Ep 326: Where Endometriosis and Surgery Intersect in IVF

 Fertility Docs Uncensored Today’s episode of Fertility Docs Uncensored is 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. In this episode, our guest, Dr. Zoran Pavlovic of IVF Florida in Boca Raton and Jupiter, discusses the role of reproductive surgery in managing endometriosis. He takes a practical, patient-centered look at endometriosis, focusing on when surgical intervention may help improve fertility outcomes and quality of life. He discusses the goals of surgery, such as pain relief and fertility improvement. He explains how dynamic ultrasound helps determine whether pelvic structures are fixed or adherent and guides surgical planning. Other questions discussed include what types of procedures reproductive surgeons perform. Treatments include excision of endometriosis, fibroid removal, and fallopian tube surgery. What are the benefits of surgery, such as reducing pelvic pain, improving pain with intercourse, removing endometriomas, and restoring normal pelvic anatomy? What are the risks, including bleeding, scarring, and potential reduction in ovarian reserve, when removing ovarian cysts? When is surgery necessary, particularly in patients with severe, life-limiting pain? What medical management options exist, including continuous oral contraceptives, progestins, GnRH antagonists, and IUDs? Why is endometriosis considered a chronic condition requiring ongoing management? What are recurrence rates, and why do 25–40% of patients require additional treatment within two years? Finally, how do patients know when it’s time to see a reproductive surgeon? This episode offers clear, actionable guidance for managing endometriosis and preserving fertility. This episode is sponsored by IVF Florida. 

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 episode of Fertility Docs Uncensored. I am one of your hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas, joined by my two fantastically fantasmagorical co-host, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center. And we are joined today by the marvelous Zoran Pavlovich from IVF, Florida. He is at their Jupiter and Boca Raton offices. And we are very privileged to have Dr. Z with us today because there's not that many REIs, infertility specialists, who do a lot of reproductive surgery. And so we have cornered the market on Dr. Z today. And so we're going to be talking about endometriosis and surgery. So thank you so much for joining us today.

Zoran Pavlovic (01:10)

Thank you all for having me on. It's a pleasure to be here and I really appreciate the opportunity.

Carrie Bedient MD (01:14)

So you were telling us before we logged on that you and your wife like to snowboard. And as someone who grew up in the desert, who doesn't really understand snow sports, what is it that's appealing about getting on a giant tongue depressor and hurtling yourself down a mountain? How is this a great thing to do? Because I hear it from so many people that it's amazing, but I would love to know how this works.

Zoran Pavlovic (01:44)

That's a good question. I definitely have some friends that would prefer, let's say, to golf over ever going on a ski trip or snowboarding trip. It's a little hard to describe. The beginning is rough when you're learning how to use a snowboard or skis and you're falling a lot. But once you get good at it and can navigate downhill a little bit faster in the terrain, you get a little bit of that exhilaration. One from becoming more skilled and then also from just being on a mountain and seeing really great sites. And I personally love, it's just maybe a little crazy to me, but I love going through the trees and tree runs. And yes, it's a little bit dangerous, it is fun to navigate and wind through them as safely as you can. But it's fun to be able to, it's almost a puzzle in your mind. You have to look forward, see what spaces you can get through and try to navigate that. I don't know, I find that a lot of fun. that's that. What's that?

Abby Eblen MD (02:32)

I'm guessing you wear a helmet at least, right? At least a helmet?

Do you wear a helmet at least? Okay.

Zoran Pavlovic (02:35)

Yes, I do. My wife and I, both, have full on helmets, knee pads. We wear the football shorts that have all the padding around the lower back and the leg and the hips. We wear it all. And I do that on purpose because I know I'm going to be going off on a little bit off the beaten track and through trees. I want to be safe and I always recommend

Susan Hudson MD (02:55)

Where did you grow up? Because you're currently in Florida, so it's not something you do on your regular weekend off. Did you grow up in a winter wonderland?

Zoran Pavlovic (03:00)

Yeah. No, so I actually grew up in Chicago, which is a winter wonderland of a different kind. That's cold, sure, and the snow is there. But I went to Wisconsin, Devil's Head. It's a smaller mountain where my father took me initially when I was three to five years old to start. And then actually lived in Salt Lake City for about four years. That's where I really, between ages eight and 12, that's where I really kind of honed in my skills because my mom put me in ski school five to six months out of the year back then. It was really cheap too to get on the mountain. 30 bucks a day at the most. Not like it is today, but that's what I learned and fell in love with it and then continued that obsession throughout my life. And it's funny, cause my wife comes from an Indian background family and they don't ski or snowboard at all. Normally I really liked the cold at all because their family is from all over the world and they live in Florida, but she picked it up really well and loves it too. Now we both go out with our friends.

Carrie Bedient MD (03:56)

That's so cool.

Susan Hudson MD (03:57)

That's great. I tried to learn how to snowboard and on my first snowboarding trip, believe on my first time up the lift and I was about to head down, I fell on my bootay and broke my tailbone. And I was a good sport. I got up and I just kept on going and doing those things. But I'm like, I don't do those, but the rest of my family does. So it's great. It's great.

Carrie Bedient MD (04:23)

You almost sound like you believe that.

Abby Eblen MD (04:25)

Yeah, you said that really non-convincingly, Susan. It's great! It's great!

Susan Hudson MD (04:29)

Lot of fun doing all the other things at winter venues.

Carrie Bedient MD (04:36)

Okay, all right, so let's go to our question of the day. What do we have, Susan?

Susan Hudson MD (04:42)

Okay, our question today is, hello, I'm trying to pursue the known donor route and one of the people I'd like to approach has had a vasectomy. Is it possible that he could still be a donor and if so, what is that process?

I've actually had a patient who came to me exactly like this, so I want to know what you guys think.

Carrie Bedient MD (05:01)

Okay, well Zoran, why don't you get us started. How would you approach someone who wants to use known donor where the donor's had a vasectomy before?

Zoran Pavlovic (05:09)

It's a unique situation and a tough one too, because there are definitely patients that come in that have someone that they know that they would like to use a sperm donor. They maybe feel more in a way connected to that person because it's a little less, it's different than going online and just trying to shop for a sperm donor. But I do talk to that patient that we, anytime a sperm donor is used, we want enough viable and good quality sperm. And If this patient that they know has had a vasectomy, it may be difficult to obtain the amount of sperm that we need, especially for more conservative treatments, such as insemination, for example. You would also have to have go through all the regulations of the infectious disease testing and the FDA requirements. There's a lot of hoops that need to be jumped through, but even getting through all of that, if they were able to get to the point where they're qualified to provide the sperm to be used, then we have to also work with a male fertility specialist or urologist that can extract that sperm. And we may not get enough to be able to use for an insemination and you may have to pigeonhole yourself into doing IVF only. And that's where it becomes a little tough.

Carrie Bedient MD (06:16)

Especially when you think about maybe having more than one child because let's say you do an IVF cycle and you don't get enough embryos to build the family size you want. That means that not only do you have to go through IVF again, but he's got to go through another TESE again, which would impact it as well. Have you ever had a situation like this, Abby? What did you do?

Abby Eblen MD (06:36)

Yeah, and I think, well, the one thing I was thinking about, I always think about this with known donor, and that's whether you have enough sperm or not, it's just the other side of that is, certainly we want you to have a legal document between you and the donor to really outline what your parental rights are going to be, what his parental rights are going to be. But at any point, the one issue is down the road, if he decides, hey, I really want to be involved with this child's life, even though that's not the way it started out.

It's pretty easy, it's pretty likely a judge may overturn the documents that you had before. So I think that's the other layer of using a known donor aside from the vasectomy part. But yeah, generally when we see patients who have had a vasectomy and want to use sperm from that person, whether it's donor or husband, usually that means you're going to do IVF. And like Carrie said, once you create a child through IVF with that donor, if you don't have embryos left over, then in order to have a child that's biologically fully a sibling with your child, you'd have to go back through IVF again. So those are just things to think about. It doesn't mean you can't do it that way. Everybody creates families in different ways, but there's a lot of different layers there that you have to think about when you're using a known donor and the has to have sperm aspirated in order to do the procedure.

Susan Hudson MD (07:48)

Another thing to consider, and like I said, I've had a patient like this before, and when I had a patient like this, when they came to me and asked this question, they didn't really realize that we can't usually aspirate enough sperm to use for insemination. So if you're aspirating sperm, it has to be used for IVF, and that ended up being a no-go for that particular patient. But the other thing to consider is if we're concerned about needing sperm in the future for future IVF cycles, whatnot, that when your known donor undergoes that aspiration, potentially freezing additional vials more than we would normally freeze and just get all of that taken care of in one, be very intentional knowing, hey, there's a chance where I may have to do this more than one time for me to have my family size of choice.

That's again another option.

Carrie Bedient MD (08:45)

And one other consideration with a donor having to go through an aspiration is whenever we're working with donors, whether they're known or undisclosed, our goal is to minimize the risk to that donor. And when you compare what somebody has to go through to aspirate sperm versus an ejaculated sperm sample, it does expose them to a different level of risk. And it's not phenomenally high, but it's also poking a needle where most people do not generally want to have a needle approach them and that plays a role in it as well.

Susan Hudson MD (09:18)

But on the contraside, we have women who are egg donors all the time. Like no offense to the guys, this is usually done under anesthesia. Not always, sometimes it's under local, but it's usually done under anesthesia. It's not that it can't be done. It is something to consider because it an additional step. It's not just an ejaculation.

Zoran Pavlovic (09:37)

Yeah, I feel like the hardest thing is just getting good quality sperm in the amounts that a patient may want would be harder in the vasectomy situation than finding a different donor, an undisclosed donor for example.

Susan Hudson MD (09:49)

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Carrie Bedient MD (10:55)

All right, so Zoran, you spend a third of your time on reproductive surgery. And for our listeners, what does that mean? What are the reproductive surgeries that take you to the OR?

Zoran Pavlovic (11:09)

So the majority of my surgeries deal with fibroids, endometriosis, adenomyosis, and then some more niche surgeries such as C-section scar, defect repairs, the occasional abdominal cerclage, which that's pretty rare, but I'll get some of those too. And then almost anything in between, whether there's some partners in my practice that don't operate at all. So even tubal bilateral salpingectomy, so taking out the tubes, for example, that's something that I'll do for them. And then hysteroscopies, of course, which is the bread and butter of our fertility practice.

Carrie Bedient MD (11:44)

So when you've got someone who comes to you who has endometriosis, and we'll focus on the fertility component of it for now, but when you have someone who needs fertility treatment, they're not getting pregnant on their own, and they come to you, what are the things that you look for to say, yes, you do need a surgery versus no, you don't?

Susan Hudson MD (12:06)

And no, you don't, may need medical intervention. So when do you do medical intervention versus surgery, et cetera?

Zoran Pavlovic (12:13)

Yeah. So it's when my patients come and see me, it's really important for me to set the stage of what the actual goal of this appointment is because I do have patients that come for primarily fertility and then they'll mention pelvic pain or issues with that, or they'll come in primarily for pelvic pain. And then when, we get into our discussion, they start saying well, I am interested in having kids one day, maybe not now. And how, how's my endometriosis or my endometrioma is on my ovaries going to affect that?

And then also in between where they come with both, with the history of endometriosis and they're currently trying to get pregnant. I try to set the stage and see what the main goals are. And then anytime I do have someone that mentions potentially endometriosis or fibroids or something that maybe need to handle surgically, personally, do my own ultrasounds and physical exams. And I do a of a combination of a a physical exam, dynamic complex gyn ultrasound, and then sometimes plus or minus a saline ultrasound if there's evaluation of the cavity that's needed or part of that is the fertility evaluation. And really the dynamic gyn ultrasound, which is something that's unique to our practice and that I do and that I was trained at Tampa General to do, is this is an ultrasound that's not just looking at the uterus and the ovaries and the endometriomas, but you're using the ultrasound kind of probing, pushing against the ovaries, against the back of the cervix. You're looking at the uterosacral ligaments. You're looking to see if organs are sliding next to each other or not, things appear fixed. You can also look at the cul-de-sac to even sometimes find superficial endometriosis, which I think is really what's changing a lot of this diagnosis care is the paradigm of the imaging is getting better. I use that then to determine what stage they may be at.

If we're going to move more towards surgery because of the pelvic pain and what I see, or is it maybe a lighter stage, a stage one or two endo that may not need to jump into surgery right away and we can do medical management or try a fertility treatment to see if that works for the patient. And I think that's really helped my personal practice a lot. That and once in a while, I will also have to get MRIs to sometimes evaluate a pelvis. 95 % of the time it's stage one, two or three, maybe four endometriosis that we can handle at our clinic. About 5 % of the time I would be diagnosed bowel endometriosis that may require a resection. And then that's where there are some minimally invasive GYN surgeons in my community that I'm very close with that have multidisciplinary teams that I can then get those patients connected to also in order to do a full resection if we need to, and then work on the fertility after that. So I do think the ultrasound component is really helping my practice.

Abby Eblen MD (14:45)

So Zoran, can you talk a little bit about with endometriosis, you we used to be a lot quicker to operate. In fact, we would do it almost as a diagnostic test when I first started out. And then the pendulum started swinging the other way where it was like, well, maybe we don't need to do laparoscopic surgery on everybody for endometriosis, but maybe there's a certain subset that actually needs surgery. So at what point would you say, and I'm sure it's a combination of things in each patient, but when is that tipping point reached for you in which you go, Gosh, yeah, I think we really do need to take out this endometrioma or we do need to lyse these adhesions.

Zoran Pavlovic (15:19)

It's a little bit of a gray area because there's not a lot of defined guidelines of when to operate or not. For example, endometriomas, when I was trained typically five centimeters or more, we would look into operating on the ovary. But then I do have to counsel the patient that we're not operating on the endometrioma to improve a count or a quality. It's more so either the symptoms or to free up the ovary or to get the ovary in a better position for egg retrieval, for example. Those are some of the main bigger reasons to operate.

Comes down to what I can diagnose on my imaging and their symptoms, and then again, patient goals. I have had patients that want to, that have maybe a lower stage of endometriosis or the tubes are evaluated and they're both fine at the moment, no scar tissue or dilated tubes. And they would like to try some more conservative fertility treatments first. And if those don't work, then we circle back and say, do we need to do some additional testing or do you want to actually go in with a laparoscopy and see what kind of endometriosis is there and what can be cleaned up before moving on to other treatments or trying other things? So it's both the degree of the disease, the clinical picture, and then the patient's goals. So is it a young patient who is more willing to either to try a surgery and to explore things because they're not trying to fertility right now or is it an older patient that we want to talk about maybe do some fertility preservation or make embryos first, for example, and then go on to surgery, especially for operating on the ovaries. So it's not the best answer I know that I gave you because it's gray area, but that's how I put all that together. I'll try to figure out.

Abby Eblen MD (16:52)

I think a lot of patients really don't realize that it is a real gray area, they feel like it's more cut and dried, and it's really not.

Susan Hudson MD (16:59)

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Susan Hudson MD (17:39)

How do you feel that your decision making when somebody comes in with endometriosis differs from somebody who is a MIGS surgeon or a minimally invasive gynecologic surgeon? How do you approach things maybe from a different perspective than just going to a MIGS surgeon?

Zoran Pavlovic (17:59)

I think one of the nice combinations at the fellowship that I was at was that there was, had the REI department, the fertility department, and then there was a MIGS department, but no minimally invasive gyn surgery fellow. We were actually the fellows for the infertility department were responsible for all the infertility and all of the surgery. So we had a nice blend of both and you get to learn about when to operate and also when not to operate.

That's a big thing that I think is really important within the fertility world. And then also when you are operating, how can you best optimize the anatomy, preserve the fertility, restore anatomy? Those are things that you're always thinking about that may be a little bit different when you have also the fertility background. But I am happy to see a lot of the newer minimally invasive GYN surgeons that are graduating or within the early parts of their career have really been trained well to focus on the whole picture of the patient and fertility preservation and fertility restoring, rather than as may have been an older paradigm where they just mostly focus on the pain and are more quick to maybe remove a tube or operate on an ovary or even jump to a hysterectomy. I think that is changing for both in the REI field and also the MIGS field. But that's where that unique combination can come in, is when to operate, when not to operate, and then how best to preserve fertility in patients.

Susan Hudson MD (19:19)

What are some of the benefits and the risks of doing surgery for endometriosis?

Zoran Pavlovic (19:27)

Some of the benefits include, I think most obviously, help with pelvic pain and improving pelvic pain and patient's symptoms with their cycles or if they have pain with intercourse, for example. There can be some benefits to fertility, say if again, you have a large endometrioma and you're removing that to then get better access to the ovary or get the ovary in a better spot, restore that anatomy.

But the risks really are that any time you operate on a patient, there's risk of inflammation, there's going to be some bleeding, some scarring, and especially with repeated surgeries, you can get overall damage to the tubes, to the ovary, you can get decreased egg counts, you can get scarred down tubes. If you're also, let's say adenomyosis, which I call basically the cousin or the sister of endometriosis, and you're operating on the uterus, is there then a risk that the patient has to then undergo a C-section and can't do a vaginal delivery because you've cut into the uterus. So there's a lot of those risks too, where it's important to talk to a patient about that because just jumping into surgery may not be the best option for them or it may be risky in terms of their fertility if there's going to be additional scarring, especially if there's repeated surgeries. And I think that's where some of the main risks comes to.

Abby Eblen MD (20:38)

On a little bit different topic, can you explain to patients who maybe have newly been diagnosed with endometriosis or think they have endometriosis, how does the pain component relate to the stage of endometriosis, or does it?

Zoran Pavlovic (20:50)

That's it's it's a common misconception and this is why endometriosis is such a tough disease that you can have patients with a higher stage higher level disease with not as much pain and then pain patients that have excruciating pain from a stage one or two superficial endometriosis and that becomes really tough because I've done ultrasound scans when our patients describing her symptoms to me and I'm going into that thinking this is going to be a really bad pelvis disease and I go in there and there's barely anything everything's sliding nicely against each other. Nice physiologic free fluid in the cul de sac, in the back of the pelvis. But there's definitely pain there. And there's probably some superficial endometriosis causing a lot of pain. And that's the hard dynamic because it doesn't always connect and correlate with each other.

Carrie Bedient MD (21:32)

So are there conditions when somebody comes into your office and they're talking to you and you know this patient is going to get surgery? What are the tip-offs of this patient is gonna need surgery? Whether it's before or after treatment, we are definitely going to the operating room at some point.

Zoran Pavlovic (21:49)

I think when the symptoms are quite debilitating in terms of painful periods, pain with intercourse, the pain with bowel movements or urination, where they're just having these significant, significant pain symptoms that are getting in the way of a normal life. They have a hard time going to work or to school or their daily activities, and it's really affecting them. Then I feel that most likely, even if we're going to do a fertility treatment first, this patient will likely need some form of surgery, whether it's with me or one of my MIGS colleagues in the future. Because I think what's important to understand in endometriosis is that so many patients for so long express pain symptoms and are told that it's either just how period it is or it's either in their head. These are things that we're trying to remove away from in our field. And it takes on average a seven to 10 year delay in diagnosis. And in that seven to 10 year span of time those symptoms can get worse or the endometriosis can get worse, whether when it could have been caught earlier and they may have had a better outcome than being caught much later where a lot more tissue has to be removed or other organs have to be removed. I think that's the symptoms are really important to pay attention to. And sometimes they can be vague. It's not just the really painful periods, pain with intercourse. It could be just bloating that's constantly around a patient's periods or this constant nausea that's around periods. There's just symptoms that really, a normal period should not be that. And us as providers and doctors just understanding that we need to listen to these patients, understand these symptoms, and then explore and dive into that a little bit more and then see if they can be treated or helped sooner rather than later.

Susan Hudson MD (23:28)

I have a question about endometriosis and long-term successful treatment. And what I'm meaning is, and I'm taking this from a perspective of, so I have celiac, which is an autoimmune condition that has been under control since essentially I was diagnosed probably about 18 years ago. And one thing as a patient that it honestly took me about 10, plus years to understand is that even though my enzymes were normal, I was not ever going to be completely normal. Do you feel that with medicine or surgery, endometriosis is a condition that's truly ever treated and gone, or is it something that has to be managed even after you have surgery or you're treated with effective medicines or things like that.

Zoran Pavlovic (24:21)

That's an excellent question. I'm definitely of the school of thought of the latter opinion where it's a lifelong management situation. There are definitely some patient cases where you do a surgery or some medical management and they are very well controlled for a very long time or their recurrence just doesn't happen for a very long time, if at all.

But the majority I tell patients that it's something that is it's hormonally based. It's also wrapped around in immunology and there's some genetic components that we're learning about it there's this whole new field about called neural pelvic pelvimetry. They're looking at the nerves and how they're related in the pelvis and and the central sensitization in your brain So the nerve signals are responding to pain much worse in those patients all these things that we're learning that we're finding out that it's going to be a disease that's going to be managed long-term. And the goal is to minimize symptoms as much as possible, control them as much as possible, preserve fertility, help with family building, and then get patients into the later stages of their life or menopause where hopefully most patients will experience a reduction in symptoms after menopause. Although there's more and more cases coming up now where there is endometriosis in post-menopausal women that's been activated or is activating itself. So we're learning that we can do those things as well.

but I really try to, I know.

Carrie Bedient MD (25:37)

That's so rude. That is so incredibly rude. Like that's the bonus of being menopausal for so many women with endometriosis is that it goes away. How dare it?

Zoran Pavlovic (25:45)

Yeah, And most times in that case it does, but there are cases where it doesn't. I try to really counsel patients early on that where surgery in and of itself, you can't sit there and say, this is going to cure endometriosis and your pelvic pain, you're going to be fine forever. It's just not possible. There's some of my mentors that go into conferences and they say that you can never truly cure endometriosis with surgery.

We can manage it and that together as a team between us and others, pelvic floor physical therapy, for example, and neuropsychology too, because there's always a neurological component to it that we need to manage that all of us together can then in a multidisciplinary way manage that pain as best as possible for long term to allow a patient to be able to live their life, have a family and just be as comfortable as she can and not be in pain. But definitely, definitely in that second school of thought.

Abby Eblen MD (26:37)

So Zoran, if you have a patient who's been diagnosed with endometriosis in the past, maybe you even did surgery on them at some point, and say some of their symptoms start to come back, at what point would you say, okay, this patient's a candidate for medical treatment, and if so, what are those treatments, and at what point would you say, gosh, I really need to take you back to the OR again and do more surgery?

Zoran Pavlovic (26:56)

I counsel patients that within a two years time span about 25 to 40 % of patients have a recurrence, especially if you have your ovaries, which you need for your bone health and your heart health and cognition and everything. I don't think we should be ever going in and blindly taking out ovaries. But when those patients come back, looking at their history, how many surgeries have they had? What were their symptoms and outcomes after each one of those surgeries helps me understand whether or another surgery may be warranted or should we try a more medical management approach, which would include basic things such as hormonal pills, such as hormonal contraceptives. That could be a combined pill or progesterone only is a common one that I like to jump to. Start with something light such as a 0.35 milligram norethindrone. That's a progesterone that's a little bit lighter and take that daily. Don't skip the, or don't take the sugar pill week. Just go into active pills only.

And then there's the more heavy hitters that are such as the something like aygestin five milligram, norethindrone that you can go up to 20 milligrams in a day. If it's adenomyosis is involved, IUD for the local hormone suppression. You have Lupron with ad-back therapy or Orilissa, Myfembree, some of these newer medications that are on there that help shut things down, but still provide the hormones that a patient needs. I look at their surgical history, what their current pain symptoms are, what their goals are, and then just talk to them actually about both, what a repeat surgery may look like and then what medical management may look like and see if together we can figure out which initial path is best, that I most comfortable with.

Susan Hudson MD (28:31)

When people are done with their childbearing, at what point is endometriosis a reason to have a hysterectomy? Does a hysterectomy help? What do I keep? Do I keep my uterus? Do I keep my ovaries? Do I get rid of everything? What do I do with my fallopian tubes? What's your advice?

Zoran Pavlovic (28:50)

So it's tough because endometriosis, as long as you have your ovaries, it can still be activated and reactivated. As we talked about postmenopausal patients also having endometriosis symptoms, if that endometriosis lesion itself has that aromatase, which is an enzyme that helps make estrogen, has that activity there that will cause it to make its own local estrogen, it's tough because of hysterectomy then, removal of the cervix, the uterus, the tubes, and removal whatever endometriosis is there doesn't eliminate your risk of having endometriosis down the road. Hysterectomy, tubes, cervix and ovaries, that is a potential possibility that if you do that and the resection of the endometriosis that's there really clean up the pelvis and then ensure that that patient could be in a place where that pain won't come back. However, then depending on the age, they may need hormone replacement therapy.

Sometimes providers will have a post-hysterectomy patient on hormone replacement therapy and they say, you don't have a uterus, so let's just give you estrogen. And now any little bit of endometriosis that's there gets really activated by all this estrogen and no progesterone. And so then it comes back. So that's where I think hysterectomy in and of itself, if we're dealing with endometriosis, isn't my go-to, but I definitely counsel patients on it. And I just tell them that your ovaries are really important. And there's some studies and data that suggest that your ovaries are still important to you up until the age of 65 and the hormones that are involved there. So that thought process of doing a major surgery like that to eliminate all pain, I'm very cautious about because the last thing I want to do is have someone go through a surgery like that where they take everything out completely and then they're still in pain. And now they're really racking their brain about what to do and they feel hopeless and frustrated. And that's, that's tough.

Susan Hudson MD (30:32)

I'm a big proponent of pelvic physical therapists. It's amazing how much of that cross innervation happens and how much bowel activity in your bladder and potential endometriosis and hormonal fluctuations all play in together. And without getting literally to the root of the problem sometimes, no matter what we do surgically, if you don't have those neurons retrained, we're not going to make the progress that we need.

Abby Eblen MD (31:01)

Yeah, and I think it's just amazing sometimes for patients and physicians alike how you send somebody to pelvic floor or have them do pelvic therapy first and sometimes people feel completely different. They're like, my gosh, this is, I mean, that was their whole problem. It didn't have anything to do with endometriosis and those were the ones you definitely want to catch before you take to the OR for a big surgery.

Carrie Bedient MD (31:22)

Zoran, why when you have an endometrioma, do you have to surgically remove it? If you have to deal with it, if you have to get rid of it, why do you have to surgically remove it? Why can't you just stick a needle in and drain it?

Zoran Pavlovic (31:35)

Yeah, that's, that's an excellent question, which is one that I get a lot. And the thing is, that if you just drain an endometrioma, that cyst wall in the ovary is still there. And a very high probability that it will, the endometrioma will refill, it'll just expand and down the road, you'll have the endometrioma back. So to try to prevent that recurrence, the best thing to do is to resect that cyst fully or there's some newer techniques that are out there that are still being studied, such as sclerotherapy, which is basically using alcohol to burn that cyst wall from the inside out while protecting the ovary that I have some physicians out there that I know that are very big proponents of it. So there's newer things that are out there, but one way or another, if you just leave the endometrioma cyst there, then the endometrial cells that are there can continue to be activated, will continue to grow, will continue to bleed out into those spaces and then reform that endometrioma and the symptoms don't really, it's a very temporary fix if you just drain it rather than removing the cyst.

Susan Hudson MD (32:37)

I'm curious on the sclerotherapy. Do you essentially stick a needle in it like with a IVF needle and drain out the endometrioma stuff and put some sort of other chemical in there to erode the wall?

Zoran Pavlovic (32:51)

It's slightly a little more involved in the sense that you typically do it laparoscopically and you make a very small incision in the ovary where the cyst is, drain that out with a suction device, of rinse and drain out a few times. And then you actually, what I've seen mostly done is a Foley balloon goes into that area and then is expanded so that when you're pushing that alcohol sclerotherapy through, or that the fluid through, it remains in the ovary and doesn't spill out into the pelvis because then you can have irritation and inflammation in that regard and you don't want that.

You fill up the ovary about three-fourths of the way and then you leave it in there for there's varying times Maybe 10 minutes 30 minutes. There's different studies that have different different time points But you leave it in there for that time point Which is within the surgery and then you drain all that out and then put the suction device back in and kind of rinse things So you don't leave it fluid in there forever. You don't leave it in there. You don't leave it in the pelvis So it's just in that time frame that you're kind of burning it up

Abby Eblen MD (33:42)

⁓ gotcha. Can you explain to our patients, and I think we all know, because we've done surgery on endometriomas, but explain how endometriomas can cause issues, like if you're trying to get those out, why do you damage egg cells in the process? Because I think most people envision an endometrioma just stuck to the top of the ovary. So can you let our listeners know why we don't want to jump right in and cut into your ovary and take an endometrioma out?

Zoran Pavlovic (34:14)

Right, so the endometrioma cyst and the ovarian cortex where all of the eggs reside have a very close and intimate relationship and they're right next to each other. So no matter how careful or good of a surgeon you are, when you're cutting into the ovary, even if you're very gentle about it, there's going to be some normal ovarian tissue that's either cut or cauterized or burned and damaged. And so that can lower the egg reserve that's already a little bit lower. And that's why doing these surgeries, you have to be careful, try to preserve as much as the normal ovarian cortex as possible. And also know that it's important to tell the patient ahead of time that, as we mentioned earlier together, that the removal of that cyst is not for the goal of increasing an egg reserve number or an AMH, for example, because the damage of a large endometrioma is already done. That endometrioma itself has toxic inflammatory markers and fluid that goes out to the cortex and causes inflammation and damages those egg cells already. And so now we're trying to prevent any further damage by removing that endometrioma as safely as possible. But there'll always be any surgery on the ovaries going to damage the normal cells, which can reduce counts a little bit as well.

Carrie Bedient MD (35:24)

Is there any damage when we go in during a retrieval and enter an endometrioma that doesn't necessarily look like one on the ultrasound? Many ultrasounds will show that abnormal filled in look, but sometimes, especially when you go in a retrieval, it looks completely normal and you expect it's going to be that clear follicular fluid that's going to yield an egg. And then we go in and turns out it's endometrioma. Is there any damage done during the retrieval when we encounter that?

Zoran Pavlovic (35:55)

There so the potentially can be all of us is REIs I know we try our best never to go into an endometrioma as much as possible in a retrieval because there can be some some spreading or some seeding of those endometrials like cells into the other parts of the pelvis and the body that's that's one part and then there's also it can become a nidus for infection because if our patients don't know just yeah the normal vaginal bacteria that's there that we don't use sterilization obviously before an egg retrieval because we don't want to damage the eggs, but that bacteria can then be pushed into this endometrioma. It finds a nice home to live in. And my two worst cystectomies in my life that were done at midnight both times, of course, that's always how it is, was when fellowship were infected endometrioma's post retrieval. So post retrieval found it and then that five centimeter endometrioma blew up to 10 centimeters and had a big abscess pocket inside of it that was not fun. So we were lucky we were able to save that patient's ovary, but that's some of the risks that those these small endometriomas can have. And there's not much, hard to be prevented by not going into it with the needle. But if you do, one thing I personally do is just give some IV antibiotic after two grams of Ancef and hope that that's enough to cover what may be there. But sometimes it isn't.

Carrie Bedient MD (37:11)

What should our patients look for when they're looking for a reproductive surgeon?

Zoran Pavlovic (37:15)

I think it's important to ask, is this part of your practice? Because as we know, lot of fertility physicians nowadays may not operate as much as we used to. And which surgeries do you perform? And then also to talk about what kind of team you have around you, what kind of backup plans do you have? I think it's really important if you're going to be a fertility specialist that also does a lot of surgeries is to know which surgeries that you're well trained in, that you're good at, and also know your limitations and be able to find those partnerships in the community. Like for example, I was saying that 5 % of the time I'll diagnose a bowel endometriosis lesion that likely needs a resection. And I work with some great MIGS in the field. In my area, particularly Dr. Miguel Luna, he's great. I'll be able to send him my note, my images, the MRI report and the disc, and he just has to see the patient introduce himself but he doesn't have to repeat the workup and he just brings it to his multidisciplinary team. We have general surgery, colorectal, et cetera, that can fully take care of that patient. I think that that's really important to tell a patient ahead of time to just let them know what we're able to treat and what may be some limitations to be honest about it, knowing when to operate, when not to operate again. And then seeing what kind of support is there in the clinic. Is it truly multidisciplinary? Do you have people such as pelvic floor physical therapists you work with or pain specialists that you work with that you can add on to the team because endometriosis and chronic pelvic pain can be very become very complex very quickly and multifactorial. And I really truly think that if you don't have a good team around you a good multidisciplinary approach, other specialists such as pelvic floor PT that you have on speed dial to tell patients bring patients to that, that taking care of endometriosis in your practice, you may not be there just yet. You need to build some of that up and have that available to truly do it right. And that's important for patients to ask and advocate for when they go see a specialist.

Carrie Bedient MD (39:07)

That's fantastic advice. Thank you so much for talking with us today and walking our listeners through some of the intricacies of reproductive surgery.

Zoran Pavlovic (39:17)

Appreciate it. Thanks for having me come on and talk about a topic that I love, but it's a really tough topic and I appreciate all the work you guys do with your podcast and getting this information out to patients. It's awesome.

Carrie Bedient MD (39:27)

Thank you. So we've been talking with Dr. Zoran Pavlovich of IVF Florida at the Boca Raton and Jupiter clinics. And he is both a reproductive endocrinologist and infertility specialist as well as a reproductive surgeon. So if you are in need of those services, you at least know one place to go for an opinion or a second opinion.

To our listeners, thank you so much for listening and 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 (40:02)

You can also visit us at fertilitydocsuncensored.com to ask questions for our Ask the Docs segment. Also check out our new book, the IVF Blueprint, to help you understand IVF in detail. You can get that at Amazon, Barnes & Noble, and bookshop.org. We'd love for you to subscribe, and we'd really love to hear from you.

Susan Hudson MD (40:20)

Check out our Instagram and TikTok for quick hits of fertility tips between weekly episodes. And as always, this 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.

Carrie Bedient MD (40:35)

Bye.