brazil does a good job, Latin America too.
00:21:24.480 --> 00:21:27.359
So and hopefully we're also catching up to all of that.
00:21:27.680 --> 00:21:28.240
I hope so.
00:21:28.400 --> 00:21:33.759
But I think that sounds like that's really positive, though, the new guidelines and being able to image first.
00:21:33.839 --> 00:21:46.079
And I think, like you said, you know, make sure you're going to a specialist and you're going to someone also that knows how to read the image, because a lot of times things are overlooked or missed by someone that's not, they don't know what to look for.
00:21:46.240 --> 00:21:54.799
And so, really to listen to your gut and advocate for yourself and don't necessarily just take someone's answer to be the answer.
00:21:55.599 --> 00:21:55.759
Yeah.
00:21:55.920 --> 00:21:58.880
And for us providers, we have to work on building our network.
00:21:59.039 --> 00:21:59.759
So I have a good relationship.
00:22:00.079 --> 00:22:08.880
Relationship with pelvic floor physical therapists in the area, with pain management clinic and with a mix minimal invasive guine surgery endometriosis-specific surgeon specialist.
00:22:08.960 --> 00:22:16.319
That when I diagnose 5% of the time, I'll diagnose a bad bowel endometriosis that'll require a removal of that bowel and putting it back together.
00:22:16.480 --> 00:22:21.680
My team doesn't have that multidisciplinary aspect to it where we can handle that large of an endosurgery.
00:22:21.759 --> 00:22:24.559
So I refer them out to this colleague of mine.
00:22:24.720 --> 00:22:28.400
But I have my note, my pictures, the MRI disks, all the workups done.
00:22:28.480 --> 00:22:31.200
So it's kind of packaged nicely to him and then handed over.
00:22:31.279 --> 00:22:43.440
And he's just able to meet this patient and then just have a quick one-on-one and then get it right into surgery because he knows exactly what's happening, thanks to the time that I was able to spend with her and do the imaging and diagnose things and explain everything to her.
00:22:43.519 --> 00:22:46.880
And that's the kind of relationship that makes this care a lot better.
00:22:47.119 --> 00:22:55.119
That we shouldn't be working on such a complex disease in silos because you can't, you need a multidisciplinary team.
00:22:55.200 --> 00:23:01.119
And if it's not at your direct institution, you have to go out there and find the people that are part of that so you can build that community.
00:23:01.279 --> 00:23:02.640
That's the only way to really do it.
00:23:02.960 --> 00:23:09.440
Well, and I think that's a great tip for people that make sure you're working with a provider who can tell you, right, like, okay, this is who I refer to.
00:23:09.519 --> 00:23:12.240
I have these relationships, this is who I collaborate with.
00:23:12.319 --> 00:23:21.200
And it's this, it's a system, you know, because that's what makes it easier versus someone that says, okay, but now you go source, you know, the next people that you need.
00:23:21.359 --> 00:23:22.799
That makes it so much harder.
00:23:23.119 --> 00:23:25.119
Yeah, really hard to navigate that on your own.
00:23:25.519 --> 00:23:25.680
Yeah.
00:23:25.839 --> 00:23:30.480
So I think that's a great tip for someone to ask in an initial appointment with someone, right?
00:23:30.640 --> 00:23:31.839
Okay, who do you refer to?
00:23:32.000 --> 00:23:35.039
You know, do you have all of this list handy, right?
00:23:35.119 --> 00:23:36.400
And then I can just take it and go.
00:23:36.559 --> 00:23:37.920
That makes a huge difference.
00:23:38.240 --> 00:23:38.960
That's very helpful.
00:23:39.039 --> 00:23:43.599
And that's what some of the questions that I get asked by a lot of patients how do you do your diagnosis?
00:23:43.759 --> 00:23:44.720
Where do you do your surgeries?
00:23:44.799 --> 00:23:45.839
What kind of surgeries do you do?
00:23:46.160 --> 00:23:48.000
Who do you refer out to if there's any issues?
00:23:48.079 --> 00:23:59.759
And that's really important for patients to ask for themselves and not to be afraid to ask, because I do think sometimes some patients may feel worried that they are stepping on some toes with the doctor or something like that.
00:23:59.920 --> 00:24:01.279
And I don't want them to feel like that at all.
00:24:01.359 --> 00:24:03.279
Like they should be asking those questions.
00:24:03.440 --> 00:24:10.160
And if you're with a provider that gives you a hard time about it, then you kind of have your answer that that's not somebody that you want to receive your care with.
00:24:10.319 --> 00:24:22.079
Because, in my personal opinion, within the disease like this and with fertility and how complex all of it is and how complex these surgeries are, there's just no room for egos in the OR or in the diagnosis or in the management of this.
00:24:22.160 --> 00:24:25.920
You have to put, you know, check that out the door and really just try to do what's best for the patient.
00:24:26.000 --> 00:24:29.039
And that's important for doctors to do and for patients to ask for.
00:24:29.279 --> 00:24:29.599
Yes.
00:24:29.680 --> 00:24:32.240
Well, you seem like a real diamond in the rough.
00:24:32.319 --> 00:24:34.160
And that's what I always tell patients too.
00:24:34.319 --> 00:24:39.759
I say, if a doctor makes you feel badly for asking a question, that's not the provider for you.
00:24:39.920 --> 00:24:53.440
You know, because there's a difference in saying, okay, you know, unfortunately I have 15 minutes for this appointment, et cetera, et cetera, than someone just sort of brushing you off and not giving any validity to your questions.
00:24:53.680 --> 00:25:02.960
You want to work with a provider that's able to communicate and dialogue with you and you know, again, a mutual understanding about how much time is allowed in the appointment, and maybe you need to make another one.
00:25:03.119 --> 00:25:10.160
That's fine, versus someone that's you know gonna give you some ego and pigeonhole you into one direction, right?
00:25:10.240 --> 00:25:11.440
Yeah, exactly.
00:25:11.839 --> 00:25:15.359
So, I mean, you seem wonderful and like a great resource.
00:25:15.519 --> 00:25:21.759
Now, do you work telehealth at all with New York patients since we have so many New York listeners or only Florida?
00:25:22.319 --> 00:25:24.559
No, I do telehealth visits all the time.
00:25:24.799 --> 00:25:35.200
And of course, MRIs can be done anywhere as long as I can get the actual physical disk because not all MRI reads are created equal, and sometimes it's just you know where to look on an MRI disk.
00:25:35.359 --> 00:25:51.440
The one thing that has to just be done in person is the complex gyne ultrasound, which is more than just a regular transvaginal ultrasound because most people get sent for imaging for their pelvic pain or their endo, and it's a quick five-minute check the uterus, look at the ovaries, and you know it looks fine and they're out.
00:25:51.680 --> 00:26:03.039
A complex gyne ultrasound or dynamic ultrasound is where not only are you looking at the uterus and the ovaries, but you're dynamically pushing against the uterus and the ovaries, looking for things such as sliding sign.
00:26:03.279 --> 00:26:05.200
Are the organs all frozen and stuck together?
00:26:05.359 --> 00:26:06.720
Are they freely moving?
00:26:06.960 --> 00:26:17.440
You're checking out for cysts, you're looking at the uterus sacrils, and you can even, if you've done enough of these, you can actually look for superficial endometriosis in the cul de set, you can visualize it on an ultrasound.
00:26:17.599 --> 00:26:32.880
So that visit between the physical exam I have to do, the ultrasound, and sometimes the saline ultrasound, which is where we can put some fluid in the cavity to look at the inside of the uterus, especially for adenomyosis, and then use some of that fluid to look for superficial endomes.
00:26:32.960 --> 00:26:34.960
That takes that's a 30 to 45 minute visit.
00:26:35.200 --> 00:26:36.799
That's the HSG you're talking about.
00:26:37.279 --> 00:26:40.880
No, it's a physical exam, ultrasound and saline, all three together.
00:26:41.519 --> 00:26:52.480
The dynamic ultrasound part of it is where we're using the probe to just look at these different parts of the pelvis where the endometriosis likes to live and lie and look for signs of endometriosis and lesions.
00:26:52.559 --> 00:26:53.759
You can tell them pretty well.
00:26:53.839 --> 00:26:59.839
It just takes longer to do because there's so many different parts of the pelvis that you're looking at and interrogating with the probe.
00:27:00.000 --> 00:27:01.599
You can't do it in a five-minute visit.
00:27:01.680 --> 00:27:03.119
And that's an in-person thing, too.
00:27:03.279 --> 00:27:04.000
So got it.
00:27:04.079 --> 00:27:04.240
Okay.
00:27:04.400 --> 00:27:07.119
If I ever saw a person on telehealth, I would say, Hey, yeah, this is great.
00:27:07.200 --> 00:27:14.640
You can give you the MRI, send me to this, but you'll have to come down here for me to do this ultrasound because I can't just send you over to do a random ultrasound somewhere else.
00:27:14.799 --> 00:27:18.559
Unless I know that person can do that same guy in dynamic ultrasound.
00:27:18.720 --> 00:27:23.359
And there's that's slowly starting to become a bigger part of practice in New York.
00:27:23.839 --> 00:27:25.680
I know there's a couple of good groups out there.
00:27:25.759 --> 00:27:26.160
I know Dr.
00:27:26.240 --> 00:27:28.160
Vidali's up there and his group does that stuff.
00:27:28.240 --> 00:27:30.960
There's Matthew Leonardi that's in Toronto that's not too far away.
00:27:31.039 --> 00:27:34.720
He's kind of been the pioneer of uh complex guy and ultrasound.
00:27:34.960 --> 00:27:40.400
So that's the really the tough part that you can do a television, but really you need that in-person exam.
00:27:40.880 --> 00:27:43.279
Okay, that's very helpful to know.
00:27:43.519 --> 00:27:46.799
Any other parting thoughts for our listeners?
00:27:47.440 --> 00:28:04.960
I think, you know, when it comes to fertility, and if you're talking with fertility specialists, I think it's important to not just look at the hormones, the egg reserve, the basic fertility tests, but also to inquire and ask your provider or your doctor, do you see any signs of adenomiosis?
00:28:05.039 --> 00:28:06.640
Do you believe I may have endometriosis?
00:28:06.720 --> 00:28:07.680
Do you see fibroids?
00:28:07.839 --> 00:28:22.000
Because I have seen some crazy things out there where there's patients with really large, even cavity distorting intramural fibroids that are going through either multiple cycles of IDF and things aren't or implanting, or have a large C-section scar defect.
00:28:22.079 --> 00:28:36.319
That's something I see a lot too, the isthmusels, where they have fluid that builds up in the C-section scar, and they either have to cancel an embryo transfer because there's fluid in the cavity, or an embryo just never sticks after multiple euploid embryo transfers.
00:28:36.640 --> 00:28:38.559
To ask, is there something else going on?
00:28:38.720 --> 00:28:40.319
Is there something structural going on?
00:28:40.480 --> 00:28:42.960
Is there something is this fibroid impacting it?
00:28:43.039 --> 00:28:44.720
Does my C-section scar play a role?
00:28:44.880 --> 00:28:46.000
Does do you believe there's endo?
00:28:46.240 --> 00:28:47.440
Do you believe there's adeno?
00:28:47.599 --> 00:29:02.240
And going back to the reproductive endocrine and reproductive surgery part of our field that was so prevalent 30, 40 years ago before IVF was a thing, to bring that back a little bit in addition to all the regular fertility tests that we're doing.
00:29:02.319 --> 00:29:08.000
I think that's something that's important for both providers and patients to look into and try to train themselves to be better at.
00:29:08.880 --> 00:29:09.200
Okay.
00:29:09.519 --> 00:29:10.880
Very exciting field.
00:29:10.960 --> 00:29:21.680
And I am hopeful that this episode brings hope to patients because I know with my own clients, can be feel, like I said at the beginning, very lonely, very frustrating.
00:29:22.000 --> 00:29:24.640
I know a lot of them feel like no one's really listening.
00:29:24.799 --> 00:29:29.119
I mean their symptoms are kind of just being gaslit or overlooked.
00:29:29.200 --> 00:29:35.839
And to really have an understanding of how debilitating, you know, either of these really can be on somebody's life.
00:29:36.160 --> 00:29:54.480
Yeah, I think that's where doctors, physicians, providers, et cetera, can all continuously try to be better, where it's validating, understanding, knowing how complex it is, and knowing that you have to take the time to talk to these patients, to examine them, to do the testing and counsel, because it's not going to be a quick five-minute general unexplained infertility visit.
00:29:54.559 --> 00:29:59.599
There's going to be a lot more to it and to take that time because it's going to be meaningful for them for sure.
00:29:59.839 --> 00:30:01.519
Because it's a complex disease.
00:30:01.680 --> 00:30:10.720
And maybe one day we'll have that holy grail of an immunotherapy where it targets the endometriosis cell perfectly, which is, I guess, would be the ultimate treatment.
00:30:10.880 --> 00:30:15.519
But until then, we got to manage it in multiple ways and with the multidisciplinary team.
00:30:15.680 --> 00:30:17.440
And that takes time, takes time and effort.
00:30:17.519 --> 00:30:18.640
So it does.
00:30:18.799 --> 00:30:22.799
But I think the good news is once you figure it out, it can be managed.
00:30:22.960 --> 00:30:27.839
And it does not mean that you will not be able to family build or carry or have children.
00:30:28.160 --> 00:30:35.200
Yeah, it can definitely be managed, and especially if it's caught earlier, it can be very managed very easily and very well, optimizing your fertility.
00:30:35.440 --> 00:30:38.720
And as I told a patient earlier today that I saw it was a straight question.
00:30:38.799 --> 00:30:42.559
She was like, I've been told so many things that I will never have kids, it'll take me forever to have kids.
00:30:42.640 --> 00:30:44.799
And I'll be like, No, you're going to be able to have kids.
00:30:44.880 --> 00:30:45.839
It's going to happen.
00:30:46.000 --> 00:30:47.519
And this is how we're going to get you there.
00:30:47.599 --> 00:30:52.720
So it's just a lot of, like you said, misinformation out there and fearful statements for patients.
00:30:52.880 --> 00:30:56.640
So if we can just take that a little bit of extra time, I think it'll help them out a lot.
00:30:56.960 --> 00:30:57.279
Yeah.
00:30:57.519 --> 00:31:03.359
Well, thank you so much for taking the time to come on and share your advice and guidance.
00:31:03.440 --> 00:31:10.960
And it sounds like you really are such a great practitioner and really understand a patient's need beyond the physical, but the emotional as well.
00:31:11.279 --> 00:31:13.599
Hope so I try some great mentors in my training.
00:31:13.680 --> 00:31:16.000
I try to take examples from them and then build upon that.
00:31:16.160 --> 00:31:17.839
But just, you know, I'm here to help, right?
00:31:17.920 --> 00:31:20.079
So that's what my job is, and uh enjoy it.
00:31:20.160 --> 00:31:23.119
So well, hopefully we can myself and others can keep doing that.
00:31:23.359 --> 00:31:23.599
Yes.
00:31:23.759 --> 00:31:25.119
Well, thank you so much.
00:31:25.279 --> 00:31:30.000
And the way we like to end our episodes is by saying something that you're grateful for.
00:31:30.319 --> 00:31:32.240
There's so many things to be grateful about.
00:31:33.119 --> 00:31:39.359
Really truly grateful of the people that I'm surrounded with, which includes my wife, my family, my friends, my colleagues, and my patients.
00:31:39.519 --> 00:31:42.559
I think the community I'm just surrounded by here in South Florida is awesome.
00:31:42.720 --> 00:31:45.920
And it's fun to go to work every day and work with the team that I'm with.
00:31:46.079 --> 00:31:49.359
It's fun to go home and have the support that I have there, my family, my wife.
00:31:49.440 --> 00:31:57.200
And it's fun to uh work with the patients I have here that are complex, but it's really rewarding being able to help them through those tough times.
00:31:57.359 --> 00:31:59.920
So I'm grateful for the community that I have around me.
00:32:00.000 --> 00:32:02.480
That's makes each day awesome to live.
00:32:02.720 --> 00:32:03.839
Oh, that's so beautiful.
00:32:03.920 --> 00:32:08.720
And what a gratitude to say, oh gosh, I have so many things to be grateful for that I don't know if I can pick one.
00:32:09.200 --> 00:32:13.599
A lot of things going on around them in the world, but we there's a lot of things you can be grateful for too, as well.
00:32:13.920 --> 00:32:14.559
Exactly.
00:32:14.799 --> 00:32:15.440
Exactly.
00:32:15.599 --> 00:32:22.880
I will say for today that I'm grateful for my community of my dog who's always, always by my side.
00:32:22.960 --> 00:32:27.759
I was feeling under the weather over the weekend, and she was with me the whole time.
00:32:27.920 --> 00:32:29.920
And so just lots of gratitude.
00:32:30.319 --> 00:32:31.279
What kind of dog is she?
00:32:31.440 --> 00:32:33.519
She's a Cavalier King Charles Spaniel.
00:32:33.680 --> 00:32:34.000
Awesome.
00:32:34.079 --> 00:32:34.240
Yeah.
00:32:34.319 --> 00:32:36.559
I brought my dog to work uh last week.
00:32:36.720 --> 00:32:38.480
It was a gold mini golden doodle.
00:32:38.720 --> 00:32:40.319
Oh, cute named Rufus.
00:32:40.559 --> 00:32:46.319
And then the whole staff loved him so much that one of the nurses got inspired to over the weekend buy her get her own golden doodle.
00:32:46.400 --> 00:32:48.960
So she brought him to the office today.
00:32:49.200 --> 00:32:51.359
She's like 14 weeks old, so that's cool.
00:32:51.599 --> 00:32:59.440
Oh, well, animals are so therapeutic, and really so many of my patients know Dolce, my dog, just from our meetings, and they're just the best.
00:32:59.599 --> 00:33:03.119
So well, thank you so much for coming on.
00:33:03.440 --> 00:33:03.920
No problem.
00:33:04.079 --> 00:33:05.920
Thanks for having me, and I'll look forward to these chats.
00:33:06.000 --> 00:33:08.400
And if anyone ever has any questions, just let me know.
00:33:08.799 --> 00:33:09.759
Amazing.
00:33:10.319 --> 00:33:12.400
Thank you so much for listening today.
00:33:12.559 --> 00:33:21.200
And always remember, practice gratitude, give a little love to someone else and yourself, and remember you are not alone.
00:33:21.359 --> 00:33:25.359
Find us on Instagram at fertility underscore forward.
00:33:25.519 --> 00:33:35.279
And if you're looking for more support, visit us at www.rmany.com and tune in next week for more fertility forward.
00:00:13.679 --> 00:00:17.839
Hi everyone, we are Rena and Dara, and welcome to Fertility Ford.
00:00:18.000 --> 00:00:24.399
We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City.
00:00:24.640 --> 00:00:35.920
Our Fertility Ford podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
00:00:36.960 --> 00:00:41.200
I am so excited to welcome to Fertility for today, Dr.
00:00:41.359 --> 00:00:43.840
Zoran Pavlovich, or Dr.
00:00:44.079 --> 00:00:50.560
Zee, who is a physician under US Fertility working at IVF Florida.
00:00:50.719 --> 00:00:56.799
And in addition to being an accomplished REI, he is passionate about endometriosis.
00:00:56.960 --> 00:01:04.799
And I'm so excited to have you on because I know that I myself have so many patients who have endo or have the dual endoadno.
00:01:05.359 --> 00:01:09.840
And they just feel really alone, both in the diagnosis and the treatment.
00:01:10.000 --> 00:01:17.280
And then they feel a lot of fear about future implications in terms of reproduction and what that might mean for them.
00:01:17.439 --> 00:01:26.000
So I'm really excited to have you on to talk about this and hopefully alleviate some of that and just share all of your expertise and guidance.
00:01:26.319 --> 00:01:26.879
Of course, yeah.
00:01:26.959 --> 00:01:28.000
Thanks for having me on.
00:01:28.079 --> 00:01:34.239
It's great to have this opportunity to talk about this really, I think, important topic and how it interplays with fertility.
00:01:34.400 --> 00:01:37.680
So again, thanks for having me, and I'm excited to get our conversation going.
00:01:38.159 --> 00:01:38.319
Yeah.
00:01:38.480 --> 00:01:48.799
Well, so first let's tell our listeners who may not know the definition of both endometriosis and then a domiosis, because I think there's a lot of misinformation about both of those.
00:01:49.120 --> 00:01:49.840
There is, yeah.
00:01:50.079 --> 00:02:04.879
So the statement used to always be that endometriosis is endometrium or endometrial-like cells growing outside of the endometrium, so in the pelvis or elsewhere in the body in the abdominal cavity, and can even go to other places such as the lungs and the brain.
00:02:05.040 --> 00:02:06.480
That's a good basic definition.
00:02:06.560 --> 00:02:20.400
But now we're starting to find out that it's not just endometrial-like cells, but cells that are also highly involved in inflammatory processes, autoimmune processes, nerve, pelvic pelvimetry issues, and affecting the nerve structure in the pelvis.
00:02:20.560 --> 00:02:31.120
So altogether, it's kind of this hormonal, autoimmune, inflammatory, nerve-affecting disease that stems from endometriosis or endometrial-like cells in the pelvis.
00:02:31.360 --> 00:02:41.840
And then adenomyosis is really those same or similar cells, but now located in the muscle layer of the uterus and confined to the uterus rather than extra pelvic.
00:02:42.159 --> 00:02:46.800
Are these conditions genetic or are they random in appearance?
00:02:46.960 --> 00:02:49.520
How might you know that you're at higher risk for them?
00:02:49.680 --> 00:02:53.039
And then also that you may be having symptoms of them.
00:02:53.759 --> 00:02:54.960
So it's a little bit of both.
00:02:55.120 --> 00:03:04.080
There are some genetic components to it that we're starting to discover, but it's also there's patients that may not have any family history or that can develop it as well.
00:03:04.319 --> 00:03:16.400
One of the longtime older theories was that retrograde menstruation was a big part of it, where instead of having a period that flows forward, some of those cells would flow backwards through the tubes and then implant in the pelvis.
00:03:16.560 --> 00:03:21.680
Although we're starting to learn that that one mechanism is just one part of a much larger picture.
00:03:21.840 --> 00:03:28.319
And in fact, endometriosis can spread commonly through the vasculature, through the vessels, through the lymphatic system.
00:03:28.479 --> 00:03:30.400
There's a genetic component to it.
00:03:30.639 --> 00:03:44.560
There's either embryonic stem cells or bone marrow stem cells that can transform into endometriosis-like cells, as well as the cells of the lining of the abdomen and the pelvis, can then they themselves transform into endometriosis cells.
00:03:44.639 --> 00:03:48.479
So there's a large combination of theories of how a patient could get it.
00:03:48.719 --> 00:03:55.439
And no single one of them actually explains all the instances of how someone gets endometriosis, but they're all play a role.
00:03:55.680 --> 00:04:22.240
And really the first indication that endometriosis may be part of your picture is the clinical symptoms, which usually include chronic pelvic pain, pain with intercourse, very painful or heavy periods, issues with infertility, generalized pelvic pain or sciatic nerve pain that shoots down their legs, lower back pain, and then also fatigue, bloating, generalized feelings of inflammation that people can have in their abdomen.
00:04:22.399 --> 00:04:25.920
All of that can be a constellation to symptoms of endometriosis.
00:04:26.240 --> 00:04:31.600
Is this something that you're born with and is present your whole life, or could you develop it later in life?
00:04:32.000 --> 00:04:32.560
So both.
00:04:32.639 --> 00:04:40.319
You can either sometimes there's indications or instances where adolescents will have endometriosis even before the menstruation starts.
00:04:40.480 --> 00:04:48.240
And that is usually cells that come from an embryonic or stem cell origin that are present and then transform to endometriosis cells.
00:04:48.399 --> 00:04:57.360
And then patients can also develop it later in life, either where these cells travel through the vessels or post-surgically, some of these cells get implanted into the uterus.
00:04:57.519 --> 00:04:58.800
You can develop it later in life.
00:04:58.879 --> 00:05:00.800
So it's a combination of the two, actually.
00:05:01.279 --> 00:05:03.040
And how might you treat it?
00:05:03.759 --> 00:05:12.480
So treatment, it's a complex answer because endometriosis, adenomiosis is again a complex constellation of symptoms.
00:05:12.800 --> 00:05:25.279
And of course, there's the mainstay of surgery, which for endometriosis especially, patients will have to at some point get an endometriosis surgical treatment, whether that's excision or fulguration, which is burning.
00:05:25.360 --> 00:05:29.519
Although I personally believe in excision and removal of the endometriosis rather than burning.
00:05:29.839 --> 00:05:30.480
Okay, great.
00:05:30.560 --> 00:05:32.800
Let's break both of those down for our listeners.
00:05:33.199 --> 00:05:39.439
So when it comes to surgery, you can have either actually removal of an endometriosis lesion.
00:05:39.519 --> 00:05:45.920
So you go in and you surgically take out the tissue that contains the endometriosis, so it's removed from the patient's body.
00:05:46.079 --> 00:05:53.839
Whereas the fulguration or burning is where you go in and you just use uh cautery to zap and to burn off those little lesions.
00:05:54.160 --> 00:05:56.560
So physicians often do either or.
00:05:56.800 --> 00:06:11.519
Why I'm more of the school of thought of excision is because when you're burning the endometriosis, sometimes there are parts of that endometriosis that are deeper and you can't really burn too deep, and you don't even know how far deeply you need to burn to fully get rid of the lesion.
00:06:11.680 --> 00:06:24.800
And sometimes the endometriosis is on important structures, so on the ovaries or around the ureters, around the bladder, around the bowel, and you can't burn those lesions because you don't want to burn into the normal tissue and then cause other issues and complications.
00:06:25.120 --> 00:06:27.199
So that's where the two different schools of thought are.
00:06:27.279 --> 00:06:32.000
And I do believe in the field that the actual removal of the endometriosis is the right way to go.
00:06:32.319 --> 00:06:41.040
So, okay, and I don't want to get sidetracked from the initial question, but I think this is super important because I know so many of my clients then deal with this.
00:06:41.120 --> 00:06:50.240
So if you are someone that's having the surgery, right, okay, you find out, and I know a lot of people don't find out that they have endo or adeno until they start trying to conceive, right?
00:06:50.319 --> 00:06:56.480
And then it's not happening because maybe you're someone that you didn't ever present with heavy periods or abdominal pain.
00:06:56.639 --> 00:07:02.000
You had more of the silent endo or adeno, which means you didn't really experience these physical symptoms.
00:07:02.160 --> 00:07:08.319
And it's not until you go to try and conceive and it's not happening, you find out, oh, okay, I have endo or adeno or both.
00:07:08.560 --> 00:07:09.759
Okay, so next steps.
00:07:09.920 --> 00:07:12.319
Now we have to have a surgery to remove this.
00:07:12.560 --> 00:07:16.000
Now, what does this mean for your reproductive future?
00:07:16.240 --> 00:07:17.120
Can you carry?
00:07:17.279 --> 00:07:19.279
Can you conceive biologically?
00:07:19.519 --> 00:07:21.279
Can you still have a vaginal birth?
00:07:21.360 --> 00:07:22.560
Do you have to have a C-section?
00:07:22.639 --> 00:07:27.600
These are all things that I know come up for patients when they're delivered this news.
00:07:28.000 --> 00:07:36.399
Actually, I should step back and you asked me initially how do you treat the endometriosis, which even before you treat it, the first most important thing is how do you diagnose it?
00:07:36.639 --> 00:07:51.360
And that's where when we talked about the clinical symptoms are really important, listening to the patient, hearing their story, having that a high inner differential of chronic pelvic pain, physical exam that you do yourself with a bimanu exam, and then imaging becomes really important.
00:07:51.920 --> 00:07:56.800
Because a transvaginal ultrasound and MRI, those are the two mainstays of imaging.
00:07:57.040 --> 00:08:09.600
And if done correctly, in terms of a complex gyne ultrasound or an MRI, where either you were able to read it yourself or have a radiologist that's experienced and looking for endometriosis, will then tell you the level or stage of the disease.
00:08:09.680 --> 00:08:17.360
And then that can give you some indications of what a surgery would look like, what it would contain, and what could that mean for fertility future.
00:08:17.600 --> 00:08:27.439
So, for example, if the endometriosis is on one or both tubes and you may need to remove a tube, the implications of fertility for that are important to talk about with the patient.
00:08:27.519 --> 00:08:30.720
Because if both tubes need to be removed now, how do we bypass the tubes?
00:08:30.800 --> 00:08:33.120
We would have to do something such as IVF.
00:08:33.440 --> 00:08:43.759
But if the tubes are okay and it's it's removal of endometriosis in other areas of the pelvis, then they would have the ability to get spontaneously pregnant, vaginal delivery, all of that still stays the same.
00:08:43.919 --> 00:08:50.240
But if the ovary, for example, has a large cyst on it, we would then talk about how that could impact egg reserve and the changes in that.
00:08:50.480 --> 00:09:03.519
And when it comes to C-section, so mostly for endometriosis, even if it's bad endometriosis where there's cysts in the ovaries or on the bowel and needs to be removed from the bowel, etc., a pregnancy and vaginal delivery are still possible.
00:09:03.759 --> 00:09:13.840
Adenomiosis is a little different because when you're looking at diagnosing adenomiosis, if it's diffuse, meaning it's all around the uterus, you can't really treat that surgically.
00:09:14.000 --> 00:09:33.120
You have to manage the symptoms either hormonally with through something such as an IUD and then try to prepare the patient for pregnancy, which there's different caveats within that of how to do we do IVF right away and prepare embryos and then prepare the lining, or do we have a patient just have an IUD in place for a while for symptoms and then try naturally?
00:09:33.360 --> 00:09:40.879
Or if it's focal adenomyiosis, you can actually surgically remove that, similar to how you would remove a fibroid that's in the focal area.
00:09:41.039 --> 00:09:50.240
But once you cut into the uterus and remove the adenomyoma is what we would call it, and you stitch that back together, then that prevents the patient from having a vaginal delivery in the future.
00:09:50.320 --> 00:09:55.200
And that's where a C-section would be required between 37 to 38 weeks and six days or so.
00:09:55.360 --> 00:10:08.320
And so the fertility aspects of their future fertility and how they're going to deliver and the ability to get pregnant really depends on the degree of disease and what's present and what requirements are gonna have to happen within the surgery.
00:10:08.559 --> 00:10:10.720
Okay, so it's very patient and case dependent.
00:10:10.960 --> 00:10:12.639
Very patient and case-dependent, exactly.
00:10:12.720 --> 00:10:13.039
Yeah.
00:10:13.360 --> 00:10:24.240
And with both of these, both endo and adeno, is it something that once you quote unquote treat it, it's good, or it's ongoing treatment and ongoing maintenance?
00:10:24.639 --> 00:10:26.720
It's an ongoing treatment, ongoing maintenance.
00:10:26.960 --> 00:10:50.159
One thing that ACOC did well recently defining in their new document that they came out with was that it's a chronic pelvic pain disease and it's a chronic lifelong situation where it's all about removal of the lesions, management of the symptoms, helping with pregnancy, et cetera, up until hopefully you get to the age of menopause, which then without the hormones of the ovaries, that the disease should quiet down.
00:10:50.320 --> 00:11:05.279
However, there are instances of post-menopausal endometriosis as well, because again, it's it's a disease that's chronic, that's inflammatory, that affects the nerves, and it's not just hormonally active, which then complicates that picture a little bit, where you might have to manage a patient further and further.
00:11:05.440 --> 00:11:12.720
And I do tell patients that the recurrence risk, even for a full excision, is patient dependent, and depending on how much disease was there.
00:11:12.799 --> 00:11:21.600
And if you had a surgeon that was skilled enough to remove everything or was anything left over, that also plays into a factor of how fast a recurrence can be.
00:11:21.759 --> 00:11:27.679
But on average, sometimes it's up to 25 to 40 percent recurrence rate after a couple years after excision.
00:11:27.840 --> 00:11:33.600
So it really depends on the amount of disease that's there and then how much is able to be safely removed.
00:11:33.759 --> 00:11:49.200
But because it can come back, and it's either going to be microscopic disease that you couldn't see that activates itself, or the same way that the endometriosis and aomiosis spread the first time, let's say through the lymphatic system, can happen again, and then that endometriosis is back.
00:11:49.279 --> 00:11:55.919
So it really does become a management thing between the patient and the physicians that she's working with throughout the rest of their lives.
00:11:56.240 --> 00:12:06.080
So, what would your advice be for someone that say they're not even thinking about family building, but they're listening to this and they think, oh my gosh, wow, I really think I have endo.
00:12:06.639 --> 00:12:10.799
What type of physician would they call if they're not looking to family build?
00:12:11.120 --> 00:12:44.639
I would say so either someone that's at least comfortable with diagnosing and doing the initial workup with endometriosis, which could be either an OBGOIN that is well versed in recognizing the signs and symptoms of endo and knowing what imaging to get, or a step above that, if you have either a fertility specialist such as myself that does a lot of reproductive surgery, or a minimally invasive guidance surgeon that focuses on endometriosis and is able to also again do the diagnosis and then the imaging workup and then either the referral for the surgery yourself or to someone, a specialist.
00:12:44.879 --> 00:12:48.720
Those are the kinds of people that I would have the patient look to talk to.
00:12:48.799 --> 00:12:54.000
Because the biggest issue nowadays is there's about this, on average, seven to 10 year delay in diagnosis.
00:12:54.080 --> 00:12:56.559
The ACOG document says four to 11 years.
00:12:56.720 --> 00:13:08.159
And that's because for the longest time, so many people were thinking that, oh, this these painful periods are just how a patient's periods are, or these symptoms are something that they just have to get used to.
00:13:08.240 --> 00:13:10.000
And so the bucket gets kicked down the road.
00:13:10.080 --> 00:13:14.639
And after years and years of being told that the disease in that time gets worse and worse.
00:13:14.960 --> 00:13:28.559
And so I would say that patients really, if they're feeling that they're concerned that they may have symptoms of endometriosis, is to go talk to probably first year OBGIO and advocate for either a referral to the specialist or more imaging.
00:13:28.960 --> 00:13:48.240
And if they find like they're not getting the support there, then to either find locally through some of their own research or online groups just to see who locally in their area or a nearby city may be doing this kind of work and then go to that more specialized center because you don't want to delay your diagnosis if you truly feel like you're having these symptoms.
00:13:48.559 --> 00:13:55.840
And I think that's one of the things that a lot of people run into is being told previously, oh, you're fine, that's normal.
00:13:56.080 --> 00:14:07.600
And then people believe what their physician says and don't pursue it, and then those kind of suffer until they get to someone, usually when it's trying to conceive that recognizes it.
00:14:07.759 --> 00:14:11.279
And I know with that, certainly there's so much frustration, right?
00:14:11.360 --> 00:14:15.200
That, okay, I didn't have to live like this for the past 10 years or whatever.
00:14:15.440 --> 00:14:18.960
Because it's really quite debilitating, both of these diseases.
00:14:19.360 --> 00:14:20.080
Oh, absolutely.
00:14:20.240 --> 00:14:26.480
And I think that that's where a lot of patient frustration comes from and why there's a lot of anxiety around this.
00:14:26.639 --> 00:14:31.440
And I had a great mentor at Mayo Clinic once that just like had we were talking to a patient.
00:14:31.519 --> 00:14:39.440
He was basically took pieces of paper and he had the patient crumple the pieces of paper up and throw it in the trash to represent each person that told her that it was in her head.
00:14:39.600 --> 00:14:41.279
And that was like very cathartic for her.
00:14:41.360 --> 00:14:44.080
But it was just an example of how that happens so often.
00:14:44.159 --> 00:15:03.840
And this old school thought of thinking that we had decades ago needs to change, and luckily is changing with either physicians that are retraining themselves or younger physicians coming into the field now that are understanding and learning about chronic pelvic pain early on in med school and residency, fellowship, et cetera, and bringing that into their practices.
00:15:04.000 --> 00:15:09.440
I'm seeing noticing with the OBGONs that work around me that they are putting it higher in the differential.
00:15:09.600 --> 00:15:25.600
And I tell them all the time, I would rather you over-diagnose it and be really conservative and suspect it, and then also do either a lot of imaging or tests or even the surgery to then find that, oh, it's a low-level disease that we can take care of early rather than waiting for the patient to be diagnosed a decade down the road.
00:15:25.679 --> 00:15:28.080
And then now the disease is significantly advanced.
00:15:28.320 --> 00:15:44.559
So that's changing, I think, slowly but surely, and we're getting better at it, but it will take time, I think, until we have that perfect system of early diagnosis and early understanding and listening to the patient, good imaging, and then good referral for surgical and conservative care as well.
00:15:45.360 --> 00:15:53.120
Well, it's so heartening to hear that it's changing because I'm sure you as well, as myself, have seen so many people suffer.
00:15:53.360 --> 00:15:54.480
What about though?
00:15:54.559 --> 00:15:59.600
You know, so many women start a birth control pretty soon after they start menstruating.
00:15:59.759 --> 00:16:10.399
So, what if you're someone that's been on a birth control for most of your life and then you did not have the experience of these super heavy, painful periods because it was masked?
00:16:11.120 --> 00:16:12.320
I mean, is that possible?
00:16:12.480 --> 00:16:19.200
Is that what happens potentially with endocan being on birth control kind of your whole life until you decide that you want to conceive?
00:16:19.279 --> 00:16:20.960
It can be masked by that.
00:16:21.519 --> 00:16:26.240
It definitely can sometimes, although often there's usually something else that's going on.
00:16:26.320 --> 00:16:40.080
So they may not have these painful, debilitating periods, but they'll have a lot of pain with intercourse or a lot of pain with bowel movements or urination that gets misdiagnosed as a cystitis or constipation, something like that.
00:16:40.159 --> 00:16:42.080
And just none of those are giving the answer.
00:16:42.480 --> 00:16:58.879
And then the generalized fatigue and malaise and the bloating that is so significant every month, those are other signs that are softer signs that may indicate to a patient that there's something else going on, especially in terms of endometriosis and adenomiosis, and at least warrants them getting some imaging.
00:16:59.279 --> 00:17:01.360
But it definitely can be masked at times.
00:17:01.440 --> 00:17:19.039
And then when patients are ready to undergo fertility treatment, that's where they stop the birth control, and then a lot of these symptoms just come roaring in and they're get noticed on the imaging during a fertility workup, or there's just saying that, oh, I just thought of birth control a few months ago and I've had this really excruciating pelvic pain out of nowhere, and that's where we find out.
00:17:19.279 --> 00:17:22.160
Hopefully, we're catching those patients sooner rather than later.
00:17:22.319 --> 00:17:27.519
But it's a potential that sometimes the symptoms can be a little massed, and that can delay diagnosis as well.
00:17:28.160 --> 00:17:41.440
So I guess any final words of wisdom or thoughts for patients either that have already been diagnosed with either of these or someone that thinks that maybe they have one of these conditions?
00:17:41.839 --> 00:17:46.960
Yeah, I would say the most important thing is definitely advocate for yourself.
00:17:47.279 --> 00:17:56.000
And really, if you go online and you think your symptoms are part of this constellation, to really push for being seen and diagnosed and done imaging.
00:17:56.160 --> 00:18:02.799
And if whoever you're working with seems to be dismisses of that, to then seek a second opinion because I think that's important.
00:18:02.880 --> 00:18:09.440
I think some, as you said, patients trust their doctors, and so they'll just live with something because they believe what they're told.
00:18:09.519 --> 00:18:12.079
But if it doesn't feel right to you, then it likely isn't.
00:18:12.240 --> 00:18:18.160
So keep trying and looking until you find those people that can dive into it a little bit further for you and give you more answers.
00:18:18.319 --> 00:18:19.599
That'd be one thing.
00:18:19.759 --> 00:18:33.519
And then two, just look into what kind of either fertility or surgical expertise there is in your surrounding area because that's going to help also dictate where to go and where you could get the best possible care.
00:18:33.680 --> 00:19:06.240
I think that my dream would one day be that every single state has this multi-level tertiary system where you have uh general practitioners and OBGYNs initiating the initial diagnosis and the symptoms and then referring out to more complex guy imaging and endometriosis MRIs, and then the large, you know, at least one center per state where it's the multidisciplinary chronic pelvic team, where you have everything from the surgeon to the fertility doctor, the colorectal, the pelvic floor physical therapy, et cetera, to really tackle it all together.
00:19:06.480 --> 00:19:16.000
And so looking out for places in the states and institutions that may offer that endometriosis center of excellence would be an important thing for a patient to look into.
00:19:16.240 --> 00:19:17.119
And just not wait.
00:19:17.200 --> 00:19:22.960
You know, if you feel like something's wrong, again, just going early and going often to try to be seen and be diagnosed.
00:19:23.200 --> 00:19:33.039
Well, I mean, I hope that your dream becomes a reality because I think you just touched upon something that is part of the biggest stress for people, which is look at all those providers you just named, right?
00:19:33.119 --> 00:19:35.200
Down to a pelvic floor therapist.
00:19:35.279 --> 00:19:44.720
You know, I think that's where so many people get overwhelmed or come up with roadblocks that it's not about one provider is able to kind of one-stop shop this for you.
00:19:44.880 --> 00:19:52.799
And it takes a lot of time and patience and advocacy and navigating the healthcare system, which unfortunately is pretty daunting.
00:19:52.960 --> 00:20:00.960
And so I think a lot of people either kind of stop because they just get tired of it, or you know, they just get so overwhelmed dealing with it.
00:20:01.119 --> 00:20:03.119
And it's a lot for people to take on.
00:20:03.200 --> 00:20:09.279
And I think that's a broader conversation about our healthcare system, but that that's such an issue too.
00:20:09.440 --> 00:20:13.279
Piecing it all together is quite stressful.
00:20:13.599 --> 00:20:16.799
Yeah, it's it's definitely hard and it does take a lot of time.
00:20:16.960 --> 00:20:28.640
And I think that's, as you were saying, a broader part of our healthcare system where I can see how when a provider, say no BG Wayne has only 15 minutes with a patient to be able to go through all that and talk it through, it's gonna be really hard.
00:20:28.799 --> 00:20:36.079
I'm lucky I get to spend 45 minutes to an hour sometimes in my consults when I talk about endometriosis and the plan to diagnose an image.
00:20:36.319 --> 00:20:39.039
That's a long visit that not everyone has a luxury for.
00:20:39.119 --> 00:20:41.680
And so those are things that need to change in our system for sure.
00:20:41.839 --> 00:20:56.720
But at the very least, what can be done even in a short visit is just acknowledging that pain and that patient's vulnerability, realizing that they're telling you something important and keep keeping it high in your differential just to be able to then go try to tackle it earlier rather than later.
00:20:56.880 --> 00:20:57.839
I think will help a lot.
00:20:57.920 --> 00:21:00.559
That that's going to maybe catch a lot more people sooner.
00:21:00.720 --> 00:21:10.240
And especially as ACOG is saying that you can use imaging to help initiate treatment, then we don't have to wait for a long period of time for someone to finally get a surgery to then get the diagnosis.
00:21:10.480 --> 00:21:16.240
We can actually start examining them and treating them earlier on and then get them to surgery in a safer way.
00:21:16.319 --> 00:21:19.119
So it'd be nice, yeah, for one day to we're we're getting there.
00:21:19.200 --> 00:21:21.200
There's some countries in the world that do it really well.
00:21:21.440 --> 00:21:24.400
Europe is a good one, Brazil does a good job, Latin America too.
00:21:24.480 --> 00:21:27.359
So and hopefully we're also catching up to all of that.
00:21:27.680 --> 00:21:28.240
I hope so.
00:21:28.400 --> 00:21:33.759
But I think that sounds like that's really positive, though, the new guidelines and being able to image first.
00:21:33.839 --> 00:21:46.079
And I think, like you said, you know, make sure you're going to a specialist and you're going to someone also that knows how to read the image, because a lot of times things are overlooked or missed by someone that's not, they don't know what to look for.
00:21:46.240 --> 00:21:54.799
And so, really to listen to your gut and advocate for yourself and don't necessarily just take someone's answer to be the answer.
00:21:55.599 --> 00:21:55.759
Yeah.
00:21:55.920 --> 00:21:58.880
And for us providers, we have to work on building our network.
00:21:59.039 --> 00:21:59.759
So I have a good relationship.
00:22:00.079 --> 00:22:08.880
Relationship with pelvic floor physical therapists in the area, with pain management clinic and with a mix minimal invasive guine surgery endometriosis-specific surgeon specialist.
00:22:08.960 --> 00:22:16.319
That when I diagnose 5% of the time, I'll diagnose a bad bowel endometriosis that'll require a removal of that bowel and putting it back together.
00:22:16.480 --> 00:22:21.680
My team doesn't have that multidisciplinary aspect to it where we can handle that large of an endosurgery.
00:22:21.759 --> 00:22:24.559
So I refer them out to this colleague of mine.
00:22:24.720 --> 00:22:28.400
But I have my note, my pictures, the MRI disks, all the workups done.
00:22:28.480 --> 00:22:31.200
So it's kind of packaged nicely to him and then handed over.
00:22:31.279 --> 00:22:43.440
And he's just able to meet this patient and then just have a quick one-on-one and then get it right into surgery because he knows exactly what's happening, thanks to the time that I was able to spend with her and do the imaging and diagnose things and explain everything to her.
00:22:43.519 --> 00:22:46.880
And that's the kind of relationship that makes this care a lot better.
00:22:47.119 --> 00:22:55.119
That we shouldn't be working on such a complex disease in silos because you can't, you need a multidisciplinary team.
00:22:55.200 --> 00:23:01.119
And if it's not at your direct institution, you have to go out there and find the people that are part of that so you can build that community.
00:23:01.279 --> 00:23:02.640
That's the only way to really do it.
00:23:02.960 --> 00:23:09.440
Well, and I think that's a great tip for people that make sure you're working with a provider who can tell you, right, like, okay, this is who I refer to.
00:23:09.519 --> 00:23:12.240
I have these relationships, this is who I collaborate with.
00:23:12.319 --> 00:23:21.200
And it's this, it's a system, you know, because that's what makes it easier versus someone that says, okay, but now you go source, you know, the next people that you need.
00:23:21.359 --> 00:23:22.799
That makes it so much harder.
00:23:23.119 --> 00:23:25.119
Yeah, really hard to navigate that on your own.
00:23:25.519 --> 00:23:25.680
Yeah.
00:23:25.839 --> 00:23:30.480
So I think that's a great tip for someone to ask in an initial appointment with someone, right?
00:23:30.640 --> 00:23:31.839
Okay, who do you refer to?
00:23:32.000 --> 00:23:35.039
You know, do you have all of this list handy, right?
00:23:35.119 --> 00:23:36.400
And then I can just take it and go.
00:23:36.559 --> 00:23:37.920
That makes a huge difference.
00:23:38.240 --> 00:23:38.960
That's very helpful.
00:23:39.039 --> 00:23:43.599
And that's what some of the questions that I get asked by a lot of patients how do you do your diagnosis?
00:23:43.759 --> 00:23:44.720
Where do you do your surgeries?
00:23:44.799 --> 00:23:45.839
What kind of surgeries do you do?
00:23:46.160 --> 00:23:48.000
Who do you refer out to if there's any issues?
00:23:48.079 --> 00:23:59.759
And that's really important for patients to ask for themselves and not to be afraid to ask, because I do think sometimes some patients may feel worried that they are stepping on some toes with the doctor or something like that.
00:23:59.920 --> 00:24:01.279
And I don't want them to feel like that at all.
00:24:01.359 --> 00:24:03.279
Like they should be asking those questions.
00:24:03.440 --> 00:24:10.160
And if you're with a provider that gives you a hard time about it, then you kind of have your answer that that's not somebody that you want to receive your care with.
00:24:10.319 --> 00:24:22.079
Because, in my personal opinion, within the disease like this and with fertility and how complex all of it is and how complex these surgeries are, there's just no room for egos in the OR or in the diagnosis or in the management of this.
00:24:22.160 --> 00:24:25.920
You have to put, you know, check that out the door and really just try to do what's best for the patient.
00:24:26.000 --> 00:24:29.039
And that's important for doctors to do and for patients to ask for.
00:24:29.279 --> 00:24:29.599
Yes.
00:24:29.680 --> 00:24:32.240
Well, you seem like a real diamond in the rough.
00:24:32.319 --> 00:24:34.160
And that's what I always tell patients too.
00:24:34.319 --> 00:24:39.759
I say, if a doctor makes you feel badly for asking a question, that's not the provider for you.
00:24:39.920 --> 00:24:53.440
You know, because there's a difference in saying, okay, you know, unfortunately I have 15 minutes for this appointment, et cetera, et cetera, than someone just sort of brushing you off and not giving any validity to your questions.
00:24:53.680 --> 00:25:02.960
You want to work with a provider that's able to communicate and dialogue with you and you know, again, a mutual understanding about how much time is allowed in the appointment, and maybe you need to make another one.
00:25:03.119 --> 00:25:10.160
That's fine, versus someone that's you know gonna give you some ego and pigeonhole you into one direction, right?
00:25:10.240 --> 00:25:11.440
Yeah, exactly.
00:25:11.839 --> 00:25:15.359
So, I mean, you seem wonderful and like a great resource.
00:25:15.519 --> 00:25:21.759
Now, do you work telehealth at all with New York patients since we have so many New York listeners or only Florida?
00:25:22.319 --> 00:25:24.559
No, I do telehealth visits all the time.
00:25:24.799 --> 00:25:35.200
And of course, MRIs can be done anywhere as long as I can get the actual physical disk because not all MRI reads are created equal, and sometimes it's just you know where to look on an MRI disk.
00:25:35.359 --> 00:25:51.440
The one thing that has to just be done in person is the complex gyne ultrasound, which is more than just a regular transvaginal ultrasound because most people get sent for imaging for their pelvic pain or their endo, and it's a quick five-minute check the uterus, look at the ovaries, and you know it looks fine and they're out.
00:25:51.680 --> 00:26:03.039
A complex gyne ultrasound or dynamic ultrasound is where not only are you looking at the uterus and the ovaries, but you're dynamically pushing against the uterus and the ovaries, looking for things such as sliding sign.
00:26:03.279 --> 00:26:05.200
Are the organs all frozen and stuck together?
00:26:05.359 --> 00:26:06.720
Are they freely moving?
00:26:06.960 --> 00:26:17.440
You're checking out for cysts, you're looking at the uterus sacrils, and you can even, if you've done enough of these, you can actually look for superficial endometriosis in the cul de set, you can visualize it on an ultrasound.
00:26:17.599 --> 00:26:32.880
So that visit between the physical exam I have to do, the ultrasound, and sometimes the saline ultrasound, which is where we can put some fluid in the cavity to look at the inside of the uterus, especially for adenomyosis, and then use some of that fluid to look for superficial endomes.
00:26:32.960 --> 00:26:34.960
That takes that's a 30 to 45 minute visit.
00:26:35.200 --> 00:26:36.799
That's the HSG you're talking about.
00:26:37.279 --> 00:26:40.880
No, it's a physical exam, ultrasound and saline, all three together.
00:26:41.519 --> 00:26:52.480
The dynamic ultrasound part of it is where we're using the probe to just look at these different parts of the pelvis where the endometriosis likes to live and lie and look for signs of endometriosis and lesions.
00:26:52.559 --> 00:26:53.759
You can tell them pretty well.
00:26:53.839 --> 00:26:59.839
It just takes longer to do because there's so many different parts of the pelvis that you're looking at and interrogating with the probe.
00:27:00.000 --> 00:27:01.599
You can't do it in a five-minute visit.
00:27:01.680 --> 00:27:03.119
And that's an in-person thing, too.
00:27:03.279 --> 00:27:04.000
So got it.
00:27:04.079 --> 00:27:04.240
Okay.
00:27:04.400 --> 00:27:07.119
If I ever saw a person on telehealth, I would say, Hey, yeah, this is great.
00:27:07.200 --> 00:27:14.640
You can give you the MRI, send me to this, but you'll have to come down here for me to do this ultrasound because I can't just send you over to do a random ultrasound somewhere else.
00:27:14.799 --> 00:27:18.559
Unless I know that person can do that same guy in dynamic ultrasound.
00:27:18.720 --> 00:27:23.359
And there's that's slowly starting to become a bigger part of practice in New York.
00:27:23.839 --> 00:27:25.680
I know there's a couple of good groups out there.
00:27:25.759 --> 00:27:26.160
I know Dr.
00:27:26.240 --> 00:27:28.160
Vidali's up there and his group does that stuff.
00:27:28.240 --> 00:27:30.960
There's Matthew Leonardi that's in Toronto that's not too far away.
00:27:31.039 --> 00:27:34.720
He's kind of been the pioneer of uh complex guy and ultrasound.
00:27:34.960 --> 00:27:40.400
So that's the really the tough part that you can do a television, but really you need that in-person exam.
00:27:40.880 --> 00:27:43.279
Okay, that's very helpful to know.
00:27:43.519 --> 00:27:46.799
Any other parting thoughts for our listeners?
00:27:47.440 --> 00:28:04.960
I think, you know, when it comes to fertility, and if you're talking with fertility specialists, I think it's important to not just look at the hormones, the egg reserve, the basic fertility tests, but also to inquire and ask your provider or your doctor, do you see any signs of adenomiosis?
00:28:05.039 --> 00:28:06.640
Do you believe I may have endometriosis?
00:28:06.720 --> 00:28:07.680
Do you see fibroids?
00:28:07.839 --> 00:28:22.000
Because I have seen some crazy things out there where there's patients with really large, even cavity distorting intramural fibroids that are going through either multiple cycles of IDF and things aren't or implanting, or have a large C-section scar defect.
00:28:22.079 --> 00:28:36.319
That's something I see a lot too, the isthmusels, where they have fluid that builds up in the C-section scar, and they either have to cancel an embryo transfer because there's fluid in the cavity, or an embryo just never sticks after multiple euploid embryo transfers.
00:28:36.640 --> 00:28:38.559
To ask, is there something else going on?
00:28:38.720 --> 00:28:40.319
Is there something structural going on?
00:28:40.480 --> 00:28:42.960
Is there something is this fibroid impacting it?
00:28:43.039 --> 00:28:44.720
Does my C-section scar play a role?
00:28:44.880 --> 00:28:46.000
Does do you believe there's endo?
00:28:46.240 --> 00:28:47.440
Do you believe there's adeno?
00:28:47.599 --> 00:29:02.240
And going back to the reproductive endocrine and reproductive surgery part of our field that was so prevalent 30, 40 years ago before IVF was a thing, to bring that back a little bit in addition to all the regular fertility tests that we're doing.
00:29:02.319 --> 00:29:08.000
I think that's something that's important for both providers and patients to look into and try to train themselves to be better at.
00:29:08.880 --> 00:29:09.200
Okay.
00:29:09.519 --> 00:29:10.880
Very exciting field.
00:29:10.960 --> 00:29:21.680
And I am hopeful that this episode brings hope to patients because I know with my own clients, can be feel, like I said at the beginning, very lonely, very frustrating.
00:29:22.000 --> 00:29:24.640
I know a lot of them feel like no one's really listening.
00:29:24.799 --> 00:29:29.119
I mean their symptoms are kind of just being gaslit or overlooked.
00:29:29.200 --> 00:29:35.839
And to really have an understanding of how debilitating, you know, either of these really can be on somebody's life.
00:29:36.160 --> 00:29:54.480
Yeah, I think that's where doctors, physicians, providers, et cetera, can all continuously try to be better, where it's validating, understanding, knowing how complex it is, and knowing that you have to take the time to talk to these patients, to examine them, to do the testing and counsel, because it's not going to be a quick five-minute general unexplained infertility visit.
00:29:54.559 --> 00:29:59.599
There's going to be a lot more to it and to take that time because it's going to be meaningful for them for sure.
00:29:59.839 --> 00:30:01.519
Because it's a complex disease.
00:30:01.680 --> 00:30:10.720
And maybe one day we'll have that holy grail of an immunotherapy where it targets the endometriosis cell perfectly, which is, I guess, would be the ultimate treatment.
00:30:10.880 --> 00:30:15.519
But until then, we got to manage it in multiple ways and with the multidisciplinary team.
00:30:15.680 --> 00:30:17.440
And that takes time, takes time and effort.
00:30:17.519 --> 00:30:18.640
So it does.
00:30:18.799 --> 00:30:22.799
But I think the good news is once you figure it out, it can be managed.
00:30:22.960 --> 00:30:27.839
And it does not mean that you will not be able to family build or carry or have children.
00:30:28.160 --> 00:30:35.200
Yeah, it can definitely be managed, and especially if it's caught earlier, it can be very managed very easily and very well, optimizing your fertility.
00:30:35.440 --> 00:30:38.720
And as I told a patient earlier today that I saw it was a straight question.
00:30:38.799 --> 00:30:42.559
She was like, I've been told so many things that I will never have kids, it'll take me forever to have kids.
00:30:42.640 --> 00:30:44.799
And I'll be like, No, you're going to be able to have kids.
00:30:44.880 --> 00:30:45.839
It's going to happen.
00:30:46.000 --> 00:30:47.519
And this is how we're going to get you there.
00:30:47.599 --> 00:30:52.720
So it's just a lot of, like you said, misinformation out there and fearful statements for patients.
00:30:52.880 --> 00:30:56.640
So if we can just take that a little bit of extra time, I think it'll help them out a lot.
00:30:56.960 --> 00:30:57.279
Yeah.
00:30:57.519 --> 00:31:03.359
Well, thank you so much for taking the time to come on and share your advice and guidance.
00:31:03.440 --> 00:31:10.960
And it sounds like you really are such a great practitioner and really understand a patient's need beyond the physical, but the emotional as well.
00:31:11.279 --> 00:31:13.599
Hope so I try some great mentors in my training.
00:31:13.680 --> 00:31:16.000
I try to take examples from them and then build upon that.
00:31:16.160 --> 00:31:17.839
But just, you know, I'm here to help, right?
00:31:17.920 --> 00:31:20.079
So that's what my job is, and uh enjoy it.
00:31:20.160 --> 00:31:23.119
So well, hopefully we can myself and others can keep doing that.
00:31:23.359 --> 00:31:23.599
Yes.
00:31:23.759 --> 00:31:25.119
Well, thank you so much.
00:31:25.279 --> 00:31:30.000
And the way we like to end our episodes is by saying something that you're grateful for.
00:31:30.319 --> 00:31:32.240
There's so many things to be grateful about.
00:31:33.119 --> 00:31:39.359
Really truly grateful of the people that I'm surrounded with, which includes my wife, my family, my friends, my colleagues, and my patients.
00:31:39.519 --> 00:31:42.559
I think the community I'm just surrounded by here in South Florida is awesome.
00:31:42.720 --> 00:31:45.920
And it's fun to go to work every day and work with the team that I'm with.
00:31:46.079 --> 00:31:49.359
It's fun to go home and have the support that I have there, my family, my wife.
00:31:49.440 --> 00:31:57.200
And it's fun to uh work with the patients I have here that are complex, but it's really rewarding being able to help them through those tough times.
00:31:57.359 --> 00:31:59.920
So I'm grateful for the community that I have around me.
00:32:00.000 --> 00:32:02.480
That's makes each day awesome to live.
00:32:02.720 --> 00:32:03.839
Oh, that's so beautiful.
00:32:03.920 --> 00:32:08.720
And what a gratitude to say, oh gosh, I have so many things to be grateful for that I don't know if I can pick one.
00:32:09.200 --> 00:32:13.599
A lot of things going on around them in the world, but we there's a lot of things you can be grateful for too, as well.
00:32:13.920 --> 00:32:14.559
Exactly.
00:32:14.799 --> 00:32:15.440
Exactly.
00:32:15.599 --> 00:32:22.880
I will say for today that I'm grateful for my community of my dog who's always, always by my side.
00:32:22.960 --> 00:32:27.759
I was feeling under the weather over the weekend, and she was with me the whole time.
00:32:27.920 --> 00:32:29.920
And so just lots of gratitude.
00:32:30.319 --> 00:32:31.279
What kind of dog is she?
00:32:31.440 --> 00:32:33.519
She's a Cavalier King Charles Spaniel.
00:32:33.680 --> 00:32:34.000
Awesome.
00:32:34.079 --> 00:32:34.240
Yeah.
00:32:34.319 --> 00:32:36.559
I brought my dog to work uh last week.
00:32:36.720 --> 00:32:38.480
It was a gold mini golden doodle.
00:32:38.720 --> 00:32:40.319
Oh, cute named Rufus.
00:32:40.559 --> 00:32:46.319
And then the whole staff loved him so much that one of the nurses got inspired to over the weekend buy her get her own golden doodle.
00:32:46.400 --> 00:32:48.960
So she brought him to the office today.
00:32:49.200 --> 00:32:51.359
She's like 14 weeks old, so that's cool.
00:32:51.599 --> 00:32:59.440
Oh, well, animals are so therapeutic, and really so many of my patients know Dolce, my dog, just from our meetings, and they're just the best.
00:32:59.599 --> 00:33:03.119
So well, thank you so much for coming on.
00:33:03.440 --> 00:33:03.920
No problem.
00:33:04.079 --> 00:33:05.920
Thanks for having me, and I'll look forward to these chats.
00:33:06.000 --> 00:33:08.400
And if anyone ever has any questions, just let me know.
00:33:08.799 --> 00:33:09.759
Amazing.
00:33:10.319 --> 00:33:12.400
Thank you so much for listening today.
00:33:12.559 --> 00:33:21.200
And always remember, practice gratitude, give a little love to someone else and yourself, and remember you are not alone.
00:33:21.359 --> 00:33:25.359
Find us on Instagram at fertility underscore forward.
00:33:25.519 --> 00:33:35.279
And if you're looking for more support, visit us at www.rmany.com and tune in next week for more fertility forward.
