Ep 289: Lining Up for Success: Fertility and the Endometrial Lining

Fertility Docs Uncensored is back with a deep dive into the endometrium—your uterine lining and a key player in fertility. Hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center, this episode answers listener questions and unpacks everything you need to know about this important tissue. The docs start with uterine artery embolization and how it can impact future pregnancies—touching on risks like decreased blood flow to the baby, stillbirth, and placenta increta. They also explore different endometrial biopsies (Receptiva, ALICE, EMMA, and ERA) and how they help evaluate the lining. Endometritis and polyps are also on the table: what they mean, how often they appear, and why treatment is often recommended. The docs start with uterine artery embolization and how it can impact future pregnancies—touching on risks like decreased blood flow to the baby, stillbirth, and placenta increta. They also explore different endometrial biopsies (Receptiva, ALICE, EMMA, and ERA) and how they help evaluate the lining. Endometritis and polyps are also on the table: what they mean, how often they appear, and why treatment is often recommended. You’ll also hear about stimulation options using estrogen patches or FSH, the use of modified natural cycles, and the role of hormones like prolactin and thyroid in cycle length. Even weight changes can alter hormones and ovulation. Finally, the docs explain endometrial thickness and the relationship to frozen embryo transfer (FET) success rates. Tune in for this essential guide to all things endometrium! This podcast was sponsored by Shady Grove Fertility.

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Carrie Bedient, MD (00:22)

Hello and welcome to another fantastically fabulously phantasmagorical episode of Fertility Docs Uncensored. I am one of your co-hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas. And I am joined by my two energetic, enticing, and enthralling co-hosts who are going to talk today about the endometrium, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center.

Abby Eblen MD (00:46)

Hey guys.

Carrie Bedient, MD (00:48)

Okay, so Abby, Susan gets massive points for remembering this tiny little tidbit about you because you told us that you just went and did something and she recognized it for the phenomenal occurrence that it was. So please spill.

Abby Eblen MD (01:04)

I'm starting to think if you truly are just sisters, because you're remembering the things I really don't want you to remember, so that you can later use it against me. I really feel like we're already almost like relatives now.

Carrie Bedient, MD (01:14)

Score!

Susan Hudson MD (01:16)

For any of our long-term listeners may remember that Carrie and I are huge musical aficionados. We love them, we love them. And Abby has her heart in the visual arts, but she dove in and she actually enjoyed it.

Abby Eblen MD (01:30)

Yes!

Yeah, I actually went to a musical. I asked to go to this musical and my husband was so excited because he loves musicals also.

Carrie Bedient, MD (01:43)

Wait, you asked? You didn't tell us that. We thought that you just went with your husband because you're good wife.

Abby Eblen MD (01:46)

No, because see, well, here's the deal. It's Dolly Parton. So it's called Dolly the Musical. And apparently as the story goes, it's a story of her life and it's a musical and it has lots of her songs in it, has a couple of new songs. I will say my connection is I was a young girl growing up in East Tennessee. Now I'm younger than Dolly. Let me just put that out there. But I do remember vaguely when I was really young, I remember her being on this variety show that she, there was like a little snippet in the musical about it where she was 10 years old and well, I don't remember that part, she was in another, like it's Kaz Walker, this guy that owns grocery stores in Tennessee. She was on his variety hour when she was really young. And I remember that she was with Porter Wagner. So there was a snippet of that too on the musical. And so it's just kind of cool because of stuff I could link to and remembered. Plus, Dolly's well-known in our state, not just for being a performer, but she's a really wonderful philanthropist. So most everybody in the state of Tennessee, if you have a child, you get free books every year for the first five years of your kid's life. And that's all because of her imagination library. So everybody in Tennessee just loves Dolly. And so this musical is all about her life. It's from the time she's a little girl all the way until she becomes an adult. And just recently, unfortunately, her husband passed away. And so he had a real, obviously, pivotal role in her whole career. It was neat. We all felt like she's our home girl.

So it was a fun musical and I really enjoyed being there.

Carrie Bedient, MD (03:14)

Inappropriate question. Did the actress who played Dolly, did she have to wear like a quadruple Q bra?

Abby Eblen MD (03:15)

Okay.

Probably. She looked like Dolly physically, body-wise, she looked like Dolly and she sounded just like Dolly. I'd say probably yes. All these people in Nashville doing this, these performances were actually Broadway actors and actresses and she had been the lead in the Wiz on Broadway. I doubt she was an as endowed as she looked, but I'm sure she probably had to wear something to make her look physically a lot more like Dolly. But there's a lot of really funny, yes, there's a lot of really funny one-liners and Dolly can say some really funny things. so It'll be really good. And I think they're trying to get it on Broadway sometime next year or something, but it'd be really good.

Susan Hudson MD (03:47)

To accentuate certain areas.

Carrie Bedient, MD (04:00)

That'll be awesome. Excellent. Well, we are very proud of you, Abby. And in celebration of your going to see a musical, we are going to do an episode on Endometrium and the uterus.

Abby Eblen MD (04:05)

Thank you, thank you.

You're gonna sing for me?

Carrie Bedient, MD (04:16)

We're gonna sing the episode on the endometrium and uterus.

Abby Eblen MD (04:19)

Like Rent, kind of when you go to a musical, you just sing it. You don't talk it, you sing it the whole time.

Carrie Bedient, MD (04:23)

Exactly. So, Susan, you're up to sing the question to us.

Susan Hudson MD (04:28)

I don't think that's a great idea. We would encourage listenership not have them turn us off.

Abby Eblen MD (04:33)

That's probably true.

Carrie Bedient, MD (04:34)

Alright, that's fair.

Susan Hudson MD (04:36)

All right, so let's start off with some questions. So our first question, she is a 31 year old female who has a genetic disorder that she's trying to prevent from going to her children using PGT-A and PGT-M starting in early summer of 2024. She had a retrieval in June 2024, 42 eggs. 26 fertilized, 11 biopsied, three unaffected by the gene. Her IUD was removed in August of 2024, but the endometrium would not get thick. Negative hysteroscopy, May of 2025, used injected progesterone and estrogen to achieve an adequate lining of eight millimeters and transferred, became pregnant. She was traveling, so ultrasound was done at five and a half weeks confirming at intrauterine pregnancy, though the gestational sac was a bit odd shaped, ultrasound at seven and a half weeks, missed abortion. Three weeks after expected management took Mifeprinstone and misoprostol. Follow-up ultrasound showed an AVM. She was admitted for MRI and had a uterine artery embolization of two arteries. No evidence of this on previous ultrasounds.

Chances of successful pregnancy? Also, IUD contributions to the endometrium? She had the IUD for almost five years.

Are you guys as worried as I am?

Abby Eblen MD (06:10)

Yeah, mean, uterine embolization is not a minor thing. That's a big deal. And that really significantly decreases blood flow to the endometrium. Not only do we worry about an increased risk of stillborn, fetal demise, that sort of thing, but also there's an increased risk of placenta accreta and increta as well. I would be really nervous about getting pregnant with a uterus that had had artery embolization.

Carrie Bedient, MD (06:11)

Yeah.

Yeah, I don't think the IUD is an issue here at all. Usually after a couple of months of the IUD being out, things go back to normal. She was able to get a thicker lining after the fact. I think the AVM may have played a role in her difficulty getting thick if she's got abnormal vasculature. But there have been cases of pregnancies that have been fine after UAE. It's just the trouble here is that this is not gonna be a spontaneous pregnancy where she just shows up in a doctor's office and says, I'm pregnant. This is gonna be a pregnancy that doctors are gonna have to help her achieve. And we all have had those experiences where something terrible has happened to a patient and you go back and you replay in your mind absolutely everything that you have ever done with that patient to figure out, okay, how do I avoid this? Is there anything I could have done?

What else do we need to do? And that's a really big thing because it's not typically recommended. Now, if she has a uterus that has a beautiful thick lining without her doing anything about it, maybe somebody will transfer her? I don't know. I don't think I've ever had somebody with a UAE that we've ever gotten that close to being able to do a transfer with.

Susan Hudson MD (08:02)

If you're wanting to try, definitely do mock cycles beforehand to make sure it really can get thick enough and have a good structure. And if that doesn't work, know that sometimes turning to using a gestational carrier could provide you very good chances of having a baby.

Carrie Bedient, MD (08:24)

The really big thing for her here is that it is fantastic that they discovered this AVM and dealt with it. As much as it's going to complicate the fertility part of this, you can't have fertility without mom. Having dealt with this is wonderful. I'm sorry she's going through this, very much so. But I'm so glad that it happened in a way that was reasonably controlled that didn't sound like anyway it seriously endangered her because this very much could have.

Susan Hudson MD (08:54)

Agreed. Agreed.

Susan Hudson (08:56)

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Susan Hudson MD (10:02)

Onto our next one. Hi, thank you so much for your podcast. I'm a 28 year old who just went in for my first medicated FET. I started with three estrogen patches and when I went in for a lining check, they found that my lining was 17 millimeters and that something grew in my uterus during the time that I was on the patches. Was not previously there on my saline ultrasound three weeks prior.

My FET ended up getting cancelled and she still is not sure what it could be. She said it may be a polyp, but from certain angles it goes away or fluid of some sort. She now wants to complete another saline ultrasound to see and decide if hysteroscopy is needed. She is also recommending a fully natural transfer. Do those have the same success rate and would I be a good candidate for that? Thank you so much again.

Carrie Bedient, MD (10:51)

What do you think, Abby?

Abby Eblen MD (10:52)

Well, I it'd be really unusual to have something grow in three weeks on estrogen patches. It was either there and they didn't see it before. It could have been blood though. She didn't mention it early in her cycle if she had bleeding or fluid of some sort. It seems very strange to me that there would be this big polyp. Now sometimes there's a polyp there and it depends on the size, but you don't see it when your lining's really thin, but once it gets thicker, and I just had a patient that this happened to recently. We didn't see the polyp and all of a sudden, we saw it when the lining got thicker. I'd probably just go to hysteroscopy at this point. I don't think I'd do another saline sonogram. I'd just go in and look and take it out.

Carrie Bedient, MD (11:29)

Yeah, I would do the same thing. I don't think you gain a whole lot by doing a saline sonogram because you already did one and they didn't see it. It was probably there before and that doesn't necessarily mean they did anything wrong. Sometimes you'll have a polyp that floats up when the fluid goes in and it goes up into one of the cornua and you just can't see it. If that happened, doing another saline sonogram, it's not going to get you where you want to be. I would probably just go straight to the hysteroscopy, visualize it, get it out and then be able to move on to whatever type of cycle you guys plan to do next. I don't think you necessarily have to do a completely natural cycle for your next one because the likelihood that you responded that quickly to estrogen in terms of making a polyp is very, very low. And I think if you did respond that quickly to estrogen, there's probably something growing in that polyp that we don't want to see that needs to come out anyway.

You can do whatever type of cycle makes the most sense for you, not just taking into consideration success rates, but also the logistics of doing this. Sometimes it is better to do a program cycle or a modified natural cycle or whatever, or a completely natural cycle. They're all reasonable. It's just what's going to work best for the situation.

What do you think, Susan? Anything to add there?

Susan Hudson MD (12:38)

I don't think so. There's pretty good data to say that plus or minus a percentage point or two program cycles versus modified natural cycles are pretty equivalent. Fully natural cycles. Honestly, I don't think there's really good data to say how good they are per se. But just because you had this potential polyp grow, I don't consider that an indication for not doing a program cycle. Polyps happen all the time. That's the most common surgery any of us do nowadays, so.

Abby Eblen MD (13:06)

Yeah, unfortunately, yeah. It's frustrating, but it's not life altering or anything. It'll be fine.

Susan Hudson MD (13:12)

Our next one. Hi there. stumbled upon your podcast when searching for podcasts that talked about preparing to conceive and it has been hooked since. Thank you so much for listening. I had a medical abortion about a year ago and now I'm looking to start a family with my husband. I always used to have regular 28 day cycles with two to three days of active bleeding. Since the abortion, my cycle length has varied from 38 to 44 days.

I'm devastated and feel like I ruined my perfect cycle because I panicked and made a poor choice. Should I be worried about my cycle length variation and change? And do you think my fertility has been compromised?

Abby Eblen MD (13:50)

I would ask her what else has she done? Has she gained weight? Because even the difference in 10 pounds can make her cycles become longer. She said her cycles were what? 33 days before?  28 days. Yeah, so that's, I usually think about is it a hormonal thing? Is it your thyroid? Is it your prolactin level? Has something changed with you that's made your cycle get longer? But a lot of times when I ask patients, you don't really think about gaining five or 10 pounds. It's not that much.

Abby Eblen MD (14:17)

But even a small amount of weight like that can change you hormonally and make your cycles longer. It can cause you to not ovulate regularly.

Carrie Bedient, MD (14:24)

How old is she again? Okay. Because that's the other thing is that sometimes it's just age because a lot of times what we'll see is that the cycles will be very regular, then oftentimes they will go closer together and then they will just start spreading out and out and further and further. And so that may not, it may just be a normal function of age. And the other thing is she commented on, did I do something wrong because of the decision I made?

Susan Hudson MD (14:26)

It didn't say.

Carrie Bedient, MD (14:49)

And no, you made the right decision for you at that time, which is the best that any of us can ask for. You didn't do anything that screwed this up. Part of that is not just me blowing smoke to try and make you feel better. That's also because doing a D&C shouldn't have any hormonal impact on the length of your cycles. And so it's like true, true non-related.

Susan Hudson MD (15:11)

But the length of your cycle is more related to how the brain and the ovaries communicate with each other than how the uterus responds to the things that are happening within the ovaries. So having a termination, as Carrie said, shouldn't have an implication there. As Abby said, most likely there's something else going on that contributed to this. I mean, not that you don't necessarily have it in your app because it may be in your app,

but a lot of times people don't pay quite as much attention to their actual cycle length when they're not necessarily trying to get pregnant and it seems like they're regular. And then when they really start paying attention to it, then it's like, they're more like, I am having them every month, but they're every 35 to 40 days. And I just never really paid attention to that. So that's also a possibility.

Carrie Bedient, MD (16:05)

True story.

Susan Hudson MD (16:06)

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Carrie Bedient, MD (16:43)

What else you got?

Susan Hudson MD (16:45)

Okay, hi, I'm 36 years old with male factor infertility, had my first retrieval in September of 24, 15 eggs, 13 mature, three healthy embryos, 4AA, 5AB, 4AB. First FET took 21 plus days to get my lining to eight millimeters. I was on oral estrace TID, vaginal TID, transfer failed.

Switched doctors and started Lupron in January of 25 as well as Metformin, Low dose naltrexone, and Plaquenil. HSG was normal only, showing endometritis, treated with 21 days of doxy, tried an FET cycle again, but even with TID Estrace, and IM estrogen, I barely got 6mm. We scrapped the cycle. After hearing your lighting episode, I suggested

trying a retrieval cycle, but to grow the lining. It worked. My lining got to 9.1 millimeters on the day of transfer, but I did go into OHSS. My REI kept me on Lupron 5 units. I was on aspirin, prednisone prior. My 4-AB-FET ended as a chemical pregnancy. What next?

Abby Eblen MD (17:56)

So she's had a total of how many embryos?

Susan Hudson MD (17:59)

She had three healthy embryos. The first one transfer failed. Took her three weeks to get a lining of eight. And then the second one, she ended up with a chemical pregnancy.

Abby Eblen MD (18:06)

21 day. And she has one more embryo though, right?

Susan Hudson MD (18:15)

Correct.

Carrie Bedient, MD (18:16)

So one of the things that pops into my mind is that doxycycline by itself, so the length of time that it was given is certainly enough that some cases of endometritis will be resolved. But what we find here at FCLV is that when we go back and look and confirm that the endometritis is gone, 70 % or so of the time it is, but about 30 % of the time it's not, and we need to do different course of antibiotics. We'll oftentimes use double agents to cover every possible bug that it might be. That might be something where it's worth going back to do another hysteroscopy, because the endometritis may not be fully cleared yet. And that may be one thing that's contributing.

Abby Eblen MD (18:56)

Carrie, would you think about doing an endometrial biopsy instead of doing another hysteroscopy or do you guys always go back and do another hysteroscopy?

Carrie Bedient, MD (19:02)

We typically do a hysteroscopy primarily because the endometrial biopsies are not super sensitive for picking it up. So if you do an endometrial biopsy and you pick up plasma cells or CD138s, that's fairly reliable as long as you have more than just a couple. But I have done hysteroscopies where I go in and I'm getting a biopsy at the same time for some other reason, like I'm doing a Receptiva or whatever, and I get the CD138 and it's negative.

Carrie Bedient, MD (19:32)

But I'm looking at it and that endometrium is red and angry and looks infected. In those cases I've treated and then when I've gone back to look again, it's resolved. I actually have a nice set of pictures on my wall next to me here that are all the different ways that endometritis can show up because sometimes it's really obvious and it's just bright red everywhere.

Carrie Bedient, MD (19:52)

But there are other presentations of it that you don't necessarily think of as endometritis and we may not think about unless we are really paying attention to it.

Susan Hudson MD (20:02)

I would recommend for this patient also after two failed embryo transfers considering something like Receptiva. So Receptiva, as Carrie just mentioned, is a test that where we sample the endometrium at a very specific point and it looks for a chemical called BCL6, which can be in the endometrium or the lining of the uterus. If BCL6 is present, we know that there is a decreased chance of pregnancy and increased risk of miscarriage. There is a relationship with endometriosis, but not everybody with BCL-6 has endometriosis, not everybody with endometriosis has BCL-6. But we know that if you have this and it is not treated, which would have been treated with some Lupron, but usually maybe a little bit differently than what you've done in the past.

Because in lupron, if you are looking at getting our book, the IVF Blueprint, we have all kinds of information about the five million and one ways that Lupron can be used in an IVF cycle. So just because you used it, Lupron doesn't necessarily tell us how it was utilized. And so sometimes that's used in a different way to help get rid of that chemical. So that's one thing that I would think about. The other thing is, doing another stimulation exactly the way you did it before may not be a great idea because OHSS itself can increase risk of miscarriages and maybe doing another type of modified natural cycle with letrozole, maybe less injectables, something I call it a min stim cycle where I use letrozole and a little bit of injectable so that it's more similar to an IUI stimulation where we still get maybe two or three healthy follicles and maybe not 15 or 20 healthy follicles, thereby keeping you safe in the long term.

Abby Eblen MD (21:54)

I'd be interested to know what dose of FSH they use because generally when I do FSH to build a lining, I don't really care if there's a follicle that develops. I usually just do it to get the estrogen level up and to see if they respond to their own endogenous estrogen. So I'm really surprised that she got OHSS because, back in the day where we routinely did FSH and IUI, we almost, I almost never went above 75 and usually those people usually don't get severely hyperstimulated. I think looking at the dose might be another thing too, if you just did pure FSH, but I certainly think the idea of doing, doing femara and FSH is a good idea as well. And one other thing I was gonna say too, cause I think since we're talking about endometrium, we might as well just throw it out there. Susan mentioned the Receptiva assay. That's one that I personally do a lot and I like that one, but just so you'll know, a lot of people will go, well, what are the other biopsies that are out there?

So there's Alice and Emma, and they're by a company Igenomix. They look at the microbiome of your vagina. And the other test, I believe it's the Alice test, looks to see if you have a predominant organism in your uterus, like E. coli or something like that that we know shouldn't be there. The third biopsy type is called the ERA biopsy. Personally, I don't do that one anymore. There was a pretty decent randomized prospective study done that looked at when it was powered appropriately that looked at women to see if they really had benefit from that biopsy and the study actually showed that they didn't and it's an expensive test. I don't typically do that one of the four. I typically do the Receptiva and most of the time.

Susan Hudson MD (23:31)

So I do those tests. I still do some ERAs. I don't do as many as I used to. I do still have some people that honestly, I don't think I could have gotten. The problem is, ERA is good for a sub segment of the population, but we don't necessarily know what that sub segment is. And so I still offer it. I still discuss it, but I don't do it as often as I do the Receptiva test.

Then I used to do Emma and Alice when it was covered by some of the insurances, but now that it's not, usually test for chronic endometritis with the test that can go along with the Receptiva. So that's what I typically do. Carrie.

Carrie Bedient, MD (24:11)

Mm-hmm. Yeah, I do hysteroscopy on pretty much everybody because it's a good way to just get an idea of what we're looking at. I'll do Receptiva on a fair number of people. Not much of an ERA girl, but the the hysteroscopies and taking a direct look is something we do quite a lot. And we're very, we're very meticulous about our linings. They've got to be just so and that's in part growing up in a clinic with Bruce Shapiro where he's my senior partner and he pioneered a lot of the research and so we are very attentive to it as one might expect.

Susan Hudson MD (24:45)

Good stuff. All right. Our next one. I'm 33 started trying in August of 2023 within a topic pregnancy resulting in a right salpingectomy. So had their right tube removed in November of 2023, got pregnant in January of 24, which resulted in miscarriage at seven to eight weeks after failed medical management. She had a D&C, got a fertility assessment, including hysteroscopy, which showed a minor adhesion, which was removed and moved on to IVF.

We seem to have no problem making good looking embryos with good fertilization blast rates, but my lining is always thin. I've tried high levels of estrogen, vaginally, oral and transdermal, Viagra and aspirin, but my endometrium is usually between 5.5 to 6 millimeters. Is there anything more I can do to improve my endometrial lining and does the thickness matter that much? Thank you. I love this question.

Carrie Bedient, MD (25:39)

This is an excellent question. It goes into all the different protocols that there are.

Alright, Susan, start us off.

Susan Hudson MD (25:45)

So the data, the research shows us that the actual thickness probably doesn't make as much difference as we all like to think.

Abby Eblen MD (25:55)

What would you say would be your low end?

Susan Hudson MD (25:57)

I think it depends on where you start. If you start off with a one or two millimeter lining and you end up with a beautiful, trilaminar six millimeter stripe, then I think that's probably a good stripe. And I've definitely gotten people pregnant with it before. Do I try to attain a seven or eight millimeter stripe? Absolutely. But where my heart and my brain come together, I do have to acknowledge that absolute number of no you can't transfer with a lining less than seven millimeters that it really doesn't have scientific backing to prove it. Not that we don't try all those other things, but when it all comes said and done, I think most people, not everybody, but most people are going to be able to achieve a reasonable delta. And like I said, if it's a beautiful tri-laminar stripe where there's three little lines and it just happens to be shorter than what I expect, but there's a change from baseline to that, then I think it's actually probably a reasonable lining.

Carrie Bedient, MD (27:03)

I think there was a study that just came out relatively recently, Susan, about natural cycles with that. And I don't remember if it was natural or modified, but they said exactly what you said, that it's more, as long as you get a good trilaminar lining that is different from where you started, it should be fine. I don't know that anybody's really looked at it for programmed cycles. I could have sworn there was a study that showed you needed to be at least six or seven in a programmed cycle, but it has been a long time since I've looked at that specifically.

Abby Eblen MD (27:33)

Okay, so let me throw something out to you guys. What do you think about cystic endometriums?

Susan Hudson MD (27:38)

Ooh, I hate them. I'm gonna... ⁓ Well, mean, cystic endometriums, I definitely am gonna look with a hysteroscopy. I am probably going to do a Receptiva and see what kind of funky stuff is going on there. ⁓ And I'm going to start over. Now, I've had some people that they always consistently just...

Carrie Bedient, MD (27:39)

I don't like them. They just...

Susan Hudson MD (28:06)

make a funky cystic endometrium and using something like a gestational carrier, sometimes those things aren't options and we just keep on going. And sometimes with ugly endometriums, we still get beautiful babies. But it's, it's, we're definitely going to do a lot of groundwork before we really put a very valuable, precious little embryo in there.

Abby Eblen MD (28:08)

Yeah, a patient like that right now.

Carrie Bedient, MD (28:26)

The other thing is that she, for this patient in particular, she said she's tried high doses of estrogen, Viagra, aspirin, those types of things. It doesn't sound like she's tried modified cycles. It doesn't sound like she has tried FSH. I think there's some more protocol places to go. Lupron is another one. I like Lupron for cystic endometrium too. Scrap it, start over, and see what the Lupron does.

Abby Eblen MD (28:47)

And like Susan said, we have all of that. In fact, I think you wrote the chapter, Susan, in the IVF Blueprint about all the different stimulation cycles. And it's really fascinating. And even I, as I was reading through it, thought, oh my gosh, I didn't realize we use Lupron in all these different ways. But we do.

Susan Hudson MD (29:03)

We do, we do.

Carrie Bedient, MD (29:05)

All right, let's keep going.

Susan Hudson MD (29:06)

Okay, so our next one is, Hey Docs, thank you for all you do. I came across your Asherman's episode and have been binging hard since. I just turned 35 and I'm trying to conceive my second. I have a two year old who was conceived naturally in 2022. I got pregnant with my second last spring. He had Down syndrome and passed away. I needed a D&C for retained products of conception. We tried for eight months afterwards during the time she had one chemical pregnancy before I was diagnosed with Ashermans. I had an operative hysteroscopy last month and am almost done with my hormone therapy. Lining is 6.8 millimeters on estrogen therapy. What are my chances of conceiving post procedure? If I have another loss, is it more likely due to scarring or an egg quality issue? At what point is it worth considering IVF?

Abby Eblen MD (29:49)

That's great. That's awesome.

So she's not done IVF at this point.

Susan Hudson MD (30:05)

Correct. She has only gotten pregnant spontaneously each time.

Abby Eblen MD (30:10)

I mean, if you truly had Ashermans and now you're lining 6.8, I think that's almost a non-issue now. You've bounced back from that. I mean, that's a great line. I thought you were gonna say the line's like five or something, because sometimes when people have D&Cs more than one or really aggressive D&Cs, sometimes it takes a long time to grow an endometrium back to that level. So I don't think that's really an issue for you anymore. I think at 35, you still should have good egg quality. So, but you know, I know going through a miscarriage with a baby with Down syndrome is really traumatic and I think it really, really is more an emotional decision right now than a physical decision. I think if you're tired of going through all the things you've gone through and you want to have another baby sooner, IVF might be a better call. But I think you could also try and get pregnant on your own and see what happens. You just wouldn't be able to test the genetics of the embryo, obviously.

Susan Hudson MD (31:00)

I mean, think an important thing to understand is that most miscarriages are due to embryos not developing correctly. And the most common reason for that is chromosomal abnormality at the embryo. And so, yes, you have multiple things going on. All people, even if you're under 35, half of the embryos you create are chromosomally abnormal. Most of those chromosomally abnormal embryos are never going to implant.

Most of those that do implant are going to result in miscarriage and only a very small proportion result in a live birth of a chromosomally abnormal child. So yes, Ashermans can play a factor. Having a second look hysteroscopy would not be a bad decision. Even having a saline ultrasound. I mean, you get a stone cold, normal, beautiful saline ultrasound. That may be all you need to give you the reassurance you need to move forward.

IVF is great in that it helps you get to where you want to be a little bit faster. It's great because you can do chromosome testing because we've all had patients who've had a chromosomally abnormal child that's passed away. Then they come to us to do PGT-A or pre-implantation genetic testing for aneuploidy just to give them the mental reassurance that they're minimizing their risk of having another chromosomally abnormal child. But I don't think that IVF in itself is, necessarily a quote treatment for Ashermans. If anything, we kind of battle against it a little bit more. But, the biggest thing is feeling like you have a good uterine cavity and doing what your heart tells you to.

Carrie Bedient, MD (32:41)

I would agree with all of that. All right, let's do one more.

Susan Hudson MD (32:44)

Okay, this one. Love your podcast. It's given me so much hope during my journey. We're so glad you were able to listen. I am 30 years old, AMH of 0.7, FSH 13.9, husband's sperm is normal. I've done three retrievals and only have four PGT-A normal embryos. I recently tested positive for BCL6 and will begin lupron suppression for two months prior to our first transfer. Our goal is to have three to four children.

How long does Lupron suppress endometriosis? Should I prepare for IVF or suppression each time we want to expand our family? Would smaller age gaps between children be better so endometriosis doesn't grow back?

Carrie Bedient, MD (33:26)

So how old is she?

Abby Eblen MD (33:27)

30.

Susan Hudson MD (33:28)

She's 30. Well, number one, you have four PGT-A tested embryos. Statistically, each of those have between a 60 to 70 % chance of resulting in a pregnancy. And you have established diminished ovarian reserve. So the chances of you getting three to four children out of four embryos, not impossible, but it's not at a, I think there's a good chance of you getting one or two children, maybe three, chances of four straight in a row, not, not great odds.

Carrie Bedient, MD (34:08)

Yeah, I think knowing that you want more children, I think it's probably worthwhile to do another retrieval cycle now and bank some more so that you have them if you need them. With respect to short interval pregnancies, some of this is gonna depend on how you deliver. So if you have a vaginal delivery, the recovery is faster. If you have a C-section, we typically make people wait at least one year in order to let that scar tissue really come together and minimize the risk of uterine rupture, which is when a baby growing and pushing against the scar and the uterus pops open that scar and that is a life-threatening event for both the baby and the mom. And so that will have an impact on how quickly you can get pregnant again. Another thing that's going to have an impact on how quickly you get pregnant again is are you breastfeeding? Because if you are breastfeeding, we're typically not going to move forward with an FET cycle for a couple of reasons. Number one, in general, we don't want all the meds that we give you to go into your breast milk and then get fed to your baby. But also the medications that we give you, particularly the estrogen, will turn off your breast milk supply. And nobody wants that to happen. We want you to decide on your own terms that you and your baby are done breastfeeding. And then whenever you're ready for that, you come back and see us and we will more than happily get you pregnant.

But I think the short interval is gonna have some very real logistical components, as well as the fact that you are going to have a new small human being. Those little creatures are terribly rude. They do things like not sleep through the night, they make your house messy, they're very expensive, and while they are just cute as a button, a lot of people who have not yet necessarily had a baby don't realize the extent to which it...changes and it changes in very functional, practical ways. There's the pie in the sky, your life will change forever. Well, yeah, it is going to change forever and that's going to be a lot of different things. And so many people don't tend to come back quickly just because they're dealing to what is a very massive adjustment in their world.

Susan Hudson MD (36:13)

Another thing for closely spaced pregnancies is that if you conceive within a year of your delivery, also does increase the risk of autism. And considering there's so little things we can do to help minimize that risk, that's also a consideration.

Abby Eblen MD (36:31)

Yeah, we generally wait a year between pregnancies. We generally don't encourage anyone to transfer before a year after their last pregnancy.

Susan Hudson MD (36:38)

And considering you're a 30, you've got some baby making time. It's just we need to make sure we have the embryos to make sure that you can maybe make as much as you're wanting to.

Carrie Bedient, MD (36:49)

Yeah, absolutely. All right. Well, that was a lovely episode. So thank you so much, you guys, for answering all those questions. And thank you so much for our listeners for submitting all of these fun questions for us to think about and noodle about and come up with the answers to. To our audience, thank you for listening. Subscribe to Apple Podcasts to have next Tuesday's episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Abby Eblen MD (37:15)

Don't forget to subscribe to our email list so we can send you great information about what we're doing and things that we're doing in the near future. And that way you can learn about all things IVF and infertility.

Susan Hudson MD (37:29)

Keep an eye out for our book, is getting released on September 23rd, the IVF Blueprint. Check out our Instagram TikTok for quick hits of fertility tips between weekly episodes. And as always, the podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye.