How do Endometriosis and Ashermans affect Fertility with Haider Jan Consultant Gynaecologist & Obstetrician

Worried you might have endometriosis? Concerns post surgical management of miscarriage? Haider Jan, Consultant Gynaecologist, Obstetrician and Clinical Director for Women's Health at Epsom & Surrey NHS talks us through these conditions and will give you practical tips about what to do next. 

Haider Jan is based at Epsom & Surrey NHS and also privately at Parkside Hospital, CRP clinic & Ashtead Hospital. You can contact his wonderful secretary Helen on: 
07757 310098 or pa@migynaecology.com

Transcript

Unknown: 0:01

Hi, I'm Rachel Sherriff, and welcome to the fertility suite podcast. Our aim is to educate and empower couples who are struggling with all aspects of fertility. By giving you the information to make informed decisions along the way. We've had a little rebrand since series one, we were formerly the fertility method podcast. But in this second series, rest assured, we still have the same high standard of fertility experts coming to share their knowledge and support you. So if you are struggling with fertility, miscarriage or you just want to arm yourself with the facts, then this podcast is for you. So hi, everybody, and welcome back to another one of our podcast episodes. And this week, we have a jam with us. And Haida is a consultant gynaecologist and the clinical director for women's health apps, and I'm sorry, NHS, and today we're going to be talking about endometriosis and Ashland, and how that might affect fertility, whether to know whether you might have that, and then what to do. More importantly, if you think that you might have that. So welcome, hider. Hello, thank you for inviting me to speak today. Thanks for coming. Thanks for coming to you. I know I've given you a little bit of an introduction, but I'm sure you can probably introduce yourself a little bit better to you just want to sort of tell us a little bit more about yourself. And yeah, so I'm a consultant gynaecologist and been working for about 20 years and in gynaecology, and I'm the clinical director, so director of gynaecology and obstetrics at Epsom and St. Helier hospitals and the NHS I work at privately apart side as an Ashford hospital, and the CRP clinic in Epsom my specialise mainly, I lead the endometriosis services specialist and Demetrius serviceware regional centre where we get referrals from other hospitals, and also specialises in specific surgery for people who have trouble conceiving, so fertility type surgery. And so that's why I have an expertise in specifically ashrams and endometriosis and other things as well. But those specifically are things that we deal with on an everyday basis. That's your back that's where you've spent a lot of your time sort of researching so your your main man to talk to you for and Dimitrios this nationalists and fab? Well, let's just start a little bit because I'm conscious that anyone listening, you know, might not know much about endometriosis, it is one of those conditions that takes a long time generally to diagnose and people can sort of maybe not know whether they've got it or not. So do you want to just explain to us a little bit more about exactly what endometriosis is and how it presents? Maybe? Cause Yeah, so individuals, this is a condition where cells that normally line the womb, they're called the endometrium, those cells that are they normally shed during a period. But cells like those are found inside the tummy. So inside the abdomen, and they embedded in the abdomen, and they cause inflammation. And that inflammation can be mild, moderate or severe. And that can cause blockages of the fallopian tube, and just the presence of it can affect can cause pelvic pain, but also difficulty in conceiving naturally. And would it be correct to say and I could be completely wrong on this? But would it be correct to say that endometriosis doesn't actually present within the uterus, and that's why you can't tend to see it on an ultrasound like it's found on either the fallopian tubes, ovaries, or anywhere else in the peritoneal cavity. That's right. So the difficulty in seeing it on ultrasound is that sometimes the lesions the ultrasound doesn't have the sensitivity, that's sort of resolutions fail to pick them up. And often they look like surface deposits when we look through keyhole surgery. So that's a difficulty in picking up an ultrasound. But ultrasound is good at picking up very severe disease that involves cysts, and other things. So it is a good first line tool. So investigating for endometriosis and other causes other pelvic pain things because, you know, understand if one does have pelvic pain or not sounds a good first line tool in picking things up and having a look. Because it's not the only chords and so it's worth looking at other things as well. Yeah, so you know, if you have got that pelvic sort of pain, like you're saying like a first point of call would be to have a chance of dying or ultrasound, have someone to have for one of a better phrase, a good look at your uterus and really see whether there is anything there. But if it comes back clear, not to sort of exclude endometriosis, because it could be that it's not visible. That's, that's right. Yeah, so it all sounds a good pickup tool, but if it's not present on the ultrasound, you may still have endometriosis. specific symptoms that might indicate to people that they might have endometriosis include sort of pelvic pain, chronic pain, painful periods, painful intercourse, pain on opening bowels or or sometimes pain on passing urine as well. And those are the but but a very key way of thinking about it that, you know, a strong indicator would be that if you have a cyclical pain so if the pain tracks with your periods, then that is a good indicator that it may be gynaecological origin and that would indicate endometriosis. So this might sound like a really silly question. But why is it that endo is more painful? When you're having your period? Or maybe just before your periods? Like why? Why does if it's there all of the time? What is the difference? Is it hormonally driven from a pain perspective? Yes, so the cells are similar to the cells that line the womb, and they react to hormones. So you imagine the cells are shed, and during a period don't in the lining of the women, so the endometriosis react similarly, in turn in the abdomen, so it bleeds it causes inflammation at the same time as the period. So that's why it gets exacerbated at that time. Equally, the womb itself, often, when people have endometriosis, they'll have coexisting a condition called adenoma, this is where you have endometriosis in the actual muscle of the womb. So you can often get painful periods or heavy periods associated with endometriosis. Okay, but Adalet meiosis, you'd be able to see that on an ultrasound because it's, if you're if people have been trained to look for it, it can, there are signs that would indicate that. The other thing is that heavy periods in of themselves can cause endometriosis. Because one of the theories as to why and Demetrius occurs is that you can get shedding of the cells and that come out during the period, but you get bleeding. The blood also goes through the fallopian tubes, and out into the abdomen, and blood, it's proven that blood does go into the abdomen, we know that for certain. We also know that cells, we can track cells and their genetic changes as they morph into endometriosis. So there's good evidence that that is actually one of the major causes. It's not the only cause there are other ways that endometriosis can be formed. But that's one of the things that did. That seems to be quite well established. Yeah, that's fascinating, right? Because I think endo is one of those conditions that, again, correct me if I'm wrong, we're still learning a lot about. So it's interesting to know, you know, the pathological process behind why it might occur. Obviously, there's not a lot you can do to stop that happening. I think, you know, if you, if you've got no, you've got no right, I guess you would never know that was happening. Yeah, by controlling the period. So often, when people have heavy periods, if they're on sort of contraception or other things that make periods lighter and less painful, that can in of itself can also help prevent the progression. So it's a very popular thing to take a progesterone pill that stops periods altogether, and by not having periods you in a way also preventing progression and so forth. But there are newer licenced medicines for endometriosis that work in reverse the condition and shrink it. So yeah, so that is, they've been there more effective than just pills and contraception pills. So in terms of fertility, then like, again, like the our sort of listeners are perhaps people that are struggling to conceive and maybe have been doing so for some time. Like, what would your kind of advice be if someone thinks they've got Endo? Maybe they've got a diagnosis in terms of treatment? Like, if you're struggling to conceive what is kind of like the ideal treatment for endometriosis? And what sort of difference in outcomes do you see when you sort of put those treatments in place? So there's two different kinds of endometriosis that we can look at when it comes to fertility. There's endometriosis in the form of cysts on the ovaries, they're called endometrium is and we can put that to one side for now because there's some complexity in answering that question. But when it comes to endometriosis within the pelvis, it they have we've done what's called randomised trials where we take a patient's and half of them they do keyhole surgery removed endometriosis and and the half they don't. And they found that with in those patient groups that have endometriosis treated with surgery, they have an improvement in the chance of conceiving naturally. So, surgical treatment for endometriosis through keyhole surgery has been shown to be effective in improving the fertility chances. So gone in the short term, like how long does that last for people like if they had the surgery like how long would you say they would having creased fertility for after the surgery? Well, we only know because we only have data for about six months to a year. And in those trials, they only follow them up that long. And so we know that in that year following surgery that they have a much higher chance of successfully falling pregnant naturally. Why do you think that is? Do you think that it's because you're like, endometriosis is inflammatory, right? It releases like inflammatory cytokines. Is that right? Like, like by removing the lesions you're taking, like you're physically removing that inflammation that can stop someone from getting pregnant? Yes. So there's two aspects to it. One aspect is that it's inflammatory, and it creates an environment that may be that may interfere with the process of the egg being collected from the ovary. But the other aspect is that endometriosis can cause painful intercourse. And so by removing improving the symptoms, people are more able to have intercourse and so we're able to conceive. So there's two parts to that. Okay, and if that makes sense? Yeah, it does make perfect sense. Yeah, it does. Yeah. And then you talked, you touched on endometriosis, which are endometriosis type cysts on the ovaries now. Yeah. Like, I know that can affect fertility differently. Do you want to just explain a little bit about? Because I think it's quite different. Isn't it like this actually, I would say probably that can be maybe more serious again, on terms of like, more complex, maybe it's the best way to describe it. Yes, so it's more complex. So we know that if you have a cyst from from endometriosis, that can affect chances falling pregnant and removing the cyst and, and treating the cyst, especially by excision, which means cutting out and that improves the chance of falling pregnant naturally. The complex part is that the way that the cyst is removed can affect the rest of the ovary. So many people will use sort of n because it's quite a vascular area, there's quite a lot of blood supply, it can bleed a lot. And many people aren't trained to do stitching through keyhole surgery. And so what they do to control the bleeding is they use what's called cautery, which is heat treatment. But heat treatment on the ovary caused a lot of collateral damage. And so that affects the, the amount of eggs in the ovary. People are born with a fixed number of eggs. And as one gets older, the eggs are released and the number decrease over time. So by doing by removing the cyst that affects the number of eggs on that ovary. So it does matter how careful want you are in performing the surgery. So really, if you have treatment for the system, it's better to be done by somebody with expertise who's careful about it. Okay, the other effect is that because it affects the number of eggs on the ovary, I, we recommend that you actually check, there are ways of checking the number of eggs you have, there are measurements, blood tests that you can take called Hmh. And there's another check, by doing an ultrasound scan, we can count the number of follicles, which are collections of fluid that contain eggs, every cycle, so you can count it in a cycle and see what the reserve is like, then you have because if the reserve is low, then it doesn't have a low number of eggs, then I probably wouldn't recommend surgery at all. And in fact, I would recommend something else like IVF first. Now, in terms of collecting the eggs and making embryos and then having surgery, either in the interim or not at all, depending on how the symptoms are. So what I'm saying is that having cysts on the ovaries requires a sort of individualised approach to the patient and the partner and look at the bigger picture, right. Is that male factor issues as well, like it's looking at? Yeah, exactly. So that was, that was my other point in that if the sperm is not of good quality, and there is an indication that IVF will be required regardless, even if the reserve is higher would still say actually have IVF first because you're more likely to get more eggs. And so you would preserve the fertility before undergoing surgery, or equally if somebody is really young and then not near the chance of falling. You know, they're not with a partner and they haven't gotten any conception of falling pregnant in the near future. Again, some kind of preservation or it's really an insurance for the future. I would say it's worth considering and thinking about before having the surgery so these kinds of discussions will be halved on an individual basis based on what people's needs are and their position. And that is a really important aspect of having cysts from from from endometriosis. And the sad thing is that most of the times if you go to the hospital, you'll either see a surgeon who specialises in removing cysts, or you'll see a facility doctor. And having that sort of joined up thinking and holistic approach to to your problem is really important to the person who's looking after he understands that actually, there is an important aspect there of fertility and also an important aspect of treating symptoms. Yes, like opening that conversation in the first place, like looking at someone's age asking, you know, what their plans are, and then helping them to make that decision. Because like you said, it's when you have IVF, it's not necessarily about having IVF and having a transfer. Now, it might just be that you collect eggs, if you're with a partner, you collect eggs, and hopefully make some nice healthy embryos, and then you freeze them. And then maybe considering surgery, but like you said, You've preserved as would you say, in your experience? And this is without question, but just for like asking it, like in your experience when you're operating on someone with your level of expertise? Because I know that is your area of specialty? Are you able to preserve Hmh? Or are you saying that there was always going to be an impact on Hmh? Or like you would you be confident that you're able to kind of do that minimally? Yeah, I can minimise it, but there will always be an impact regardless. So as much as we take all the measures necessary to minimise that by suturing, not using energy, using all the things that maximise the reserve, the the cyst is already there, and removing the cyst removes part of the ovary because the cyst is part of the ovary. It's not a separate entity, it's contained within the ovary. And so an effect on the reserve is observed regardless. Yeah, the other complicating factor, like we said, sometimes the cysts so are too big to be collected. So if there is a cyst that's very large, a collection cannot be done, regardless, in which case surgery will be the primary treatment method anyway. So these are all sort of things to think about. And we have medicines that shrinks this as well. So sometimes as the system is too big is sometimes worth trying a medicine for a little while that may shrink the cyst. It may not, but it may do. And so that can maybe lead to being able to collect later on. So there's there's so many aspects to think about with. But that'd be like a down regulation, type Med, like something that stops the hormone production in a short term. Is that what you're talking about? What sort of newer, newer sorts of medicines around now? Yeah, there are. So there's a licence treatment is called the energist. It's a modified progesterone. And but it has an anti inflammatory effect. And interestingly, we've seen in, in the research and also in real life with patients, that when people on it tend to have some kind of shrinkage of the cysts. And so because it shrinks endometriosis, often, it's really good after surgery, because it prevents recurrence, for example, the chance of endometriosis came back within two years following surgery is around 40%. But with this medicine, the chance of it coming back is estimated to be around 4%. So it has a massive, has a massive reduction in the chance of it coming back. It's not something that's available on the NHS at the moment. It is it is recommended by the National Committee, but locally in different areas. Some of the GP surgeries don't want to fund it. And so there is a but it is available in in many places, but not all places. Okay, so worth knowing for listeners that, you know, if you have got endo and you're looking at other treatments or different options, you know, maybe just check in with your primary care trustee GP see what's going on, and whether that's something that you can have access to. Yeah, that's really amazing, because that's a massive reduction. Like when you look at us big sticks, right, if that. And if that's going to help your chance of conceiving naturally, whether or not you've preserved extra embryos, you know, the idea is that people want to get pregnant naturally as much as they can. Right. So if you can improve that, but also improve symptoms, like because surely that's gonna improve somebody's symptoms at the same time. Yeah, absolutely. And many people now choose the medicine whilst waiting for the surgery or whatever. And many people will not actually go ahead with the surgery. If they're not trying for a baby now because they say, well, medicines working, I'm not in pain. Yeah, I'll just leave it and then when I come to when the time comes close to the time to have surgery that might be to have a baby that might be the opportunity to have surgery. I just want to touch on something that comes up in our clinic a lot and just sort of get your opinion on it really but like, we tend to have lots of patients that come through with ultrasound scan reports that the scan reports will often say the you know, the presence of a cyst on one of the ovaries or sometimes both and kind of like a question mark over that cyst in terms of what type of cyst it is, you know, they'll measure it, but it's, sometimes people are not, they haven't got a committed diagnosis. It's like someone a sonographer has scanned them. The report has been written up and it's like this big question mark over a cyst. And I always say to patients, like, we need some more information on that because you can have cysts on your ovaries that are non endometriosis related, right? And actually, they can be nowhere near as much of an issue and the treatment options, you know, there might not be any treatment required. Or if you've got Endo, I think it's again, opening that conversation up about okay, you have got these endometriosis cysts on your ovaries, what can we do to preserve your fertility and how this might affect you now or in 10 years time? Is that something you see often where patients are coming to you with like a question mark over whether they've actually got a cyst in the first place? Like is this something that's quite common like? And what would you recommend people do if they've got that sort of scan report where there's no commitment to a diagnosis? That is common, and there are different kinds of cysts. So some of them such as if they're just containing clear fluid, they're called simple cysts, they will 80% of them will go away within three months or their own without action. Then you have cysts called Dermoid cysts, which are which won't go away on their own, and those ones would probably require some kind of operation at some point. And then you have something called hemorrhagic cysts where you get a bleed within the within the cyst. And they look very similar to endometrium, as you see. So on an ultrasound scan, because they both contain the same kind of liquid in blood. It's often difficult to distinguish between a hemorrhagic cyst or an endometrium, hemorrhagic cysts go away on their own and Demetrius Delmas do not so quite often, if there is a question mark, a repeat scanner, say six weeks or three months, usually three months would be a really good starting point, provided that the system isn't too big or worried and so yeah, okay. So yeah, the message I guess for listeners is if you've had a scan report that's confirmed, you know, a hemorrhagic cyst or cyst that's just got question mark over it's get a second opinion with someone like yourself, or someone who specialises in fitness, heal that area of gynaecology, and really kind of get the answers, it's really good to know because like I said, it is something that we see quite a lot in the clinic. And I think people are obviously reluctant to go and get another scan, or you have to wait a long time on the NHS for another scan. So it's really good to know that that is perhaps the right course of action. And that's what we're often advising people. So it's reassuring for me as far as giving up the right advice. If there's more urgent attention to the system, an MRI scan can be helpful. So if the system is particularly large or worrying then an MRI scan an urgent referral can be done. It gives us a different look of this consistency, this so they're often very useful. Okay, so this further options for diagnosis as well. Okay, let's move on and talk about talk about Ashman Sen. So Asha minutes is another one of your areas of expertise. ashram ins is something that actually I probably see in clinic more commonly than perhaps people might expect. And, but it's something that's not commonly talked about. And actually, I think, unless you've had it, you probably wouldn't really have heard of it. Right? I think lots of more women have heard of endometriosis, another Ashlynn? Still kind of? Not really that well. Well heard of. So just do you want to just tell us a little bit about Watchmen? Yes, so Ashman is a condition, whereby the cavity of the womb, where the where a baby or embryo would implant is affected and damaged in some way, by having adhesions across it. So the and that can be caused by infection. But most commonly, it's caused by surgery to the cavity of the womb. And the most common surgery that causes Ashman is actually a procedure done following miscarriage. Where a suction tube is used to complete the miscarriage, it's estimated something in the region of between 10 and 17% of people who've had that kind of procedure will have some kind of adhesions within the camp to the woods. Yes, like it like you said it, you know, I think for women who've been in that position, there's often not much choice like like you're having, you know, you've got the choice of a medical management or surgical management and sometimes there's not even that choice. And, you know, sometimes medical management involves a lot of waiting and people sometimes just want to get on with a surgical management, it is a risk and although you sign at the time, you know, that's the risk actually, when you haven't got any options. You know, it's a really difficult place to be right now. Knowing that you're gonna put yourself at, you know, what I would say is, you know, sort of fairly high ish percentage of something of some scar tissue forming, but you don't really have a choice? Well, um, well, there are things that we can do to help reduce that risk. Yeah. So for example, when we perform the procedure, traditionally, it's performed without ultrasound guidance. So the way I do it, is that replace an ultrasound probe during the surgery and watch the tumours again, so that you minimise the risk of any damage. And the second thing that we do is place a hyaluronic acid gel afterwards, after the procedure. And that's also been shown in those randomised trials that we talked about that to reduce the chance of measurements from forming. So those are the two things that can be done, that should be done or offered. To help reduce that risk for people. It doesn't eliminate it completely, because there's no 100%. But that's the maximum that can be done. I'm going to come back and talk about that shortly. Because yeah, there can definitely be some definitely some questions I've got around that. But going back to kind of like maybe, you know, working out with us, you've got Ashland, so yes, it's can come from surgical management of miscarriage, is there anything else that can cause it? Or is it infections, okay, infections or any other surgery to the uterus, so sometimes by removing a fibroid or polyp but it's much less common, really the miscarriage is the most common cause that surgical management of the miscarriage. And what might be if if someone has this thing has had surgical management of miscarriage, what are the signs to look out for after that surgical management that might indicate that you have scar tissue? The most common sign is that your periods will become lighter. And potentially, sometimes it's more painful as well. So if you've had a miscarriage and you have a light, painful periods, it's almost certain you have measurements. Okay, so another ultrasound, so get yourself back, I wouldn't necessarily pick it up. Unless people are particularly trained with it, because it doesn't look well at the cavity that womb. If you have like painful periods following a miscarriage, we'd recommend something called hysteroscopy, where we pass a telescope inside the womb and check it. But the good thing about the hysteroscopy is that we can treat it the same time we can actually remove the instruments and help prevent recurrence as well as diagnostic and treatment in in one. That's a surgical procedure, right? That's right, yeah, it's a minor, but it doesn't take very long as probably 1015 minutes, but it will require some kind of anaesthetic, but the recovery is very quick back to work the next day. And then in terms of when to try depending on how severe the adhesions are. So if they are severe, then I would normally recommend a repeat hysteroscopy because there is a chance they can recur. They can come back with. So repeat hysteroscopy a month later, but if they're mild, then I would say there's no need for a piece Ross could be you can just try again for a baby after the next period. Okay, and this is something that the NHS offer as well, this is not something you'd have to seek out privately after surgical management if you had those lighter periods and pain. Yes. The NHS? Absolutely. provide that. Yeah, they would normally do hysteroscopy. And they should know about Absolutely. And again, might sound like a really silly question, but why would adhesions, again for for people listening to really understand how this can affect fertility and again, possible further loss. But why would having adhesions impact fertility outcomes, so the cavity the womb is where the baby implants, but if the it's blocked by film, then there's no way for the egg and the sperm to meet an implant there. So it's, it's like having a coil, they know a barrier. So an obstruction. A block is basically a physical blockage of this egg to the sperm and the location for the for the implantation. So it's really critical that you get that you get that treated. And then you talked about the hyaluronic gel. Now I have seen again through the clinic, lots of patients who have been diagnosed with aspirins, had the hysteroscopy have the treatment had the scar tissue removed, and then are fitted with a coil. And the frustration there is that then obviously they can't conceive for some time afterwards. And often, you know, when women have suffered through a loss, they are often keen to try again as quickly as possible. So can you just talk a little bit about the difference in treatment in terms of why someone would choose a coil over the hyaluronic gel? How the why the coil helps the uterus lining to recover and the differences between those two treatments. Yeah, so there are three possible ways of preventing recurrence following the surgery. The first is a cool now it wouldn't be a quilt that has hormone in it because that inhibits the lining from growing so there'd be a couple coil. There is also something called a balloon where you can place a small balloon inside the cavity to keep it open. But that needs to be removed in seven days. Or you can place a gel, which is the hyaluronic acid gel. Now, the coil is what people used to use previously, because there was no alternative. So, you know, 20 years ago, there wasn't really any other option other than placing a coil. And so by putting the coil that it kind of stops, help stop things sticking back together, because it's an obstruction. The and that's why it's used, it hasn't been tested thoroughly in the same way in randomised trials or things like that. The balloon, again, is useful, but then it's invasive, and it's potential infection risk. So hyaluronic acid is an interesting substance in that it's, many people will know of it because it's used for filler. So people will know when it's used for filling the face, lips, so on, but it's also a naturally occurring substance. So for example, in your joints, the fluid in there contains hyaluronic acid, and it prevents things sticking together, it prevents your joints from sticking, it's a useful barrier. So when the gel was invented, and it was used they we did do randomised control trials. So they took people who had adhesions, and in one group, they placed the gel on the other group they didn't. And then they actually repeated the process and looked at the difference. And so the good thing about the hiring acid gel, it's been tested, medically in a randomised control trial, which is the highest level of evidence that we have. The other reason why I like it particularly is it's not it's doesn't, it's non invasive, so you don't have to have a coil removed. It doesn't delay you trying for a baby next time. And it it's, it's effective, as we already said, So the message is if you know, if you are having that surgery, and you're having the hyaluronic gel, you can providing the adhesions weren't severe enough to warrant a second hysteroscopy you can try again in the next cycle using the gel. And the gel is available on the NHS depends on the hospital. It's a medical device product that's available in the UK and can be purchased by him. So it would depend on individual for us. Okay. I'm not saying that the coil isn't effective, because it can be and you would need to have a repeat hysteroscopy anyway. But the it's more invasive, there's a lot more to it. And it takes a long time. And it's yeah, the time to time to future pregnancy as long as it's a lot cheaper than the gym. So that's another reason why it's used on the NHS. Because it would you Yeah, yeah, obviously that we know the NHS abandoned by cost resources. It's not something we can get away from, like, I think, what would your advice be, again, if someone was having this surgery, and they're having this conversation with the consultant before they go to the surgery? Like ask if the hyaluronic gel acid is an option? You know, because like you said, it is possible they might be able to get hold of it. If you're if you know if you know you're gonna want to try again fairly soon. You're not going to have another hysteroscopy then might be worth asking. Yeah, no, absolutely. I don't think it's absolutely. You know, if your only option is that hospital, and they are willing to put the call and then repeat this recipe and yes, it may take longer. So it's not the end of the world. I wouldn't say Oh, you have to have the jealousy of any option. But I'm saying it's the better options preferred option. Yeah, for the reasons that we've discussed. There is another thing that some people offer, which is to have a oestrogen tablets to help grow the lining the womb belonging. And when looking at the data. There's no real benefit in using that because provided you have natural cycles. Then oestrogen, your natural oestrogen will regrow the lining and additional oestrogen doesn't add additional benefit. But that may be useful in people who don't have natural cycles or have low oestrogen for other reasons. Yeah, that's interesting. So we've definitely had a lot of women coming through the clinic door who Yeah, in that situation who have been prescribed oestrogen. So it's really good to know what it's not harmful to have it, but it's not beneficial. beneficial. Yeah. And so again, for listeners who are you know, they might have been through this, and they're sat there thinking, you know, well, how does this affect my chance of having a future healthy pregnancy? Like, what are the fertility outcomes when you have treated this effectively? Like, should someone go on to have a healthy pregnancy? I know that's a big question because we don't know the bigger picture the context but you know, providing all other possible causative factors are treated, you know, what other facility outcomes which after you've treated as humans well In theory, they should be as if they've never had it before. Because once the womb is restored to normal shape, then you know theoretically they should be as if they don't have it. So back to normal. Now obviously other things can be dependent in them egg quality and sperm and various other things but provide all else is equal. It should be as as good as it was a show that will reassure a lot of our listeners because the endometrium regrows every month so every month you get new lining and binding camp new lining and it's all clear then quite often that the next time you do hysteroscopy you can't even tell they've had surgery. It looks so good afterwards. Yeah, when you've done it well, I can't go in and others but yeah, it looks good. Yeah, how can we do work? So that has been like super helpful I'm sure probably for lots of our listeners just kind of clarified coming from a patient perspective you know when if you think you've got endometriosis, the signs and symptoms and where to go and and what to do about it. And the same with instruments. So how do people find you both on the NHS and obviously, you have a private practice for people who perhaps don't want to wait? If you could just tell people a little bit more about how they can get in touch with you? Yes, so for the NHS. I work in Epsom and St. Helier hospital NHS Trust. And if you ask the GP they can refer you to see me it's Hyder Jan, if you wanted to contact on privately. I'm just looking at Don't worry, I will for anyone listening. I will post this in the podcast information as well. So don't worry about scribbling it down as Hader tells us that. Yeah, so you can either contact the hospitals where I work at and we could print side hospital Ashford hospital, Lawson Antony's or at the CRP clinic, or you can contact my secretary directly at pa at mi gynaecology.com. Or you could ring her directly. I'll give you her number. I'll give you her mobile suits, and people don't have to wait. And go straight to her. Yeah, go for it. Which is Oh, double 757310098. And it's gonna get inundated now. For anyone listening. Hey, the Secretary hidden is wonderful. She's one of the most helpful secretaries I think I've ever spoken to. So yeah, if you think you're struggling and you want to maybe not wait for NHS treatment, I take your shoes, your private secretary and my private secretary. Yes. So if you don't want to wait on the NHS or you can't get a referral to see hate on the NHS and you want to see him privately at any of these clinics that he mentioned, you can contact Helen on that number. And again, I'll pop that in the podcast information. Thank you so much. It's