Mandy Moore’s Endo Suspicion & The Shift in Endometriosis Care Every Fertility Patient Needs to Know

Watch this (Season 3, Episode 15) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

Dr. Beverly Reed and Dr. Amber Klimczak discuss Mandy Moore’s fertility journey and a fertility doctor’s suspicion of endometriosis before she became pregnant. They highlight new endometriosis guidelines, shifting diagnosis from requiring laparoscopic biopsy to a clinical diagnosis based on symptoms plus exam and imaging. They review ultrasound findings and the role of MRI, especially for surgical planning. They cover treatments including birth control suppression to protect fertility, IUI with ovulation meds (especially early-stage disease), and when to move to IVF or consider surgery for pain and selected fertility benefits.

https://www.youtube.com/@peakfertility

https://podcasts.apple.com/us/podcast/two-peaks-in-a-pod/id1694248202

Links are in @drhappyeggs IG bio.

Transcript

0:06

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber k Clack. And we are two two peaks in a pod. Pod. Well, welcome back everybody. Um, okay, Dr. K. I'm mad at you. Oh, why? What? Why today? 'cause yesterday you were telling me about your health ring and how young you are. Okay. So we both have health rings now. We're tracking our sleep and our hormones and all these things. Um, and one of the things you can do is find out your age. Mm-hmm. And I. Am two and a half years older than my stated age. I'm, I literally look too, I'm aging by the month. This happens like in the last month. Oh geez. That's a little questionable. And then, and I did have a rough month. Yeah. Maybe it was just me being sick, but I've never been younger than my age. And would you like to tell everybody how young you are? I don't know how these biometrics are are calibrated, but I am very proud that I am 6.5 years younger than stated age. Oh, you're so lucky. I actually logged in to check though. I'm like, does it think that I'm really old and it's just, and so I've been asking everybody. Everybody who works here has one. All my patients, I have tons of patients that have these. Everybody's younger except for me. Really? Up with that? Yes. What's wrong with me? Here's my theory though. Tell you've had your for a while, I feel like you were one of the OGs, right? Like how long have you been wearing yours? I mean, I don't think that long, just from, I think November maybe, or something like that. Okay. So yeah, because I do think it's kind of a ploy. Mm-hmm. Like when they first have you tracking, they're probably like, oh yeah, like you're young, you're so young. And then they're gonna be like, oh, look at you. You're aging, and then you're gonna wanna track your data more to improve it. Yeah, I do. I'm like, how can I get younger? Mm-hmm. Um, actually I did see too, when I was looking, they have a little. Six minute walking test you can do Uhhuh. So I'm gonna do the six minute walking test. It's definitely an old person test, and I wanna see can I get my score to be better. If I'm a good fast walker and my heart rate responds appropriately, maybe I can get younger. I, I remember from my geriatrics rotation in med school though the walking test is definitely for Jerry's. So this is only adding like it's if you hit the button, do the walking test. They're like that just added five years. Yeah. Only old people do the walking test. Okay. Great. Great. Okay, well I'm very happy for you guys. This means Dr. K is gonna be around for a long time and I'm gonna be working on it and I will keep you. Um, okay. So I hear you have a celebrity to tell us about today. Yes. Okay. This is like. My generation, celebrity I love. Okay. Tell me. I absolutely love her. Mandy Moore. Oh, yes, Moore. Okay. Yes. Um, first of all, she's reinvented herself because she's on a very popular television show. Oh. What is she on? This Is Us right? Oh, did you watch it? I watched it like when it first started. Okay. But she, I feel like they did very well. It was a very popular show. I actually don't know if it still has New Seasons, but I've never seen it. But I heard it was rather emotional. It's, and I was like, I dunno if I, I need something like a little, yeah. Less deep. Sometimes to watch. Yes, same for sure. But she is awesome. I think she's like such a good like female friend, you know, like she's a girlfriend type of, um, type of celebrity. Yeah. Always positive. Mm-hmm. Um, and I guess when we were looking, you know, through celebrity stuff, she definitely has come out with. That she had her own fertility struggles. Right. Did she? Okay. Um, and I guess when she was trying to get pregnant, maybe most recently, Mandy, you're gonna have to write into us and tell us if I'm getting your story wrong. I'm sure she'll be right on that. Okay. Um, at peak fertility, you can, you can DM us. Yes. But my understanding is that she was kind of getting this workup, right? Yeah. To figure out why she wasn't getting pregnant this most recent time. And her fertility doctor had suggested that he or she was. Suspicious of endometriosis. Okay. Okay. Which I feel like is fairly common, right? Sure. We do. We often have patients where we do a workup, they come back with unexplained infertility. We talk a lot about how one explanation for unexplained infertility can be endometriosis. Sure. Um, but then I guess like right when she was about to go for surgery to confirm this diagnosis of endometriosis. She got pregnant. Oh, good. So it's a good story. Good ending. I like the story. Yeah. Okay. Good, good. But I'll say her fertility doctor was doing the standard of care. Okay. Way to diagnose endometriosis. Mm-hmm. Right. So this is what you and I were taught for years. Mm-hmm. Right? The only way that you can. Officially diagnose endometriosis is to take someone to surgery, take a small sample of cells called a biopsy, have a pathologist look at it and say, yes, this is endometriosis. Right. Well, and even more specifically, a camera in the belly button. Mm-hmm. Inside the, mm-hmm. Um. Pelvis. Mm-hmm. Sometimes we have another procedure called hysteroscopy. Mm-hmm. That's a different thing. You can't see endometriosis on that, but yes, with a laparoscopy we can look for endometriosis and yes, we have to not even see it, but biopsy it. Yeah. Yeah. Yeah. So that, I mean, I've been getting that spiel my whole career. Yes. Right. I, I'm so used to explaining that in kind of layman's terms. Yeah. So, however, acog, ACOG is our governing body of OBGYNs, and it kind of sets. The standards, the gold practice and standard guidelines for OBGYNs across the country has recently released new guidelines for endometriosis, which is really exciting. Absolutely. Our lives are kind of boring. This is exciting for us. I know, I have, I, I'm sure people, I've been telling my patients about this change. Mm-hmm. Like over the last week. Mm-hmm. And I think they're like, why is she so excited right now? And again, let's bring up the H thing. I've been doing this for a long time, for many years. Always been the same. Mm-hmm. And then they change it. Yeah. And I'm like, oh my gosh. And they change it for the better, I think. Yeah. And we're gonna kind of talk through that, but Yeah. But I wanna break down this Mandy Moore story a little bit. Mm-hmm. Because from what I understand, she's kind of saying she got misdiagnosed. Right. Yeah. I do feel like the article's message, yeah. Was that she felt maybe her fertility doctor misdiagnosed her 'cause she got pregnant. Right. Yeah. But I think there's a little bit of a cautionary tale there, right? Yeah. You can still get pregnant if you have endometriosis. Exactly. Endometriosis. Can come with infertility and vice versa, but it doesn't mean you can't get pregnant on your own. Mm-hmm. In fact, I would say probably most women with endometriosis are going to be able to get pregnant on their own. So I don't want to create any fear in women at all. Mm-hmm. Who've been given a diagnosis of endometriosis prior to ever trying to get. Right. Right. Right. And I do think a lot of the purpose of, um, sort of Reba rebranding our guidelines is to validate women. Right? Yeah. For so many years, women have really struggled with healthcare providers to get accurately diagnosed mm-hmm. With conditions such as endometriosis. And I think that these guidelines, a lot of the goal is. So that we can believe women and understand what they're saying and treat them without making you jump through a ton of hoops to get treatment. Yes, absolutely. Yeah. So I would say my opinion on the Mandy Moore strike from the details we know is. She, I don't know that she's been misdiagnosed. She, that may have been correct. She may have had endometriosis or she may not have. But either way, I think it's always a good thing to be thinking about during some of these fertility journey, for sure. Mm-hmm. Yeah. Mandy, let us know if we're misrepresenting you. Yes. Um, okay. So let's talk about all these new guidelines. I'm so excited to talk about them. So previously the, the gold standard was you had to do laparoscopic surgery and take a biopsy of a lesion to know you have endometriosis. The new guidelines say you don't have to have surgery. Yay. I, you know, I always love the more natural stuff. Mm-hmm. I'm more granola crunchy. Mm-hmm. I don't want my patients to have to undergo invasive things, um, unnecessarily. So I think that's why I'm so excited about these guidelines. So, but if you don't have to have surgery, then how do we know if you have it? Well, it's based on what you tell us. Isn't this nice acog listening to women? And so an important part of your doctor seeing you is that they should be listening to your symptoms. Are you having painful periods? I do think this can be hard, right? Because probably everybody has a little bit of cramping with their periods. Okay. Usually what we're meaning is more severe cramping. Um, so for me trying to describe that is if you've ever had to call into work or missed school because your periods are so severe. Or if your period pain has ever been so bad that you've been to the er, those are kind of red flags for me, right? Mm-hmm. I would say that is more just than just the average cramping there. Um, what are some other symptoms that we might hear from patients with endometriosis? Um, pain with intercourse. Yeah, pain with. Bowel movements. Mm-hmm. Um, and sometimes they can have pain not on their periods. Mm-hmm. Right. Um, of course, if you're coming to see an infertility specialist, infertility is one of the symptoms of, um, endometriosis. So we kind of think about that as like that triad of things that go together. And so Acec, ACOG really says you kinda have to put the whole picture. Yeah. And let's dig into the pain with intercourse a little bit more. Mm-hmm. Because. We actually see quite a number of patients that have difficulty having intercourse due to pain, but there are different locations at which that pain can occur. So you can have pain on the vulva or in the vagina, or you could have pain deeper inside. And I think most classic for endometriosis would be that deeper pain that you can feel. However, sometimes when people have had intercourse and they've had that deep pain, they can develop more external pain. Because it's almost like your brain is saying, oh my gosh, anytime anything comes in here, it makes it painful. So let's try to keep anything mm-hmm. From coming in here. And so you can get these muscle squeezes or muscle spasms, we call this vaginismus, that can be, um, connected to kind of the ultimate root of possible endometriosis there as well. Mm-hmm. How do your patients describe endometriosis pain to you? Well, it's interesting 'cause I can sometimes tell when somebody thinks they have endometriosis mm-hmm. When they come in or not. Mm-hmm. Right. When I have somebody who's never heard of endometriosis oftentimes, and this is crazy, they kind of feel like, oh, there's something wrong with me. I'm a wimp. Mm-hmm. And it makes me so sad. Mm-hmm. You know, because they'll just be saying, gosh, like, oh, my periods are so painful, but I am really sensitive to pain and everything. Mm-hmm. And I'm like, I don't think you're, yeah. You know? Yeah. Shouldn't feel like that. Mm-hmm. To them, they're just like, oh, I thought this was normal, and it was just me. Yeah. Yeah. You know, it just breaks my heart. Whereas when I have somebody who comes in and has kind of done their own reading and education and everything, oftentimes they'll be even saying those key words. Mm-hmm. I have this met reality. Oh yeah. I'm like, oh, she's been studying. Yeah. You know? What about you? I, this, I, this is just like anecdotal. I feel like I do have, uh, quite a few women mm-hmm. Who tell me it feels like a knife. In their abdomen turning. Oh, okay. And that, I don't know, I've meant to like kind of look into this if there's, but for some reason they all, like many people describe it as like this feeling. Mm-hmm. And I don't know if it's just like that's what people say as an extreme abdominal pain or something. Yeah. But that like twisting sensation of, and so I'm like, whenever they say that, I'm like, oh yeah. And we do have a wonderful doctor that we work with a lot who specializes in endometriosis surgery. Mm-hmm. So we do see a lot of, um. Endometriosis patients that have had surgery and had really severe, you know, findings in their abdomen. Mm-hmm. And so I've kind of like taken note of that and I ask people, I'm like, how did it feel for you? And a lot of people say like that, it sounds pretty bad. Yeah, yeah. Yeah. Oh, that's heartbreaking. Mm-hmm. It's hard to be a woman. Mm-hmm. I know. I know. And for years I feel like there was kind of this mantra of. Well, you know, women have pain. Mm-hmm. You know, your period is painful. Mm-hmm. You know? Mm-hmm. And now I think that we're kind of trying to not normalize that. Yeah. You know? Well, I think that's almost what it is, is when somebody gets a diagnosis of endometriosis, they suddenly feel like. Oh, that's why. Yeah. But now you have your why and you also have your people. Mm-hmm. Because it's nice these days with social media and internet groups and everything that you can find these groups of other women who are going through exactly what you've gone through. And it's, it's nice to know you're not alone. Mm-hmm. Yeah. Absolutely. You, you call it your tribe. Your tribe. Yeah. You're Endo tribe. Yeah. And it's great 'cause those women also connect with each other. They help each other. Mm-hmm. And all of that too, so. Mm-hmm. Um, I think that's wonderful. And so, you know, really I think what ACOG was trying to achieve with these newer guidelines is they were trying to help women get to treatment faster. Mm-hmm. Because what they were describing is that because women would need surgery to get a definitive diagnosis. Providers weren't always offering the treatment that they needed. And because a woman may delay surgery for many years, they found that for some women it took about seven to eight years before they can even get the treatment that they needed. And so their goal by. Loosening up how we diagnose endometriosis, taking it from a surgical diagnosis to a clinical diagnosis. The purpose or the intent of it is that they're trying to help women get treatment faster. Mm-hmm. And that really can't be underestimated. Yeah. Okay. Because endometriosis is a progressive disease. Yes. It's going to get worse as you get older. Yes. We cannot really emphasize enough. How important it is to have an early diagnosis? Yes. Because then if you get your diagnosis when you're 25, right? Before you're even thinking about how having children, you are going to be much more responsible. When you're thinking about your own fertility and what's a priority for you, maybe that's not a priority for you. Right? But you're probably gonna go see someone a lot sooner if you are having trouble getting pregnant. Not all women with endometriosis. Will have issues getting pregnant. But if you know you have a diagnosis of endometriosis early, you're probably gonna do something about it sooner. Yes. Yeah, absolutely. And I do want to just touch on one of the treatments for endometriosis that I know you and I both feel is very protective for fertility. And I know online there's a big debate about birth control pills overall, right? Um, and everybody can feel a little bit differently about it, but let me just kind of say this. When you're on birth control pills, your ovaries are not ovulating. Okay. If your ovaries are quiet, they don't have the opportunity to form cyst, which can later become endometriomas. These are what some people call chocolate cyst. Okay. Once a woman has formed an endometrioma there, it's very unlikely that's going to go away. And birth control pills have been shown to lower your chances of getting an endometrioma if you have endometriosis by. 50%. I think this is so important because endometriosis absolutely affects your fertility. It lowers your ovarian reserve and may even, um, affect the quality of your eggs and subsequently the quality of your embryos and everything too. So I know if I were a young woman with endometriosis and I wasn't currently trying to get pregnant, I would ab. Absolutely be on birth control pills to prevent ovulation and to lower my chances of getting, um, endometriomas. But then I think there's another benefit to birth control pills too, which is suppression of menses too. Mm-hmm. Yeah, absolutely. One of the theories behind how we, um. Even get endometriosis is backflow bleeding, right? You can take continuous birth control pills and get fewer bleeding episodes. In general, you don't have to completely knock out your periods, but you can get it down to like one or two bleeds a year, and that's gonna help. Not to mention most of the pain that you're gonna have from endometriosis related pain is when you're actually getting the period. Self. And so if you have fewer period events, you're gonna feel better. Your lifestyle is gonna be better, your pain scores are gonna go down. So there's a lot of advantages to being on even continuous regimen, birth control pills. Um, also birth control pills are known to kind of suppress those endometriosis implants that you, I kind of imagine them as like little inflammatory factories. Yeah. In your pelvis, right? Mm-hmm. And so endometriosis really can help to put a lot of those little factories to sleep. Absolutely. And then the other nice thing about progesterone pills, um, is so most of them have two hormones in them. And sometimes people get a little concerned because we do think that estro estrogen or estradiol can stimulate endometriosis, um, implants. We know that can happen. And yes, birth control pills do have a little bit of, um, uh, estrogen in them. However. The bigger component to birth control pills is the progestin component, and we know progestin is very suppressive for endometriosis. So because birth control pills are overall progesterone dominant, that really kind of takes away the risk, um, with estradiol pills as well too. Mm-hmm. So for multiple reasons, multiple mechanisms of action. I think birth control pills are a great, great. Contributor or to preserving your fertility later on in life. I think that's important to hear for women who are sometimes hearing opposite messages. And unfortunately, I've even had patients who come in themselves who were on birth control pills for maybe some other reason, and they say, well, I wish I wasn't on birth control pills. Birth control pills gave me endometriosis. And I say, no, that's, that's not true. You know, it's maybe coincidence that, that both of them happened together or. Or whatever the case, but it's important to you get the facts behind that too. Yeah, absolutely. Mm-hmm. Um, okay, so Dr. K. Mm-hmm. Let's say I'm your patient. I come in and I say, you know, Dr. K I've been having trouble getting pregnant. Um, I do get really painful periods. What's my next step? How can you help me decide if I have endometriosis? Mm-hmm. Yeah. Well, um, one aspect of the new ACOG Bulletin and guidelines say that we should use imaging to help us to evaluate the. Patients. So I would say we need to get you in for a full physical exam. We never wanna mistake abdominal pain for something that's pelvic or gynecologic in nature that maybe could be something else, right? Yeah. Um, and so just listening to your history can help a lot. Doing a physical exam and then doing some imaging that we do in office, like a transvaginal ultrasound can actually be really helpful. There's some really obvious signs of endometriosis on ultrasound that we can pretty much look at it and say, yeah, I think you have endometriosis, right? Yeah. Dr. Ree just mentioned an endometrioma, which is like a big ball of endometriosis. It's a cyst on your ovary. We have such good ultrasounds now that we can really look at. Cyst and the particular appearance of it and tell you, yeah, I think this is an endometrium. We can't be a hundred percent sure, but we're fairly certain. And I would say that's a another way that ACOG encourages us to say, yes, you have endometriosis, right? Yeah. There's even some newer imaging modalities and techniques to help us to kind of evaluate, can we see some of these endometriosis lesions on ultrasound with our sound waves? Vicious there so that we can give our patients the diagnosis that they're looking for as well. Yeah, and I, you know, I'm really into this concept called dynamic ultrasound, and the concept is that traditionally when women have a sonogram, sometimes your Dr. May just be seeing. Images, right? They just see this image, that image. Um, but I really love the concept of getting to see your uterus and your ovaries in motion. And so of course, to do that, either the, uh, sonography tech has to take a, it's called a cine loop. It's kind of like the video instead of the photo. Um, or it's very helpful if we get to do it, um, ourselves. And so the concept is when you're putting the probe in, you're watching does the uterus and the other organ slide freely. Or does it seem stuck in place? Okay, if things are sliding freely, you say, great, everything's moving around like it should. But if something is stuck, you are logically assuming, gosh, if something stuck, there may be endometriosis or scar tissue or something like that, causing that to be. And then other things you can look at are. There's special spots that endometriosis loves to live in. So probably one of the top spots we'll see is tucked right behind the uterus on the uterosacral ligaments and on the posterior vaginal wall. And so these are things that Dr. K and I are always looking for whenever we do an ultrasound to see, hey, are we seeing any little pockets of endometriosis there? Finally, the fallopian tubes. It's interesting 'cause most people don't realize you usually should not see your fallopian tubes on an ultrasound. However, if you see them, it's kind of a red flag because if you see them, they're probably swollen and filled with fluid. That's called a hydro cell. Pinks. If you see a hydro cell, pinks, then we say, gosh, there's probably some scar tissue, and could that be due to endometriosis as well? And that leads us down a pathway to help you figure, figure that out. So. These are all things that we are always looking for. And it's interesting because this is all going on inside of our head as we're doing a very fast ultrasound. Mm-hmm. And so, you know, this ultrasound may take two minutes or less, right. And then we take out the, um, ultrasound probe and the patient says, well, did you look for this? Did you look for that? And we're like, yes, actually. These are kind of mental checkpoints that we're looking for as we are taking care of you. But here's the most important thing, which is if everything looks totally normal on your ultrasound. We have not ruled out endometriosis. Yeah. Right? Mm-hmm. So we can rule in endometriosis. I may do your ultrasound and say, look, you've got these symptoms, you've got this suspicion on the ultrasound, I'm gonna give you this diagnosis of endometriosis. But also somebody can have no symptoms and a perfectly normal ultrasound and still have endometriosis. And that, I feel like on the patient side, that can be really confusing. Mm-hmm. But really, we're talking about these tiny little implants, like think of a mole on your arm. Okay. That's what an endometriosis implant is. That's how tiny it is, but it's just inside of the pelvis. And so you can't always see that as well. But I think that's important to know because many patients I see will come in and say, well, my doctor said I didn't have endometriosis 'cause they had a normal ultrasound. And I would say, well, we still need to think about it as a possibility. Yeah. And I think any of our fertility patients that are coming in that have had a pretty thorough workup. Yeah. And still don't have an answer. Mm-hmm. Our highest suspicion for you is probably that you have endometriosis. Yes. We might, might not always be saying that to you. Yeah. I feel like sometimes it, it just depends on the patient. Yeah. Right. Yeah. Some people will really wanna know if there's something potentially, but we kind of always keep that in the back of our minds. Yeah. Is the potential. And I would tell you that our treatment options are often considering that. Yeah. I think the other aspect of the ACOG guidelines mm-hmm. That, um, are interesting, actually have encouraged me a little bit to explore some other options as they encourage other imaging modality like an MRI. Yeah. To look at endometriosis. And I will say that I think radiologists, so traditionally the type of doctor that's gonna read mm-hmm. An MRI is called a radiologist. Yeah. I think radiologists have kind of known that this is coming even before us OBGYNs. Yeah. Because I do send a lot of my patients for MRIs for various reasons. Yeah. And I've gotten some of these reports back Yeah. That are very detailed. Mm-hmm. Looking for signs of endometriosis on an MRI. Yeah. And I have often been like, ugh. What is this radiologist talking about? Like they're coming for your job now. Yeah, like they would say things that they were suspicious for lesions for endometriosis. Yeah. And I'm like, what? You can't tell that, you know? Stay in your lane. Yeah. And now I'm kind of like, should I be sending more of my patients for an MRI solely for this purpose. I think that some of my patients would actually. Really like to add this. Yeah. To their diagnostic workup, right? Yeah. Okay. You're telling me I have unexplained infertility. Can I go for an MRI and see if they see anything? Yeah. I think it can be helpful. No, I definitely think it depends on if you get a good radiologist. Yes. Not all of them I think are as well trained, but I have found a couple in the area that I think are really good at it. I agree too, and it was interesting because a couple of years ago I had a patient who came in. She said, I have endometriosis and I'm looking through. She didn't, hadn't had surgery and everything, and I'm like, how do you know you have endometriosis? She said, I'm a radiologist. I did an M MRI myself and I saw endometriosis. That was kind of the first I heard this too, and I'm like, really? And so because of maybe her. Personal experience, she has expertise in that. And so I actually consider that when I'm sending off my MI sometimes to send to her because I know she has such a good eye for it. Mm-hmm. But I have found not all radiologists mm-hmm. Are up to date on this. Mm-hmm. And again, maybe because they're looking at these teeny tiny little spots that maybe in the past didn't have much significance. But these days we really do like to know if that's the case. Now, I would argue that if we did an ultrasound and we saw the endometriosis on the ultrasound and MRIs. Probably not gonna be helpful for us. Mm-hmm. Because we already diagnosed it. So maybe a perfect candidate would be somebody who had a normal ultrasound. Mm-hmm. And who really is just looking for more, um, facts overall, I still don't think it would be necessary in that case. Um, from what I understand the guidelines are saying, probably the people who, um, are probably gonna have the highest consideration for an MRI are people who are intending on going on to surgery. And the purpose of the MRI there is to let the surgeon know and understand how severe the endometriosis might be for surgical planning purposes. Mm-hmm. So, for example, if you can see on the MRI that endometriosis is implanted deep inside the rectum or the bowel, you may say, gosh, if I'm gonna do the surgery, I want to make sure that there is a, uh, GI surgeon on backup. Mm-hmm. If needed, or if it's involving the bladder, you might wanna say, maybe I should have a urologist available if needed, or something like that. So. If you have a patient who's not really interested in sur Surgical management may not be as important to do an MRI, but it's nice to know that it is an option these days too. Mm-hmm. Yeah. Yeah. Um, I guess this does bring up a point now. So let's say you do an ultrasound and you're like, yep, you've got an end endometriosis. Okay. What do we do? Yeah, I'm trying to get pregnant. Yeah. You just told me I had endometriosis. Maybe I'm kind of happy to finally have an answer, but I'm also stressed. Mm-hmm. Because now I'm like, okay, like am I gonna be able to have a baby? Yeah. Yeah. Absolutely. We get, I feel like we have a lot of patients like this. Mm-hmm. I always sit down and have our treatment planning discussion whenever we're thinking about what treatment option would be best for you. I really do take into age quite a bit. I would say my younger endometriosis patients, I. Very encouraging for them to try some lower level treatment options. When we think of treatment options for these couples, the idea is really to increase the likelihood that you're gonna get a positive pregnancy test on a monthly basis and get you pregnant faster. Faster time to pregnancy. So we think about treatment options like medications to trick your ovaries into ovulating more than one egg paired with an insemination or an IUI. That's kind of one of my. Lower level, least involved, um, least invasive treatment options. I would say most of my younger potentially endometriosis patients will opt for a treatment option like that. What about yours? Yeah. Yeah. And you know, I really feel like people are sleeping on I UIs insemination for endometriosis patients. Mm-hmm. It doesn't get talked about a lot, but I really wanna highlight. The link that I think occurs between women who have a narrow cervix and women who have endometriosis, because usually when you have your period, it should come out. So if you've got a cervix that is straight and wide open, it's gonna be easy for your period blood to come out. But if your cervix, it's making me laughing about a wide service. A wide service. I know, right. I don't wanna be told about wide cervix. Well, you probably do and I probably do too, right? When you've had babies, you've got a wide cervix part. Just, just flow right out. Well, but, but okay. You brought this up, right? So you and I both had vaginal deliveries for our children, right? Mm-hmm. When your cervix is wide open and you've had a delivery, endometriosis often heals after that. Mm-hmm. So you'll have somebody who had terrible endometriosis. If she does get pregnant and has vaginal delivery, her endometriosis is better, so why her period blood comes out easier now if somebody has a very narrow survey. Or if it's kinked or I've even had a patient recently that had a cervix, like a co group. Mm-hmm. Okay. Imagine that when your period of blood is trying to come out, some of it is probably more likely to backflow through the fallopian tubes. And again, you mentioned that's probably one of the top theories of how endometriosis occurs. Right. Okay. I still would prefer having a nice little skinny narrow cervix. This sounds so much better. A supermodel cervix. So I know girls on board with a big. Because, um, yeah, because I think a skinny cervix is not very poor fertility. Okay. Sounds nice, but bad for fertility. So I think number one, a narrow cervix makes you more likely to have retrograde menstruation and more likely to get endometriosis. But number two, if you've got a narrow cervix like that, it's hard for the sperm to get through sometimes too. Mm-hmm. Right? So how can we overcome that? Insemination. Right. So your husband may have completely normal sperm, but if it can't get through the cervix, you're not gonna get pregnant. Right? Well, when we're doing an IUI, we put a little tube through the cervix and we put the sperm past that point. Okay. And so I think, and, and we have data to show this. If you've got early stage endometriosis, fertility pills plus IUI absolutely increases your chances of getting pregnant. Mm-hmm. And so I think it's a great treatment and people don't really talk about why specifically. It's a great treatment for endometriosis patients do. Yeah. I think it's a really good strategy, especially now like you're a modern young woman, right? Go get diagnosed early, you're having painful periods, you're 22. Go see someone, get diagnosed early, get on birth control pills. Right. And then come see a fertility doctor sooner rather than later when it's time. And then we can tell you, you're a great candidate for Clement Insemination, right? Yeah. That can really help you to avoid some of our bigger treatment options. Mm-hmm. So I think it's really nice. Yeah. You gotta kind of strategize your future. Everyone's a planner. Yes. Yeah. So I love these IUI cycles, but also I don't want people to waste too much time trying IUI if it's not working for them. Our data shows. If IUI is gonna work for you, 90% of the time it's gonna work within three cycles. And so if you've done three cycles, it's not working, then I do like to step it up. Now, this is where I will admit some bias here. Okay. If you've done three I UIs and you say, what should I do next? It depends on who you asked. Mm-hmm. If you ask a surgeon, they're probably gonna say. You should do surgery next. Mm-hmm. And if you ask an IVF doctor, they're probably gonna say, you should do IVF next. Right. So I think it's fair to admit that there's some bias there. I think they can both be great options, you know, because I tend to trend more natural. I view IVF as the more natural option when compared to surgery. Surgery is serious. Surgery can have complications, it can be risky. That is why there are only certain surgeons in our area that I will even trust. Mm-hmm. Okay. Um, so, so I always think if it were me, I would much rather have IVF because I see that as a more minimally invasive. Natural option and the great part about IVF is you have the opportunity for fertility preservation to freeze embryos for the future. We know endometriosis is progressive and destructive, and so why not take this opportunity to get pregnant now, but also have embryos for the future. Mm-hmm. Yeah, and I talk to my patients candidly too about what their goals are, right? Yeah. Some of my patients who perhaps have endo, maybe pain control in lifestyle is also one of their really big. Uh, goals for their future in addition to getting pregnant. Mm-hmm. And I will say there's absolutely data to support surgery for that purpose. Right? Absolutely. Very good data to show if a woman is taken to surgery for endometriosis related pain, her pain scores are gonna go down after surgery. Yeah. And you might have some minimal to moderate benefits in fertility depending on this. Stage of endometriosis they ultimately see at the time of surgery. Mm-hmm. So it just depends. Right. And I do, um, want my patients through those options, you know, and a lot of people I agree, wanna avoid surgery, but not everyone. Yeah. Yeah. Um, and then the other thing I would mention, just 'cause I was saying how much I love IUI though is if you know you have. Stage endometriosis, we're talking yet severe. Stage three, stage four IUI has not been shown to be helpful. And in those patients you should, um, likely go straight to IVF as well. Mm-hmm. Um, so yeah. Um, so I feel like lots of great options for endometriosis patients and now I feel like so many more patients are gonna have access to this faster. Mm-hmm. Because they're not having to sit there and wonder. Could I, or do I have endometriosis? I guess maybe my last comment on it, my only hesitation with these new guidelines is what if I say so a patient has painful periods. I do an ultrasound. I'm like, I think it looks like you have endometriosis. Right. I'm gonna say you have endometriosis. Let's say she has surgery and they don't find any endometriosis. Right. That's probably my only hesitation is I think as doctors, we hate to be wrong. Yeah. Right. Yeah. And there is the potential for that. But here's what I would say is even if we suspect it and we're wrong. The, these are still standard treatments mm-hmm. That you would give to somebody who doesn't have endometriosis as well. So I don't think there's any harm. I think the ultimate best case scenario is that the scientists are gonna keep working on finding non-invasive markers for endometriosis. And so while we're waiting for that to happen, um, I think this is a great, um, update. Agree. Perfect. Okay. Should we wrap it up? Yeah. Y'all have a good.