Fertility Testing: What is Needed Versus What is Trendy

Join Dr. Beverly Reed and Dr. Amber Klimczak from Peak Fertility as they address common trends and discuss essential fertility tests. They dive into practical tips for managing fertility testing, ovulation issues, fallopian tube problems, and sperm analysis. Learn the importance of advanced testing, including dynamic sonograms, hysteroscopy, and DNA fragmentation. Explore how understanding the microbiome and endometriosis could impact your fertility journey. If you or a loved one are navigating the challenges of fertility, this episode offers valuable information and compassionate guidance.

Transcript

Beverly: 0:06

Hi, I am Dr. Beverly Reeb.

Amber: 0:08

And I'm Dr. Amber Kza.

Beverly: 0:09

And we are twos peaks in a pod. Well, hi everybody. Welcome back. We just did something fun. Yeah, I enjoyed it. We did our first Instagram live, and so you can go check it out on our Instagram if you want. Um, we'll probably try TikTok maybe next week or something. But it is so fun because, you know, we love to talk to each other, but to get that live interaction and live questions and everything, um, was really fun. And then we got to hear from some of our patients and everything. So we need to do that one. It

Amber: 0:36

was, it was fine. It was nice to get the feedback right. Yeah. Then and there to talk to someone.

Beverly: 0:40

Yes, yes, yes. Um, okay, well I wanted to. To tell you about something I am seeing recently with my patients is kind of a big trend. I love my patients because they are such good researchers, right? Mm-hmm. And so they come to me already knowing so much, which is really helpful. Um, but sometimes they will bring a giant list of texts that they wanna have done. And I mean, I'm talking about this list might be like a hundred things long, right? Yeah. Um, and I'm sure you're seeing this too, and I thought it might be nice for us to kind of navigate and talk about what are the fertility tests you need. Mm-hmm. What are the fertility tests you're missing and what are some good strategies overall to help you figure out why you're not getting pregnant? But. Also just to kind of keep yourself sane, keep yourself comfortable, maybe limit the resources you're having to spend on all the testing and all of that. So are you seeing this trend too?

Amber: 1:31

Yeah. Yeah. And I mean, I think that's really what I try and counsel my patients is my role as your doctor

Beverly: 1:37

Yeah.

Amber: 1:38

Is to guide you through this process. Right. To tell you, this is worth it. This is not worth it. Right. This is supported by the data. This is not, this is worth your money. This is not. Right. Yeah. Because you can do some harm along the way with a lot of testing. Yeah. That's, that's really one of the issues with medicine right now, I think, is over testing. Yeah. Yeah.

Beverly: 1:59

So I feel like when it comes to somebody who, you know, has been trying for, let's say a year, that's probably the most common thing we'll see. Oh, I've been trying for a year. Or if you're over 35. More than six months, or if you're 40 or above, if you're just ready to get pregnant right away. So patients will come to me and they say, okay, I can't get pregnant. What should I check for? And I say, look, there are hundreds of fertility tests, but let's be logical about this. Let's ask ourselves what are the top reasons that could cause fertility issues? And it often reminds me of the top three. So number one, ovulation problems. Number two, fallopian tube problems, and number three, sperm problems. So those are the top three that account for the vast majority of fertility issues. And you can knock that out with really three tests, okay?

Amber: 2:47

Mm-hmm.

Beverly: 2:48

The first test you can do yourself at home. And that's great because I will say these days there's so many different at home testing things you can do. Almost to a fault, I would say. Yes. And so, I mean, there are some fancy things out there. They've got aura rings and Mira fertility monitors and Anita monitors, and they can check all different types of things. But here's what I would say is. You need an app to just track your cycles and LH strips. Okay? And these are super cheap. You can get a huge bag of them for like 20 bucks on, um, Amazon. They're called WFO is one that I like, and you just be on'em every day. And when you get a positive LH surge, then you know you are likely to ovulate in the next um, day. Or in the next 36 hours or so. And so that will go ahead and answer. The first question is, are you ovulating, right? Yes. Yeah, I just, I don't like LH strips personally. You don't like

Amber: 3:41

them? Tell me what you like. Well, I just don't like'em'cause they were never positive and it was sad. Oh,

Beverly: 3:49

that's so true. You know what, you bring up a really good point, right? Because. I have had people who tried the strips and they didn't turn positive, so then they bought a bunch of other fertility monitors. Yes. That's a really good point because if you are not getting positive strips, go see your doctor right away. There's no other monitoring that's gonna help that issue. You just probably need fertility medication. Right? Yeah, yeah, yeah, yeah. Yeah. I think it's a great point. I've, I've seen that many times. People, these monitors are hundreds of dollars and I'm just like, oh, poor thing. You didn't need to spend all that money. You really could have just known by either not having periods or not having regular periods or by no Elliot strips that you just need to come see us and we'll just give you some fertility pills. Um, okay. And then fallopian

Amber: 4:32

tubes.

Beverly: 4:33

Oh, this is a hard one, right? Yeah, definitely.

Amber: 4:35

I mean, I think that there's a couple of things that I always warn my patients that will really dictate your treatment, right? And fallopian tubes are one of those things. Yeah, we always say. Whatever we find on testing, that's what is really gonna drive what our strategy is for treatment. And so fallopian tubes are extremely important. If you're trying to get pregnant on your own, it's for sperm and egg. Get together. If your fallopian tubes are not open or they can't freely move around, you're gonna have a lot of trouble getting pregnant, right? Mm-hmm. Um, and we wanna know about it. Sooner rather than later because it really is going to change. We're gonna pivot probably to something more like IVF if your fallopian tubes are not functioning as they should. Yeah, and so the really simple test that most of us will recommend to check your Philippian tubes, it's called the HS G. It's a really long word for an x-ray. It's called a hysterosalpingogram. Basically we just push dye that you can see on the x-ray through the cervix and uterus, and it flows through the fallopian tubes if they're open and normal. So we know right then and there are tubes open or closed.

Beverly: 5:39

Absolutely. And I, one of my favorite things about this test is not only is it a test. It's kind of a treatment because if your tubes are open, it actually cleans your tubes out for you better chances of getting pregnant the first couple of months after you've had an HSG done. So I love this test for that reason. Now, admittedly, HSGs kind of get a bad reputation online because there are some places that do them and the patients can experience some pain or discomfort with them. That is one of our missions in life here at Peak Fertility is to make HSGs really comfortable for our patients. So we actually use a very gentle device that only goes in the cervix. It doesn't go all the way into the uterus, which really decreases a lot of pain. We don't use any clamps on the cervix or anything that decreases, uh, pain quite a bit. We use numbing spray, and then we even offer our patients nitrous laughing gas if they choose to use that. And so the vast majority of patients, when they have an HSG, they say, well, that's it.

Amber: 6:39

Yeah, absolutely. Totally agree. Yeah. Yeah. The anticipation is worse.

Beverly: 6:44

Absolutely. Absolutely. And so it always makes me feel so good when I hear that. When they say that's it, I, I heard it was way worse online. And I, but I do tell them, I say, you know what, we don't wanna be dismissive of those patients' journeys because they really did have a lot of pain and discomfort. And so part of our mission is not only to help our patients, but to help patients everywhere. And so we have actually helped. Many clinics all over the United States be able to incorporate nitrous laughing gas into their clinic for procedures. And if you are a provider, um, working at a clinic right now listening to this podcast, feel free to reach out to us. We are happy to, you know, just kind of share with you how we got our nitrous laughing gas machine, what our protocols are and, and all of that. Because we always think about our daughters and our sisters going somewhere one day and we wanna make sure that, that everybody is gonna have the most comfortable experience so.

Amber: 7:32

It's very important. Yeah. Yes, absolutely.

Beverly: 7:34

Okay. Now, out of these three tests, what do you think is the hardest test to get done? Okay. We talked about ovulation testing, fallopian tube testing and sperm testing. Hmm. Yeah.

Amber: 7:45

Yeah, definitely the semen analysis. The

Beverly: 7:48

guys, I know they've got one thing to do.

Amber: 7:52

And I, you know, and I think that a lot of times women, you know, have their checklist of things. It's just the way we are. Check, check, check, check. You know? Yeah. And like sometimes you just have to put your partner on the checklist. Yes. Right? Yes, yes. That's exactly, that's right. Dead. They get their semen analysis done. Yeah. And you know, I try and reassure the guys that it's easy. It's not gonna harm you in any way. Yeah. We even let you collect at home. Yeah. Right. And drive your sample in. You don't have to collect here and have an uncomfortable situation if that makes you uncomfortable. Yeah. Um, and most of the time, right, everything's gonna be, if there is something wrong, there's, it's correctable, right? Yeah. Most of the time. What are we find we have treatments for? Yeah. Um, sperm is nice because it's regenerated and made every three months. Yeah. Um, so I think sometimes guys also don't wanna get it done'cause they're worried that something's gonna be wrong.

Beverly: 8:42

Yeah. You know? Yeah. But my favorite is the husbands who always say, well, I don't think we need to do more testing. I just think we need to have more sex. That's kind of the more common one here. But I'm like, okay. Fine, but can we also just check this firm number and make sure they're okay? Um, but, but this is also something we've really worked on trying to make us comfortable for the guys as we can. As Dr. K said, you can collect at home or sometimes they live too far away to do that.'cause if you live at home, you have to bring it within 60 minutes of collection. So we also offer collection rooms that are private in the back. And some people like to be in there by themselves. Other people like to bring their partner and we are okay with that. I guess apparently some clinics are, um, a little particular about that. But really at the end of the day, we just want it to be the best experience that it can be. And, um, if it's normal, great, then we've kind of, you know, ruled that out. Although we're gonna talk about some other testing later on in the pod, um, about more advanced testing you can do on firm. Um, but if it's abnormal, hey, information is power, right, then we can kind of give advice on next steps on. Yeah. Okay. And then I would say beyond those kind of top three, there is basic testing that I think almost everybody's gonna get at any fertility clinic. Mm-hmm. Which is blood work and sonogram, right?

Amber: 9:56

Yes. Mm-hmm. Yeah. We're always going to do a diagnostic ultrasound or sonogram on our patients, especially if you're coming to see us for fertility reasons. The reason why is we wanna look at your ovaries, make sure they're in normal shape. They don't have. Cyst. Look at your approximate follicle count, right? That gives us good snapshot of what you have in your egg storage supply, and we're gonna look at your uterus and make sure it looks nice and normal. Make sure your lining gets nice and thick when it should, gets thin when it should. You don't have any things like fibroids or obvious polyps on that.

Beverly: 10:29

Yeah, and I will say most of our patients, by the time they've come to see us, they've already had some basic blood work, whether it's with their OB, GYN or their primary care provider or whatever the case may be. But usually we'll just kind of look through the list of labs they've already had, and then we'll just kind of add anything that we feel that's missing. But in general, we're just checking. Your health in general, we wanna make sure you're not anemic, that you don't have any active infection going on in your body and, and all these things. Um, and, and then sometimes your ultrasound will actually determine what additional blood work we need to order. Um, so for example, let's say we look at your ovaries and we say, gosh, I think you may have PCOS polycystic ovary syndrome. Well, that's not something you can just tell from one piece of information. That's a diagnosis that requires. Different pieces of information, but then that may prompt me to order some additional testing that I may not have done unless I did that sonogram

Amber: 11:21

there. Mm-hmm. Yeah.

Beverly: 11:23

Yeah. Um, okay, so let's say you've got a patient and they've done all this testing that we just talked about, and maybe they've even done some treatment and it's just not working at this point. This is when people can start to feel frustrated, right? A lot of times they'll sort of call themselves, or maybe even somebody in the medical professional has said, you have unexplained infertility, but I know you and I are not really, we don't love that term.

Amber: 11:46

Yeah. Well, our patients don't like it. Yeah. Not, like I say, it's the most frustrating diagnosis to get.

Beverly: 11:51

That's right. It just really means that we haven't found the reason yet. Mm-hmm. Right. You weren't in the top three reasons, right? Mm-hmm. It doesn't mean that there's not a reason, and sometimes that's really important to give. You that validation, right? Sometimes people just feel like they're being dismissed. They keep asking their doctor What's wrong, what's wrong? And they keep, oh, just keep trying. Just keep trying. But I really try to make a point of it and say, you're right. You should have gotten pregnant with this last treatment cycle with you grew beautiful eggs, you had a lining, everything looked great, you didn't get pregnant. That tells me there is something wrong. Your treatment was a test in and of itself, and we need to now keep searching for the answers. Um, and so one of my favorite things to do is what I call a dynamic sonogram. So we already talked about you can do your regular sonogram. This is frequently done at at fertility clinic. Sometimes it's done by a sonographer or a nurse or a nurse practitioner, or sometimes even the doctor. But there's a difference between just looking at the uterus and the ovaries and moving them around and seeing what happens to them. So sometimes what I'll do if I'm really trying to search for additional answers, is I'll take the ultrasound probe and I'll kind of nudge the different structures and I'm looking for any tenderness from the patient. Sometimes tenderness in certain spots can make me think about endometriosis. I'm also looking to see do they have any fluid in the pelvis, and does that fluid outline any of the structures like the ovaries? Usually you can't see fallopian tubes on ultrasound, but sometimes if there's fluid and it outlines it, you can, and that lets me look for scar tissue outside of the fallopian tubes and everything. And also the ovaries. I kind of say, look, think about testicles, right? Testicles move all around. Okay. Ovaries are like that, except they're just inside our body, right? So if I'm nudging your ovary, your ovary should just move and slide all around. But if I'm nudging your ovary and it's just stuck there, then I have to ask myself, why is your ovary not moving? Okay, is it, is there scar tissue there? And if you have scar tissue, why do you have scar tissue? Have you had pelvic infections before? Have you had, do you have endometriosis? Endometriosis is probably the most common cause, so I feel like sometimes you can just get so much information. By essentially getting to see the video instead of just the picture. Right. Yeah. I'm really

Amber: 14:04

liking your use of the word nudge'cause it's like a nicer way of saying poke.

Beverly: 14:15

Well, you know, I'm very gentle. I know, but it's just sounds so invasive. I know, but you know, people are always

Amber: 14:21

like, my doctor's poking me and prodding me. No, Dr. R is nudging. Just nu, don't worry about it. Just a little nudge here. It's just on your ovary, but we're gonna nudge it.

Beverly: 14:34

Okay. What are some of the types of advanced testing you like to do?

Amber: 14:37

Yeah, um, okay, so we talked about more advanced ultrasound. Mm-hmm. Um, a lot of times we're exploring this maybe even after a treatment that we've done, hasn't gone well. Mm-hmm. Um, and so one of the common ones that we do here at Peak Fertility is a hysteroscopy. Um, and so this can also be one of those treatments or one of those, um, tests or investigations that can also be a treatment. Mm-hmm. So hysteroscopy is where we put a camera inside the cervix and look into the uterus to see is there any hidden pathology or any hidden abnormalities that we weren't able to see with just the ultrasound imaging. Right? Um, sometimes we're looking for polyps. Small little cellular growths on the inside of the uterus that we couldn't see. Um, maybe we're looking to see is the inside shape as normal as we thought it was. Um, sometimes I've seen maybe your HSG is a little bit unusual. We can look and see at the entrances to the fallopian tubes better when we're on hysteroscopy. So it can give us a lot of, uh, advanced answers. Then after just looking right, we can take a sampling of the inside lining of the uterus and we'll send it off for pathology just. Someone looks at it under the microscope and tells us, is it normal or not? Mm-hmm. You know? Mm-hmm. Um, and a lot of times they'll say it's not normal. And here's some things that we found. One of the most common things we see is chronic endometritis, which is basically just chronic inflammation in the layer of, um, the outer layer, most inner layer of the uterus.

Beverly: 16:03

Absolutely. I mean, I really feel like chronic Endometritis is just under recognized as a cause of fertility problems and miscarriage problems. Mm-hmm. And I wonder if, because maybe many years ago it was not as much of an issue. Mm-hmm. So for example, 40 years ago when they kind came out with some of these textbooks and everything, it may not be as much of an issue, but these days we are a different population of people. So for example. They say because of long-term contraceptive use, such as IUDs or the implants in the arm and everything, teen pregnancy is at an all time low, which is amazing. But because there is such good contraception, sometimes people are less likely to use condoms, and when you use less condoms, sometimes you are more prone to getting bacteria. Spread to your pelvic organs. Um, and so one of the causes of chronic endometritis just may be an imbalance of these bacteria levels that you're getting, and maybe that's why we're seeing it more than we used to see it a long time ago. Um, but the hard part is that you cannot see chronic endometritis on a regular ultrasound. You often can, can't see it on a SIS. Uh, which we'll talk about SIS next too. Mm-hmm. I guess.

Amber: 17:12

Mm.

Beverly: 17:12

Um, you really can only know if you have chronic endometritis, um, based on hysteroscopy, if you can see it with your eyes or on tissue sampling. So you can see that on an endometrial biopsy or a biopsy done at the time of, um, hysteroscopy. Um, and so I, I think this is huge and what most people will be very surprised on. Sometimes I'll have somebody come in years of infertility, years of miscarriages. Um. And they think they need IVF, and I'm like, but wait, has anyone looked for this for you? We clean out the uterus and, and they get pregnant on their own.

Amber: 17:45

Mm-hmm.

Beverly: 17:46

Amazing.

Amber: 17:46

Huge difference. I just had a patient come back to me after this. We did exactly that. Yep. Um, secondary infertility, meaning she had a baby previously. Mm-hmm. Couldn't get pregnant. Actually, this was her third baby. Okay. And trying to get pregnant with baby number three, right? Yeah. Like went well twice. Yeah. Diagnosed chronic endometritis. And I said, look, I don't think we need to move forward with a bunch of treatment. Yeah. Why don't y'all try for three months now that this is healed and treated. Yeah.

Beverly: 18:09

Pregnant. Amazing. Yeah. Yeah. And we see it all the time. Absolutely. Um, okay. So I wanted to just mention SIS. Um, SIS is one of my favorite tests. It stands for saline infusion Sonogram, and this is the test that we can use to look for polyps, scar tissue, sometimes inflammation. And usually it is kind of the step before you do a hysteroscopy, which is the test that Dr. K mentioned, which I love hysteroscopy too. But one of the main questions I'll get from people is they say, well, Dr. Reed, if I have a polyp, shouldn't you have already seen that on these other fancy ultrasounds you're doing on me? And. Admittedly, if you have a huge polyp, yeah, I can probably see it. But there are lots of medium to small size polyps that you cannot see on a regular ultrasound. And the reason why is the lining of our uterus is two layers that are smashed together. And when those two layers are smashed together, you can't see what's inside. So the podcasters can't see, but my YouTubers can't at this point. I've got my hands kind of smacked together, okay? Imagine if I had a jelly bean in my hand, you would not see it. And so what you do is you put fluid to force those two layers to open up. Then you can see inside the uterus perfectly. And of course we like to, if we can oftentimes combine this with 3D ultrasound, so we get this beautiful picture of the shape of the uterus, and then we get to look at all the edges of the lining and everything so that we can have a nice, clear assessment at the site of implantation. And what surprises me is this, that this is not one of the standard tests, right? Mm-hmm. We talked about the standard tests in the beginning, but I kind of almost see. So many abnormalities with this test sometimes that I'm like, it probably should be part of the standard workup, don't you think?

Amber: 19:49

Right. Yeah. And I mean, I have definitely admittedly had patients that can feel frustrated because actually the time that we most commonly do this test mm-hmm. Traditionally is once we've advanced a patient to IVF. Mm-hmm. And we've created this embryo that's so precious. Yeah. We wanna look at the uterus. Very carefully. Yeah. Before we put the embryo in. Mm-hmm. And so it's at that point, after doing IVF mm-hmm. After making an embryo that we're doing a saline infusion sonogram traditionally. And we might find something. Yeah. And then they're like, but wait, was this why I wasn't getting pregnant before that? You know, it's, it's hard to say with certainty. Right. But I can see where that would be frustrating if it's. All the way at that point. Right. We're finding it.

Beverly: 20:29

Yeah. Well it is interesting because sometimes I'll do them before the IVF and then I'll say, oh, well I found this big polyp now you don't need to do IVF. But then sometimes I'll have people be like, but I still wanna do IVF. Right. Sometimes you do at once, you've kind of made that decision. Mm-hmm. It is a little hard to go back backwards. It's never wrong to do IVF, but it is, I think it is nice. Mm-hmm. When you kind of have that information. So I do wonder if we should, you know, do do it more kind of with a, a standard workup as well, so. Um, okay, let's go back to the guys again. So I said, oh, they only have one thing to do, right? Mm-hmm. But I'll say today's modern men are so much more involved in fertility than they were, for example, even five years ago. Yeah. Mm-hmm. And maybe it's'cause we're having this information explosion. Um, maybe it's just because it's more acceptable now for the guy to be involved, but I think it's amazing because what I'll really hear from the guys is they want to do more. They say, well, I did my same analysis, but I can see my partner. She's so upset, she's crying. What else can I do? Mm-hmm. What, what other testing can I do to to know and, and see? And so I will say it's hard because we don't want him to do unnecessary testing, but sometimes they ask good questions like. Is it possible for me to still have a problem even if I have a normal semen analysis?

Amber: 21:44

What do you think? Is it possible? Yeah, yeah. Absolutely. Definitely. Yeah. Mm-hmm. I mean, semen analysis are really big parameters. Mm-hmm. Right? Um, are there big abnormalities, right? Yeah. Are the counts low or the sperm not swimming or swimming forward? Are there shapes abnormal, but we're not looking at sperm, um, internally, right? Yeah. We're not destroying them and looking at their genetics on the inside. We're not looking at the makeup of them. So there can be lots of things. That a traditional semen analysis isn't picking up on that can, um, cause fertility issues. Yeah.

Beverly: 22:15

Yeah. So I love that. Now we are offering DNA fragmentation testing and the concept with that is. The andrologist takes the sperm and he's essentially looking inside the sperm at the DNA to see is there any damage to the DNA in the sperm. And you know, here's the thing, everybody's gonna have some DNA fragmentation, right? Um, but the question is. Does your partner have more DNA fragmentation or damage than we would typically see? And if so, what? What can we do about it? Right. And I'll say, traditionally, this wasn't a test that I was necessarily recommending to patients. Um, but it's more so a, a test that my patients are really requesting because they want to know everything about their body. But the reason why I wasn't typically recommending it is because I asked myself, well, if you did have DNA fragmentation, what would you do? And so I would say, well, you should live a really healthy lifestyle. You should avoid all of the toxins around you. Um, you know, sometimes I would recommend some fertility supplements and I would give them a, a. Certain list. Um, but ultimately sometimes it doesn't necessarily change the plan. But I do understand that concept of, of wanting to know everything that's going on. And I think too, on the female side of things, it may be helpful if you, because women, we are always blaming ourselves, right? It's me, me blame the man, Simon. It's nice if you can share the blame with your partner. I agree.

Amber: 23:41

Yeah, I know. I would say. Some, some, you know, 360 view of this test though, you know, I, what I counsel my patients mm-hmm. Is there is some data to say if you do come back abnormal mm-hmm. On DNA fragmentation that probably the most successful treatment for you would be a surgical sperm extraction. Mm-hmm. And even though those guys are willing to get the test. Done. A lot of times they're not willing to get that procedure done, um, because that's the most effective way to correct this. Yeah. And most guys don't wanna have a procedure done on their test all, they're just not,

Beverly: 24:13

not into it

Amber: 24:14

that much. Well,

Beverly: 24:14

I'll say I am a big fan of sperm filtering too. Mm-hmm. So if we know somebody has high levels of DNA fragmentation, I think sperm filtering, if they're doing IVF mm-hmm. Could be helpful. Um, so that might be another, um, kind of way to come at it, but, um. But I think, you know what, what's interesting is the guys that have this, they always say, what can I do about it on my own? And there are things that we can offer. We can check their hormones for them. We can consider fertility treatment, if there's any involvement with that. Sometimes we'll also offer a testicular ultrasound so we can look for what's called a il, um, which is an abnormality in the veins, in the testicular area. So I do think it's nice. To, to get that additional, um, detail as well. But I think what's interesting is I had a patient who came to me and they said, Hey, we got on chat, GPT, we, we put all of our stuff in. My husband Smokes and chat. GPT said that we should get a DNA fragmentation test. And I said, okay. Or. He could stop smoking. Yeah. Right. Because that's the whole point. Like again, we know smokers have higher levels of DNA fragmentation testing in the stroke. So to me, rather than get the test, I'm like, why wouldn't you just stop smoking? Right. But, but again, it's important for me to hear.'cause I think really I can understand if I'm a smoker and I'm really struggling to quit. And then I find out it is affecting my body. Mm-hmm. And I can see those test results. That probably is better motivation for you to, to quit, right? Yeah. So, yeah. Absolutely. Yeah. Yeah. So I think I can understand that. Um, okay. The next one, and I feel like this is so popular online lately, is endometriosis. Mm-hmm. Okay. So endometriosis is a condition, and I will say we all debate how and why endometriosis happens, but probably the most popular theory is that when you have your period, it can backflow through the tubes and implant throughout the um, pelvis, and it can be on the ovaries, the fallopian tubes and everything, and it can really impact your. Um, your fertility, but one of the hardest parts is how do we diagnose this?

Amber: 26:17

Yeah. So, you know, the gold standard Yeah. Way that we can diagnose endometriosis is really through pathology. Mm-hmm. A tissue diagnosis. And really the only way to get that is with. Surgery. Right? Yeah. Most commonly we put a camera into the abdomen. Mm-hmm. Take a small sample of cells called a biopsy, send it off to someone to look at it under the microscope and they say yes. Mm-hmm. This is in fact endometrial glands and stroma. That's what should only be inside the uterus and it's placed outside the uterus. Mm-hmm.

Beverly: 26:46

Absolutely. I think this is probably one of the most challenging tests for me to recommend to somebody because I take surgery really seriously, and I know we talked about. Hysteroscopy earlier, which is technically a surgery, right? Mm-hmm. But with hysteroscopy, we're so sneaky in how we do it. Mm-hmm. We just put the little camera through the cervix. Mm-hmm. We're not even making any cuts on the body at all. So to me, I'm kind of almost like, is it really a surgery even? Like I kind of more so call a procedure, whereas. If you are doing a laparoscopy, they are making cuts on your body. Mm-hmm. If they've gotta put you under general anesthesia. And I take those things very seriously. And so I would never want my patient to undergo an invasive surgery unless they truly needed it. And so in these cases, I'm often kind of asking myself, number one, could my patient have endometriosis? And I would say the vast majority of the time, I'm saying yes. Mm-hmm. We know endometriosis is widespread in patients with fertility issues. Number two, would surgery change anything? If I knew it for sure, and I would say most of the time probably not. Right? What is the treatment for endometriosis? If it's mild, you do fertility pills and an insemination, and if it's severe, you do IVF. Well, that's kind of the treatment journey that most people would be on anyways. And if it doesn't really change that, I don't know that you need surgery now. Who needs surgery? I would say maybe patients that are having very severe pain from their endometriosis, um, then that's more of like, you know, to help your lifestyle. And so I think it's reasonable in that case. Or what if you've already done IVF and it didn't work? I feel like sometimes those are really good surgical candidates. Too. And then finally maybe people who just aren't open to the concept of IUI or IVFs. Um, for some people they have religious restrictions or things like that. And so maybe in that case, surgery is their only option. So I can understand it more for that,

Amber: 28:30

but yeah. Yeah, definitely.

Beverly: 28:32

Yeah. Um, okay. So another big trend I've been seeing is have you been hearing about the microbiome? Yes. Yeah.

Amber: 28:39

Microbiome was a very common thesis. Yeah. When I was in my fellowship, a lot of people were studying the microbiome, but it, the microbiome's really boring. You think? Yes. Okay. When you read all the studies, it's like the same two species, like over and over again. So it's, to me, I'm like, how did people spend like three or four years studying this?

Beverly: 29:03

Well, I feel like we kind of alluded to the microbiome. Earlier when we were talking about, you brought up chronic end metritis. Mm-hmm. Chronic end metritis is an imbalance of bacteria. Um, and so with microbiome testing, there's kind of lots of different ways to do it these days. We do usually test all new patients for gonorrhea and chlamydia. Those are bacterial, um, you know, species that can cause fertility issues. Um, but interestingly, some people are coming in and asking for additional, um, testing for other types of bacteria. And, you know, um, I've been a little bit more open to it. I'm just kind of, I'm, I'm dipping my toe in the water on this one. Um, so I'm getting a lot of. People who are requesting to be tested for urea plasma and bi mycobacterium and some different things like that. Um, when I look at our traditional literature guidelines, they don't say that you need to do this, but again, I am recognizing that sometimes our culture evolves and maybe this wasn't an issue 40 years ago. Maybe it's gonna be an issue with our, um, younger population that maybe sometimes again had more and. Protected intercourse with more partners than maybe they did long ago. Um, and so I am interested to learn, um, I'll learn a little bit more about this, so I have kind of added this to my new patient screening panel. And, and we'll kind of see what happens. I've had a couple people, um, pop up positive we're treating them with antibiotics, so we'll see if that helps their, um, fertility journey. But what's interesting is when I kind of look to see, you know, for example, when I had somebody, um, pop up for positive for pl, well, the treatment is doxycycline antibiotics for weak. Well, guess what? We already give everybody that. Yeah. And they do an HSG with us, right? And so I think maybe the issue is. It may not necessarily change your fertility journey if you've been, for example, a patient of ours because maybe we were treating you without really realizing that we were treating you for those bacteria. So maybe one way or the other, if that was an issue for you, it, it got resolved. So kind of an interesting thing to think

Amber: 30:56

about. Yeah. I mean, I definitely think that we're still in investigation mode for it. Yeah. Um, but it's, it's nice too. The way I talk about the test like this with my patients, I'm like, is it gonna harm you to do the test? Yeah. You know? You know, are you perhaps gonna pay for an unnecessary test? Maybe it wasn't necessary for your journey. Yeah, yeah. You know? Yeah. So you just have to kind of weigh the risk versus benefits on these sort of alternative tests. Right. Routes. Right.

Beverly: 31:20

Right. And then finally, I just wanted to kind of circle back to the whole concept of treatment is a test. You know, here's kind of what I think about. If I had a patient who did. Three insemination cycles. They grew eggs. The sperm looked great, the lining looked great, everything went great, and they didn't get pregnant. Then to me that was a test, and that tells me, okay, something is probably wrong on a microscopic level, meaning maybe the sperm is having trouble finding the egg, or maybe the sperm is having trouble getting through the shell of the egg. Maybe the shell of the egg is too hard and the sperm can't get through to fertilize it, or maybe it can, and fertilization is not occurring normally. Or maybe you're not. Developing your embryos properly, or maybe they're not genetically normal. These are all things that happen on a microscopic level that we can figure out if you do IVF, right? So when we do IVF, it's to help you get pregnant. It's also to help you figure out why you're not getting pregnant. Even if your IVF goes perfectly, you have lots of great embryos, then we go to your embryo transfer, right? If we're putting in a perfectly normal, genetically, um, you know, pristine embryo and it's not working, then we know you have implantation issues, right? So this is. Sometimes a very long journey. I think from a patient perspective, what you would love is you come in for your appointment, you do a long list of tests, and you get, you leave with your answer, right? But in real life, your fertility journey can be more extended. Um, and so sometimes you are just kind of finding out those answers as you go along the way, and, and so that's why we're always just trying to be logical and thoughtful about your testing, starting with the most common, but never giving up on you if you're not getting to, to your answer as well.

Amber: 33:05

Yeah, we, we can always pivot. It just, it's never too late, right? Yes. You know?

Beverly: 33:09

Exactly. Exactly. Yep. All right. Should we wrap it up for the week? Yeah. Y'all have a good one. Wonderful. Well, thank you guys so much. We would so appreciate it if you gave us a positive review on whatever platform you're listening or watching us on. Um, or if you're a patient of ours and wanna leave us a positive review on our Peak Fertility Google website, we would greatly appreciate it. We hope you have a good week. All right. Bye