Transforming Infertility Narratives alongside Dr. Naomi Whittaker

Speaker 1:
0:03

Welcome to EndoBattery, where I share about my endometriosis and adenomyosis story and continue learning along the way. This podcast is not a substitute for professional medical advice or diagnosis, but a place to equip you with information and a sense of community, ensuring you never have to face this journey alone. Join me as I navigate the ups and downs and share stories of strength, resilience and hope. While navigating the world of endometriosis and adenomyosis, from personal experience to expert insights, I'm your host, alana, and this is EndoBattery charging our lives when endometriosis drains us. Welcome back to EndoBattery, grab your cup of coffee or your cup of tea and join me at the table.

Speaker 1:
0:47

I'm joined at the table today by Dr Naomi Whitaker, who is the founder of RRM Academy and is an OBGYN fertility surgeon focused on women's restorative reproductive medicine, compassionate health care and education. Dr Whitaker is a board-certified OBGYN and a fellowship-trained surgeon who specializes in the Creighton Model Fertility Care System and Napro technology, which works cooperatively with women's body to treat the underlying cause of gynecologic issues and infertility, such as endometriosis and PCOS. Dr Whitaker helps women improve their gynecologic health and avoid or achieve pregnancy in accordance with their natural fertility, using the latest research, medicine and surgery. Please help me in welcoming Dr Naomi Whitaker. Thank you, dr Whitaker, for joining us today and taking your time out of your busy schedule to join me today.

Speaker 2:
1:40

Thank you so much for having me.

Speaker 1:
1:42

Yes, you're welcome. I do want to start off this episode by saying that what we're going to talk about today can be triggering for a lot of people. This is not an easy topic to talk about, and especially if you are in the trenches of walking through fertility issues or infertility issues, or if you've had your fertility stripped from you in the past and are unable to have kids. So this may be triggering to you, and I just want to say that I hear you and I see you and I want you to know that you are not, in any way, shape or form, looked over, and this can be hard. But this can be triggering for some and I just want to say that. But I do think it's important that we do talk about it, because a lot of people do struggle in this area specifically. So thank you for being the person to talk about this in such a great and delicate way.

Speaker 2:
2:34

Yeah, it's such an important topic and I'm so glad that you're bringing this information out there.

Speaker 1:
2:39

Yeah, can you explain to us what it is that you do, as far as what the difference is between what you do and what a typical GYN would do or typical specialty in fertility would do? Can you kind of give us a background of what it is that you specialize in?

Speaker 2:
2:58

Sure, so it's its own type of approach. Where it's not quite, it dabbles in minimally invasive gynecologic surgery. It's somewherebles in minimally invasive gynecologic surgery. It's somewhere in between minimally invasive gynecologic surgery and REI Okay, a combination of both of those. So, but I don't do IVF. I actually use surgery to treat underlying women's health issues, for example. Also I use a bioidentical hormones in cycle charting and I combine all of those together to help boost natural fertility. Timing intercourse instead of IUI, big endosurgeries, tubal corrective surgeries instead of IVF that's kind of my version. So women come to me who either failed IVF, iui or don't want to do that approach, or they're coming to me before they're actively trying to conceive and they see issues. Either they were cycle charting and they saw issues, or they're very knowledgeable, either from a family member or friend that told them something isn't right. And so they're coming to me younger and hopes that maybe one day they can preserve their fertility, maybe even enhance their fertility, so that they can be ready when the time is right to try to conceive.

Speaker 1:
4:13

Do you have patients that walk into your door that don't know that they have maybe an underlying condition or know what the condition is, but they just know that they're struggling with fertility and they maybe aren't as comfortable with IVF or they've had a reaction to IVF and they're coming to you and they're like what is going on with me? How often do you see that in your clinic?

Speaker 2:
4:34

I would say most women don't know it's endometriosis, right? Most women don't say this is absolutely endometriosis, where women are told things are normal throughout their whole life, either by their mother or their teachers or their physician, and so they come, they say something's wrong. Clearly I'm not getting pregnant and I want an answer.

Speaker 2:
4:54

Right and you and I probably know quite quickly that endometriosis is very high on the likelihood, even if only infertility is the problem. But usually when you dig deeper and I started to do this endometriosis symptom survey to pretty much any woman that walks in with fertility issues, and the main thing that I've found so far I've only been doing it for a few months is that women under report their symptoms. They have normalized it to themselves for so long that they kind of lived with it, they put up with it or they work their life around it. And then, unfortunately, many of these women I mean, I definitely have a subset of women that are coming to me mainly for pain, but there's a big subset that put up with so much pain and suffering and don't pursue aggressive options until they're trying to conceive and that's the one final thing to push them over that line to actually seek treatment.

Speaker 1:
5:54

Yeah, talking about this survey, I saw that you had recently just posted something on your Instagram account about this survey. Can you tell us a little bit about what this survey entails, what it is aimed to do, so that we can get a better picture of maybe what we can be looking at or what people can be looking at when they're thinking about this in the sense of fertility and endometriosis?

Speaker 2:
6:16

Yeah. So I put together a survey that is just my brain on paper. When someone comes to me for a surgical consult, either they're coming to me for pain or infertility or both, and then I ask them all these questions and when they say these symptoms, these are the ones that really stand out in my mind as specific to endometriosis. Obviously, it's a whole constellation of symptoms and you have to take into consideration the big picture. Some symptoms overlap with other issues that could be not related to endometriosis. But I thought, well, if I put my brain on paper, more people will have access to what it's like to be in the mind of a surgeon. Now, obviously, it's not a way to diagnose it, it's just a suspicion score. And so people ask me all the time what does the score mean? Well, I can't tell you much about it, except when the score is very high, like especially 30 or more. I think that makes it very likely for endometriosis to be there. But if the score is low, like even a score of seven or 11, I've found people report stage four endometriosis even. And of course, symptom score is not correlated to staging, right? That's not surprising, right? And this is all preliminary data.

Speaker 2:
7:38

I would love to research it. It's not research, but I think the lower symptoms score doesn't rule it out, but it's. It is something to bring up like okay, well, you know which symptoms to focus on when you go to a provider, see if, even if you are screening a surgeon, do they even take these symptoms seriously, you know. So that's something to consider as well. So I felt like it was a way to bring access to people who may not be able to see a surgeon, like myself, I only see patients in Pennsylvania and Virginia, so I know access is a huge problem and for me, I have endometriosis. I didn't realize these are symptoms until fellowship, and so even me in the field of OBGYN, I didn't even realize these symptoms are highly subjective of endometriosis.

Speaker 1:
8:30

Which I mean I think that's true with a lot of us, right, we don't put our symptoms together and even after my diagnosis and after my surgeries, there were symptoms that I had that I didn't put together with my endometriosis until after, and it was more because I was learning about these symptoms and how it correlated with the endometriosis.

Speaker 1:
8:49

For instance, I didn't really realize my UTIs that weren't really UTIs were probably endometriosis, right? So there's all these little tidbits of information our body gives us that we aren't necessarily putting our pieces together, and I would even say this is post-operatively symptoms and I'm like, okay, could this have been because of endometriosis or is this in correlation to because I've had it for so many years? And so I think that's true with a lot of us that struggle with endometriosis. Are you able to speak on the success rate for those patients that maybe have adenomyosis, because this is a big one for us in the endometriosis community, as far as a lot of us that are struggling with fertility not only have endometriosis but have adenomyosis as well. Is that something that you kind of deal with on a daily basis as part of helping those achieve success in fertility?

Speaker 2:
9:46

Absolutely so I had to really do my own research on adenomyosis because there's really not good information out there. So there's technically two different types of adenomyosis there's diffuse and there's focal. So diffuse is more common in women who have had children and does not cause infertility but can cause the symptoms like fullness, heavy bleeding. But the good thing is that shouldn't really affect fertility. It's very often visualized on ultrasound. In an article that I read analyzing many, many studies and summarizing the findings, it compared it to the boy who cried wolf. So adenomyosis is over called on ultrasound because obviously we know endometriosis is missed more often than not by ultrasound and MRI. But they might see some junctional changes or whatever the ultrasound findings are in a large uterus. So oh, it must be that right. Just because you find it doesn't mean it's clinically significant. And now that our ultrasound technologies is more clear than it used to be, we're finding it more. And now we're over calling it.

Speaker 2:
10:54

Based on what I've been able to find, I don't see other signs of issues. If it's just that, for example and I don't consider that in my other than management of symptoms, I don't consider that as a barrier to conceiving. Now it's very different. Someone messaged me today they have a seven centimeter adenomyoma. Now that's very different. That's evidence of focal adenomyosis, so a big nodule or area of endometriosis growing into the muscle of the uterus, and so those do cause infertility. But the good thing is those are resectable. You just treat it very similarly to endometriosis. Now it's definitely trickier surgically.

Speaker 1:
11:40

But and from my understanding and maybe I'm wrong on this but doing those does increase risk, sometimes with fertility, depending on who you see. Like you wouldn't want to see, just anyone to see, no matter what.

Speaker 2:
11:53

Right Period. If you are interested in fertility and I think that's something I really want to bring out today into light is that who your surgeon is matters more than anything. Right, because? Because not only finding it all, but tissue handling being very delicate with tissue I see people on social media even just grabbing the fallopian tubes. You don't want to do that with these very strong instruments. Obviously you don't want to take out fallopian tubes without patient consent, which obviously happens a lot. I'm sure you've gotten those messages, like I have. I went under anesthesia. I woke up without a fallopian tube. I've seen it on patients who go to surgeons. They go there for fertility. The tube is taken out because they thought it was endometriosis. Pathology was negative for endometriosis on the tube. They took out the whole tube. So surgeon choice matters for someone who's fertility friendly, who really respects that, and so it's. There's a lot to it. We could definitely go into it more. That's touching the surface of it. But number one respecting autonomy. Respecting that. You know I have patients all the time.

Speaker 2:
12:56

Are you going to take out my tube? Are you going to take out my ovary? I mean, you know, and I explain how often I do that, which is almost never unless I think it looks like there's a cancer how often I do that which is almost never unless I think it looks like there's a cancer, I pretty much try to save every fallopian tube or ovary. After you know, informed discussion with a patient. Of course, I'm sure there are exceptions in women who aren't trying to.

Speaker 1:
13:14

I'm talking about trying to conceive population, yeah, If someone comes into your office and they've already had excision surgery but they are still struggling with fertility or even sometimes probably pain, what are some approaches that you take to help them achieve their ultimate goal of either fertility or pain relief?

Speaker 2:
13:35

Yeah. So of course I look back at their operative reports to see what was done and I go over with them concerns from what was seen, including, you know, the potential or of adhesions, or if they did appropriate adhesion prevention. If they check the tubes with chromoprotubation they may have missed a partial occlusion of the fallopian tube, which is pretty common with endometriosis, and so for that I do a selective hysterosalpingogram which is more accurate than a regular hysterosalpingogram. It's where the x-ray is put above the body and I have an actual cania that goes into the fallopian tube and I have a pressure gauge and it measures if there's a partial occlusion. So I don't want to just see fillage of dye, I also want to see that the pressure is very low and so that that indicates the tube is wide open. And so I check each tube individually and then if there's a partial or complete occlusion, I have a guide wire that can run down the tube, kind of like snaking a sink to open it up. I just see tubal occlusion with endometriosis period Okay, more like or with infertility period.

Speaker 2:
14:49

You know I'm not sure what the risk factors are If it's congenital, you know hereditary someone's born with it.

Speaker 2:
14:56

If there's endometriosis in the tube, if there's debris in the tube or inflammation related to endometriosis or if it's just infertility as a symptom.

Speaker 2:
15:06

It's hard to say but I do screen almost all women that come to me who are undergoing surgery. I offer them that because if they haven't tried to conceive it's going to be silent and then they're at increased risk, in my opinion, if they likely have endometriosis. In my opinion, if they likely have endometriosis, I do think many times it is probably congenital and treatable and it goes away after that procedure. But I like to offer it to most women undergoing surgery, even if they're not actively trying to conceive, because I've had women come to me with endometriosis. They got excision, they got a lot better and then they come back to me with infertility because their kids were occluded and if we had just checked it when they were focused on the pain but they knew they wanted children later, I regretted not offering it earlier. I explained hey, if you haven't been trying, you may not want to do this procedure, but I like to just offer it if they're going under general anyway.

Speaker 1:
16:04

Right.

Speaker 2:
16:05

Because it's pretty quick, it's very quick.

Speaker 1:
16:08

Well, and it sounds like it's a more proactive approach as opposed to a reactive approach, which we all know that when you're reactive, that's when things can get a little hairy with outcomes, and so sometimes it's better to be proactive when it comes to things like this, specifically for fertility.

Speaker 2:
16:27

Yeah, I think it depends on the woman and what her desires are and where she is. And you know, some women really want to be on top of it, want to be ahead of it and be proactive, and that gives them peace of mind, and others want to take it as it comes.

Speaker 1:
16:39

So, yeah, and some people are just in survival mode and they aren't thinking, and that too, yeah. So some people are just in survival mode and they aren't thinking.

Speaker 2:
16:47

And that too, yeah, so when I bring it, up.

Speaker 1:
16:49

They're like what are you talking about?

Speaker 2:
16:50

They're really blindsided by it. Like why are we talking about this? Like, well, because I deal with so much infertility, it's always on my mind so I want to bring it up. I say, and if you don't want it, that's fine, because it is another intervention that may be unnecessary. So, yeah, other things you want me I can tell you that that I see that are really unknown with endometriosis include inflammation in the uterus, which could be related directly to endometriosis, and sometimes chronic endometritis, which means inflammation in the uterus from infection, and then, of course, polyps as well. It's important I like to look for polyps in everyone and biopsy everyone and look with a camera for anyone with abnormal bleeding and or pain, if they're going under surgery.

Speaker 2:
17:42

Anyway, because it's again quick and you can improve outcomes, because it's rare that I don't find endometriosis at surgery. But if if that is the case, then I usually find something else. So a common thing that I'll find is an infection in the uterus. So it can exacerbate endometriosis pain or infertility or it could be the main cause of pain for some women. That's rare but I have had that. Maybe one case a year where I'm expecting endometriosis. I don't find it, and in those cases I usually find something else, like an infection in the uterus, like E coli, which shouldn't be there. And again, that not only will help her outcome of pain and abnormal bleeding but also prevents infertility down the road. Because what I'm thinking of was a teenager.

Speaker 2:
18:28

I don't know how it gets in there, but it probably is related to immune system dysfunction. We don't really know. It's not due to lack of hygiene or STDs. That's a common question. But that's an easy thing to do at the time of surgeries get some swabs, check for infection, and I do get probably a lot more swabs than may be needed because I'm covering for infertility as well. But I typically get aerobic, anaerobic mycoplasma, ureaplasma, fungal, viral. We get 10 swabs, but it covers. That covers most of them.

Speaker 1:
19:00

Interesting. Do you think that more doctors should be looking for things like that when patients come in? I mean, I think maybe across the board, but specifically for those who are going in for excision surgery, do you think that we need to take more of those samples and swabs to be able to really identify if there's more going on than what you initially thought? More than just an endometriosis? Yeah, thought more than just endometriosis.

Speaker 2:
19:25

Yeah, I rarely just find endometriosis. Typically, you know, you have your pre-op and post-op diagnosis. My post-op diagnosis is very long. It's usually four or five lines, not just different areas of endometriosis but evidence of inflammation or polyps or cervical stenosis or tubal stenosis, adhesions. I look at the liver, you know, and I see if there's inflammation of liver or fatty liver. So I tried to do it just a whole assessment of everything that I see for health purposes, cause, as you know, women with endometriosis or pelvic pain or infertility, they're all very complicated and it's usually not just one thing going on. Especially by the time they present 10 years later, after they've been asking for help, things have usually gotten pretty bad yeah response.

Speaker 1:
20:26

portion of that is often overlooked because it's not always a definitive picture right out of the gate where people aren't just thinking, oh, there's an immune response to this. It's oh, there's endometriosis, let's go get the endometriosis. But there's, you know. I think maybe that could be another key as to why some of us struggle so much postoperatively as well is maybe we're missing a piece, oh yeah.

Speaker 2:
20:44

I mean there's. I'm always learning more about the immune system, about mast cell response. I don't know much about that. I was not taught about that at all.

Speaker 2:
20:53

And that's clearly an issue. Yeah, tons of rashes postoperatively. That's the most, by far the most common conflict. You know, complication is significant. Rashes not just a little bit. But many women react to something, whether it's the glue, whether it's the prep. It's very common. So clearly there's a lot more that we need to be doing. That I don't know about, but I'm always trying to learn. That's why I like being on social media, because I'm always learning from followers who are telling me about their experiences, what helped them.

Speaker 2:
21:23

I try to share their raw, authentic experiences, because that's how we're going to advance.

Speaker 1:
21:28

Yeah, Well, and who better to learn from sometimes than the patients?

Speaker 1:
21:32

Because you know, I think you know what I see a lot of times is doctors get really stuck in what they know, but it's because that's where it's comfortable, that's where they excel, they understand it.

Speaker 1:
21:43

But sometimes what the patient is telling you contradicts what you know, and so if you're not learning and growing from the patient, sometimes you become stagnant in your care. And I would say, like a lot of really good surgeons aren't that way and they do listen to their patients. So that's kind of is a generalization and not completely for everyone, but I do see that happen quite often, where I'm really good at this one area as a doctor but the patient is telling you something completely different than what you know, and so that can be, I think, uncomfortable for doctors. I mean, I'm not a doctor, but maybe you have had that experience at times where you're like this is not what I'm familiar with, but to hear the patient out sometimes and kind of like, suss it out and see, okay, is there validity to this? Are we, you know? Is this something I need to look at even further? Maybe our quality of care would even increase if patients spoke honestly and openly to doctors about these scenarios.

Speaker 2:
22:46

Yeah, I think, and there's a couple things contributing to that. I mean. Number one as a surgeon and a physician, we need to be in control of the situation as much as possible. That's how we have safe and good outcomes Right, and so we need to be in charge of the operating room. We need to be in charge of the labor and delivery room if we're doing obstetrics, and part of that includes a confidence in our knowledge to be able to be in control.

Speaker 2:
23:12

But, on the other hand, with endometriosis, there is some humility that it takes to be good at what you do, because endometriosis will constantly humble you. You cannot predict where it will be. It'll go on an organ in a new way every time. No two cases are the same, and so, especially in the beginning of your career, when you have no idea what you're going to encounter next, it's very scary. That's one thing you learn with endometriosis and I tell patients that all the time. I wish I could tell you if you're stage one or stage four or what organs are involved. But that's one of the hardest things about endometriosis is I can't really predict your case when I'm seeing you for a surgical consult. So there's a balance there of trying to handle that growth and humility and confidence together. There is a way to do it, but that's not something that can really be taught, right? I?

Speaker 1:
24:03

do think patients appreciate when doctors sit there and say that's an interesting perspective. I hadn't thought about that, and it feels validating to the patient to hear a doctor say you know, that's a really good point Because they're so used to being dismissed. A lot of times, specifically when it comes to endometriosis and probably infertility issues, they're so used to being dismissed or, you know, doctors aren't sure what to do so they just kind of you know, move them on along, I can't help you anymore. So when a doctor is learning more or willing to learn more and say you know, that's a really interesting point of view. I really appreciate that perspective. There might be something to that, and so thank you for taking that time to listen and hear the patients and hear the people who have walked through this day in and day out and are struggling, because sometimes that can be the most healing for sure.

Speaker 2:
24:57

Yeah, I also have been on the end of being dismissed, even recently when my husband needed back surgery on the end of being dismissed.

Speaker 2:
25:05

Even recently, when my husband needed back surgery, I had researched the advancements of back surgery and the history of it for 10 years before we decided to move forward with a more invasive option for my husband and we went to someone local, which is, I was pretty confident we probably weren't going to go with. But it was one of those things. You need to do that step before you go out of network, because I was hoping to maybe get the more advanced treatment covered. It was kind of like the excision of back surgery. You know, yeah, the excision version of surgery. I mean, if you had to compare it to endometriosis, and so it's hard to find someone that does that kind of care, had to compare it to endometriosis and so it's hard to find someone that does that kind of care. And in some ways I knew more about the advancements of spine surgery than the surgeon and he was so off foot by that it didn't go very well. You know, I would have. It would have been just really good for him to say he actually called the next day and apologize Not directly about the way he approached it.

Speaker 2:
26:06

But I agree, I don't think physicians realize that because they think we the perspective of a physician is, if we admit our weakness, you're going to lose trust in us. I think that's part of it and so it's that confidence that you want to bring. But, again, physicians sometimes forget what it's like as a patient. To live with a disease is very different than to treat a disease. Yeah, and that patient experience is very unique and you can't outdo that with clinical experience. Yeah, you just you can't. And and the mode that you get in when your life has been completely changed by a horrible disease, the motivation and the hours and the commitment to reading and learning and understanding is just so different than someone who's doing surgery.

Speaker 1:
26:57

Yeah, it's so true and I think. But it's also good for the patients to hear that perspective too, because we can get stuck in our journey and not see the perspective of the doctor sometimes of like I don't think they intended to hurt you, I think they just didn't understand, and so we can compartmentalize that and we can internalize that and it can affect how we navigate our future care, and so I think that's kind of a twofold thing, right. Just as much as we want the doctors to continue learning and to continue growing as patients, it's valuable for us to be able to do the same and have better understanding of our providers. And if something doesn't sound right, ask the question.

Speaker 1:
27:45

I don't know a provider that is a good provider that won't sit there and answer your questions. If it's a bad provider, they may not wanna answer your questions, so that may not be the doctor for you. But I do think that it's a relationship and you have to foster that relationship responsibly and with integrity on both sides. And I think to foster that relationship responsibly and with integrity on both sides and I think that if we do that, then the partnership gets stronger. I mean, that's just my take on that.

Speaker 2:
28:17

Yeah, and the surgeon. Not to knock on this surgeon, I think he meant well, I do.

Speaker 2:
28:22

I think he's a very good doctor with, but his toolkit is different than what I needed and what I was asking for and so I got him out of his comfort zone and then he wasn't used to that and so I don't think he knew how to handle that. I don't think it was anything personal against me or my husband, and I think he meant well and I actually know he's a very good surgeon from people I work with who've worked with him in the operating room. He's very respectful to staff. So it's a complicated topic, you know it's complicated. Again, it doesn't mean that it's personal or that they're a bad doctor. It's a place that we need to grow. Yeah.

Speaker 1:
28:58

But I think that, just as to say, is like we're always continuing to grow in our knowledge and understanding of endometriosis, surgical technique approaches, and I think what's interesting is you know, I went to the Endometriosis Summit and this is part of the Endometriosis Summit is they have these panels and they kind of debate this, and it's interesting to see that even some of the top excision specialists in the world are learning from other doctors that walk into the room because they're having this. I wouldn't even call it a debate necessarily, but I would say a discussion on different techniques and different approaches, and it's all keeping in mind the patient outcome. And if you can find a provider that has the patient outcome in mind, I think you have a better chance.

Speaker 2:
29:45

I think the key is patient driven in mind. I think you have a better chance. I think the key is patient-driven, patient-centered I think you nailed it right there. Truly patient-centered, which is hard to know sometimes when you don't. For example, if a surgeon doesn't understand excision is the best right, then how do they even understand what's best for the patient out there? That's the challenge.

Speaker 1:
30:08

That's a whole other topic. We could probably talk for hours on that topic.

Speaker 2:
30:13

But if you want me to get into a few other things, that go wrong with endometriosis.

Speaker 2:
30:19

you know, if a woman comes to me and her main issue is endometriosis, even if it's advanced stage, I mean that's she's very she has a very high likelihood of success. When you do thorough excision surgery, find it all, even a bowel resection, it really improves fertility rates when needed. And then adhesion prevention, especially with advanced disease. But these women often have a lot of other issues going on, especially if they tend to have other risk factors, like if they're older, if they've had a lot of abnormal bleeding, if they are married to like a man with severe male factor, and so that's what I talk about in my discussion with these patients. First we do need to find answers. So endometriosis is exciting to find because it's a big answer, and then it's a big process to overcome. That Outcomes are really good, especially if that's your main thing.

Speaker 2:
31:16

But it's important that we look at everything, including do they have an ovulation defect? So we screen for women who have ovulation defects, and so that means the follicle doesn't grow and collapse. The key is to watch it collapse as well and rupture to make sure that they're actually ovulating and releasing an egg, because there are conditions that make it look like she's ovulating but she's not really, and so we do an ultrasound series to confirm that she's actually ovulating. But she's not really, and so we do an ultrasound series to confirm that she's actually ovulating. Ovulation defects where they don't actually collapse, the follicle called luteinized, ruptured follicle syndrome, is increased in women with endometriosis and again that can be silent because their hormones can go up and make it look like she ovulated after that. Hormone dysfunction super common where they have low progesterone especially.

Speaker 2:
32:04

very common, which makes sense why they're especially if they have low progesterone especially very common, which makes sense why they're, especially if they have pain, why they're more symptomatic or maybe why their disease is more severe because they have an imbalanced ratio of estrogen progesterone. Progesterone is anti-inflammatory and likely helps offset the inflammation fueled by estradiol. Other things like insulin resistance are important to optimize because that's going to worsen inflammation and fertility issues. Women tend to age their ovaries faster, so have high FSH, may have low DHEA. These are things that are very treatable most of the time, as long as you know. We know that. So giving DHEA, kind of fueling this tank, kind of like similar to I look at it, similar to ferritin and low iron, which is also a common issue. You can do a similar thing with hormones to kind of help optimize hormones If you study that and you can work with the body to help support the hormone health. And then we often see low cervical mucus and so probably related to inflammation. That can be improved with excision sometimes or other times we do give mucus enhancers or low dose naltrexone can help with ovarian function for women who are going through quicker aging of the ovaries because it helps reduce the autoimmune component, inflammatory component. So women feel better on low-dose naltrexone and their fertility can be improved on that medication.

Speaker 2:
33:29

Thyroid fatigue from maybe blame on endometriosis, there could be thyroid issues, there could be low iron issues. And then something simple that may be overlooked is just poor timing of intercourse too. Knowing there's one main day of peak fertility the whole month, and so we educate women on thatcourse too. Knowing there's one main day of peak fertility the whole month, and so we educate women on that main day, so that's kind of an overview of everything. I mean it's a lot more complicated than I can probably get into right now, but Right, but at least there's a starting point, there's something to look at.

Speaker 1:
33:59

It's interesting that the low dose naltrexone is helpful for fertility, because I know a lot of people are starting to use that for like pain and pain response, to help our body's systems essentially calm down, because we are always in that fight flight mode, you know, and so a lot of times that will help kind of ease the pain, kind of get us out of that heightened state. So it's interesting that that works for fertility as well. I hadn't heard that before.

Speaker 2:
34:30

Yeah, it's phenomenal, very safe, very effective, very affordable. It is compounded, though, so it's not going to be marketed by big pharma. In fact, it appears that the research has kind of been suppressed by big pharma. Interesting so, because the research can't be published in mainstream journals, because it is a huge competitor for medications that cost tens of thousands of dollars for Crohn's disease, medications that cost tens of thousands of dollars for Crohn's disease. It's been shown to really improve remission of symptoms in Crohn's disease for like 30 bucks a month versus $15,000. And so these same drug companies are advertising in the same medical journals that would be otherwise publishing this data, and so they don't like that. They're going to lose their revenue with these journals.

Speaker 1:
35:27

Wow, that is interesting. See, these are the things that, as a patient, we wouldn't be privy to without. No, and it was hard for me to find this out.

Speaker 2:
35:35

But yeah, the huge, the researcher that was mainly doing all of this, I believe she was at Penn State in Pennsylvania. She had tons of research, she was doing the Cuddy Ignite research and she cleaned her website of her research. So I heard from a physician who follows this really closely.

Speaker 1:
35:51

Interesting. That's fascinating. I just I know that a lot of people in my inner circle have benefited significantly from doing it and it seems to really help with the pain more than you know any other drug that they've taken.

Speaker 2:
36:08

So I personally have benefited from it. Yeah yeah, I had nerve pain from Lyme disease and it went away in three months, which is when the amount of time it takes for it to work optimally is three months.

Speaker 1:
36:21

Interesting. Okay, well, this is a whole nother topic we're going to have to come back to at another time.

Speaker 2:
36:30

I mean, the risks are mainly vivid dreams is the most common risk side effect. I should say yeah, and then some might have decreased appetite, which can be a problem with women with low BMI you know, which can happen with endometriosis.

Speaker 2:
36:45

So that's something to talk about. But really you can stop it anytime if there's an issue. There's no problem with that. We go up slow just to make sure women can adjust, just because women with endometriosis tend to be very sensitive to medication. So you don't have to taper up slowly, but we just tend to do that. It's the most well tolerated that way.

Speaker 1:
37:07

Interesting. Okay, something else that I think would be interesting to understand and know is do you see a lot of patients that come in that maybe don't have any pain but are just struggling Because you know, we know that with endometriosis specifically, they don't always have pain and so they go in, but they're just struggling for fertility and that's how they find they have the endometriosis. Do you see that often, or is that not as often as the pain?

Speaker 2:
37:36

I see it pretty often more often than you would expect where the pain is less than you would think for the amount of disease that they have. When you finally do look, it's amazing. I don't understand. I know if you talk to any experienced endosurgeon, no one is going to say I'm super confident in predicting endometriosis stage based on symptoms, because it makes no sense. It has a mind of its own. It does. It makes no sense. I've seen some of the worst cases with minimal pain.

Speaker 1:
38:12

Yeah, but I've talked to many people who are like I didn't have a ton of endo, but my pain was severe and debilitating and that's why you know those are the best right. It's never wording You're like oh, straightforward for me. You're like this was a walk in the park for me today I love it. So this is just a good reminder that pain doesn't necessarily mean a ton of disease and no pain means no disease. That's why, again, having a specialist on your team makes the biggest difference.

Speaker 2:
38:36

Yeah, just the other week I had someone that came to me just for a Dermoid, but I had no pain before the Dermoid. It's definitely just the Dermoid. I have nothing else going on. She scored seven, I think, on the survey, but mainly because of the dermoid. She thought she had very advanced stage four and the dermoid was actually mixed in with an endometrioma. It was together. Luckily. I consented her for it, but I don't think she really mentally was prepared for that diagnosis and she really wants a family. That's so. That was a tricky situation.

Speaker 1:
39:07

Yeah, you had talked a little bit about hormones and the part that they play in your practice. Can you explain that a little bit more and the use that you have for them and how you utilize them?

Speaker 2:
39:22

Sure, one of my favorite treatments hormonally is progesterone. What I do is a full hormone profile based on a woman's ovulation. So the reason why most doctors don't do tests is because doctors assume all women ovulate on psychedate 14, and that's maybe 10% of women who actually do that. So you can't really test hormones based on that assumption. Right how to really test hormones is to know when a woman ovulates, which changes on any given cycle, and be able to. I get hormones three, five, seven, nine and 11 days after that and I watched the rise and fall of progesterone and estrogen and I often see a progesterone deficiency, sometimes in conjunction with estrogen deficiency, sometimes with high estrogen, frequently with low progesterone. They have a very truncated second half of the menstrual cycle. That's pretty frequent, or premenstrual spotting is another frequent symptom of low progesterone. So cooperatively working with the cycle, giving body identical progesterone, helps tremendously with bleeding, pain, inflammation and fertility. It's a very cheap option and it helps with implantation. You know, if a woman was trying to conceive it can even help with PMS symptoms. We often see a correlation of hormone fluctuations with the onset of PMS symptoms. So I'm actually doing a study right now based to prove that, because that's not even proven. You would think that basic event of PMS and hormone fluctuation would be a proven correlation, but it's not at all. It's not researched, mainly because researchers don't really understand the female menstrual cycle, because it's so different between woman to woman in cycle to cycle. And so I'm working with cycle charting and hormone testing that patients would be undergoing anyway and just correlating that with the survey based on symptoms, and then we're going to treat them and watch them improve. Now you may know that there's often a progesterone resistance with women with endometriosis, and so for those we can try going up on more capsules. So we not only treat the numbers but we treat the symptoms right. They're both important. And so some women we need to be more aggressive and get the progesterone shot, and I've had women say that that changed their life.

Speaker 2:
41:41

I had one. She was thinking about coming back for endosurgery again. She really didn't want to, but she didn't know what else to do, and then we started on progesterone. I said let's just try these shots. They're not fun, but for women that are suffering, to try these progesterone shots, you know, instead of surgery it's been much less invasive. So she said she had the best period of her life. Her husband noticed and now she doesn't want to do repeat surgery. I really think it helped me rule out that the recurrence of endometriosis for her, I think. So it's really neat, it's really tailored protocol that we can work with the patient and then we can check when she's on these hormones to see if she's at a good level. And you know this should be very helpful for her whole health of her brain, of her bones, for her whole health of her brain, of her bones breast tissue.

Speaker 1:
42:30

All of that is supported by bioidentical hormones. That's an interesting. I haven't really heard that before, so that's interesting.

Speaker 2:
42:34

Yeah, we monitor it because we don't want estrogen to be super high and we want the ratio of estrogen progesterone to be in balance, because progesterone should be in a natural setting and the second half of the cycle very dominant over estrogen and that technically, I think, has an effect on this next couple of weeks. Even so, it's technically, I believe, protective. I have to do more research for the whole cycle. Um, we definitely see improvements in pain and blood flow for the menses after that.

Speaker 2:
43:04

But one thing that I do when I review charts and I see women who went through IVF, their estrogen I never should see it really above 300. And that should be around ovulation, maybe 400 max, just for a day After ovulation. It really shouldn't get much higher than well. Our goal is 120 plus from you know, maybe up to 170. I don't like to see it higher. They don't typically check after stimulation in IVF very often, but when they do there'll be over a thousand estrogen and that I've seen it many times. And not to mention, some of these women still have endometriomas and then they're going to be doing egg retrievals while the estrogen is through the roof and so they're poking these ovaries and causing bleeding and so those are the pelvises that I dread going in.

Speaker 1:
44:02

That's a hard discussion to have, too going in. That's a hard discussion to have too. How do you talk to your patients when there are possibilities of not having the outcome that they want? How do you address those?

Speaker 2:
44:13

Yeah, I mean, I think it's important to be upfront from the beginning. First of all, I'm very optimistic from the get-go. I always try to point at the positive things. But then I also say no one can ever promise you a baby, right, and I think everyone knows that, Right. But and if anyone says that or says, if you give me enough money, I'll give you a baby, you know, doctors have said that. I've heard patients have told me that. You know they're red flags that you should run away from anyone guaranteeing a baby after infertility.

Speaker 2:
44:44

But what I do say is at least in the process you're going to find answers and you're going to find healing. In the end you won't be broke. I do take insurance. I know not all endometriosis surgeons are able to do that so hopefully you won't be broken emotionally, physically, financially. In fact you should be at least feeling better at the end, and that's one thing we have more control over. We don't have total control of the outcome. And then we also I try to invite, you know, discussion of being a mother now and other non-biological ways, and there are beautiful ways of doing that. And so many women have this beautiful calling of volunteering somewhere or whatever their calling is, and I really encourage them to not let infertility rob them of that. So we talk about that and try to really focus on other ways of being a mother today and not letting infertility rob someone of their life or bring desperation in, because that's when we get into problems right, Both physically in our health and financially.

Speaker 1:
45:50

And it's interesting that you say that, because I do know there are a lot of people who put a lot of weight into becoming parents. And right, I mean, if you have that desire and that passion to become a parent, it's so deep rooted and if you're unable to, you grieve and you grieve hard and it is, it's a stressor in a relationship, it's a stressor in your mental health and your emotional health. Do you have a counselor on your staff or people that you refer to through this process?

Speaker 2:
46:21

I wish, I wish, we would love to have one on staff. So unfortunately we me and my nurses end up doing counseling that we're not qualified to do. We do try to encourage support groups and books and therapists, and we do have people that we do recommend. We would love for someone in our clinic to be there on the premises because it's so needed. Every single woman facing infertility goes through trauma, like you said, and the problem is it's so drawn out, it's invisible. Women look healthy on the outside and couples and so they feel so alone. Yeah, and just that long grieving process right Of your dreams of this life that you envisioned for so many years, that maybe no one warned you you know you thought it was guaranteed so many years.

Speaker 1:
47:08

What is your advice to those people who are trying to seek out whether to do IVF or what the next stage of trying for a family should be, if they know that they have endometriosis or even if they don't know, if they have something that's prohibitive physiologically?

Speaker 2:
47:27

I think everyone deserves answers. With going through infertility, the least someone deserves is knowing why. My least favorite diagnosis is obviously unexplained infertility, because that's not really a diagnosis, right? Well, the doctors gave up or they stopped. You know conventional tests, the basic test didn't find an answer. So I think knowing why is extremely important for healing emotionally and physically. Right, because knowing for example, I found cancers in patients with infertility not, you know it's not common, but you know there are serious issues that lead to infertility, and so someone is worthy to know why.

Speaker 2:
48:09

Is it? Male factor, is it? And if it's a male factor, he has an increased risk of a shorter life expectancy. So there's abnormalities on SFA, it's often a sign of underlying health issues, and so it's a predictor of future health. And so I think it's important to find answers for emotional and physical healing, first and foremost, and being empowered with what is going on and having a sense of support from each other or faith or friends or other people going through infertility, support groups when navigating these decisions and not going from that place of desperation because that's when people have a report first mortgage on their house, and then they have no baby and no money, or no money for adoption and I had a patient that failed IVF three times and they were like just do it again. And she was very smart, she and her husband were very, very intelligent and they were like why would I repeat the same thing? And so they came to me. I said, oh, and she was older too, you know, for trying, you know like 30, late 30s or 40.

Speaker 2:
49:17

And I said you know this is probably endometriosis and we were going to do a full, thorough surgery and her pre-op labs she had a positive ACG.

Speaker 1:
49:28

Oh my gosh.

Speaker 2:
49:29

So just through time to intercourse and maybe we get a few little like maybe hormone support like a couple of little things time to intercourse hormone support and and that's true 20 of couples that fail ivf will go on to conceive naturally.

Speaker 2:
49:44

Yeah, so clearly, to me that's proof that too many patients are told to do ivf. Right, if 20 conceived naturally, naturally, that's proving that's without any intervention. Imagine how much higher we get that when we actually work and treat endometriosis, treat hormone dysfunction, treat ovulation disorders, improve the seminal fluid analysis and then in the process of I also help men to, the couple feels better and and they're excited to feel better. And there are milestones, because often with a long journey of infertility, you don't have a lot of wins. Right, because you're looking for the one win of the test. That's positive. But what I say is you should look for your biomarkers on your chart to be better as far as abnormal bleeding, pain, energy. All of that should be improving as we're optimizing your health. And so in the end, let's get you feeling better. We're going to get there. Bonus, if we can have a pregnancy and a healthy pregnancy.

Speaker 1:
50:42

Most often they are healthy when we get them to that point oh, so good to hear for a lot of people and you know, and I have heard from other patients who have done ibf and it's affected them negatively with their health, and so I I want to encourage people, before taking drastic steps, to really look at a big picture, to consider, and it's so hard because, just like with endo, if you just trust your neighborhood OBGYN, you're told you do this, you take this pill, you do this IUI, you do this quick fix Right.

Speaker 2:
51:20

And the OBGYN themselves they mean well, it's not that it's not always the best option, but they don't know what they don't know.

Speaker 2:
51:27

When you look at all the options, they don't exactly. It's so different when someone does all their research right, because they may avoid heartache, they get answers. Just being a self advocate is just so important, you know, and just knowledge and awareness before any decision is made. Because the algorithm is okay try to conceive for 12 months, random intercourse if you're not pregnant. Next step ovulation medication for three months, which I don't like to give blindly either. Right, if someone has an endometrioma I'm not going to throw high dose ovulation meds. I usually just stop all treatments and say I really recommend. I mean it's up to the patient. You know we talk about risks but most patients I don't want them to rupture that because that if they rupture their endometrioma that's going to really cause adhesions and long-term hurt their success. So we talked about they're more expedited on the surgical list to talk about risk benefits. So we try to avoid ovulation. Medic post-pig support is fine, but ovulation medications we try to avoid overstimulating or even minor stimulation of the ovaries. But typically patients are doing three rounds of ovulation meds, just some random dose, not even knowing if they need it they may be ovulatory. Then three rounds of IUI, then three rounds of IVF and then, if it fails, oh, do more IVF.

Speaker 2:
52:41

So there's some fertility doctors that people have messaged me where they do look for endometriosis and treat it. Some REIs do. I'm very impressed when they do. There are definitely some exceptional ones that are very good surgeons. Now the problem with REI as far as endometriosis is concerned from that perspective is that most of them admit that they haven't had enough surgical training. Their focus is IVF. So you have to think about it. As I'm going to this doctor, their main specialty is IVF. They have some knowledge of endometriosis. For me, I frequently look in these pelvises of women going through infertility and I'll even repeat surgeries on patients I've done surgery on if they haven't conceived in 18 months and we feel like you know we've gotten ovulation and all these other. We don't see any major obstacles.

Speaker 2:
53:31

I will offer a second look to potentially see if there are adhesions or an amyotriosis. And so you know I've really been able to through this experience and having a lot of continuity of care of patients really helped me understand the disease and what to expect in patients, and obviously it varies depending on the patient. But REIs, they don't typically have that continuity. They don't really have training in tubal corrective surgery almost at all Most of them, I think. I mean it's an exception if they do.

Speaker 2:
54:03

And so you have to think about the bias of and I tell patients this I say I am a surgeon, that is my bias. I don't do this procedure. So I just want to let you know and be transparent that when you walk in my clinic, I'm going to probably think of endometriosis more than others, of endometriosis more than others, and that's my tool. So if you go to another doctor, just think about what tools they have. It's going to lead their bias into their treatment, and so it's important when you know what treatments are and what are the causes of infertility, you're empowered to understand okay, not only what do I need, but why is this doctor offering this? And so it just helps with that informed consent process, absolutely.

Speaker 1:
54:45

Can you explain what an REI is for those who maybe don't know what that is?

Speaker 2:
54:50

Yeah, so it's a reproductive endocrinologist and infertility specialist, so they have an additional board certification. They do a fellowship in infertility. With the advent of Flomid in the 60s and IVF in the 70s, rei really that subspecialty really changed its focus to those type of procedures and IUI, which is actually from the 17th century Instead of before that time, before the 1960s, they were really endocrinologists looking at root cause. They were more looking for those types of things. Looking at root cause, they were more looking for those kinds of things, and when these technologies came about, like clomid, they thought oh, there's a quick pill, it's going to get everyone pregnant. 10, 20 years later we realized clomid doesn't have that high success for pregnancy alone. So then after that though, so then they were doing less surgery.

Speaker 2:
55:41

When Clomid happened and then with IVF, that again happened, where they're like okay, this is the fix, we don't need to put patients through all this surgery. It sounded so great and it sounded so promising that it would have super high success. Unfortunately, it didn't have high success, especially for women that are older. So women that are infertile tend to be older and women with endometriosis have lower success rates, especially deep infiltrative. But the problem is it takes 10, 20 years to see the success and in those decades skills, surgical skills are lost forever potentially. And so the art of surgery is pretty rare, especially for tubal surgery and endometriosis surgery. Obviously no, tubal surgery is even harder, unfortunately, to find surgeons to do that. So that's kind of the evolution.

Speaker 2:
56:31

I don't think it's by anyone's fault. I think it was through. Oh, this is going to be easier, less invasive, quicker. It gets the outcome we want, right. I mean it's very appealing because, especially for patients to and doctors, because it sounds great you just put the embryo in and you have a baby, right. Well, it's obvious doesn't work out that way.

Speaker 2:
56:51

So yeah, that's, there's a history behind that, and so, unfortunately, rei fellowships focus mainly on IVF training, and they do. It depends on the training program, but there was a survey a few years ago and I think over 50% said I wish I had more surgical training. So that's again. I think it speaks to the REI. As far as, do they talk about endometriosis? How upfront are they about the different diagnoses? Do they try to avoid IVF? Do they try to do it as last resort? We definitely see those. They're just more rare. The one I trained under he didn't have a diagnosis. He actually based his treatment on ability to pay, so for me my experience is biased. It's not great, because that definitely was not a good introduction to me as to his approach.

Speaker 1:
57:45

It's interesting how history affects the trajectory of a disease.

Speaker 2:
57:49

The pill was around the same time in the 60s right, so women are feeling better on the pill. It must stop the progression.

Speaker 1:
57:56

Right, of course, that's what they know. It's an easy solution, so easy, of course.

Speaker 2:
58:01

It's what they. You know it's an easy solution. It's all so easy. So I think all of that came together. It's definitely appealing. It's much quicker. We all have physicians and patients alike we love quick fixes and so it's seen that way, and I mean that's the hard part about what I do is that it takes time. There's no quick fix involved. It's definitely more of an investment in time. So that can be really hard and it's not for everyone. Not everyone wants that.

Speaker 1:
58:27

But for those who have struggled for many years and have done what they thought were all the right steps, this is definitely a good step to consider as well. So there's another resource to put into your tool belt in navigating this journey. It's so intriguing to find this out because this is all stuff that you know. I had very little knowledge on anything that you do prior to really doing my research and being introduced to you through via the Instagram. And if you want to follow more, where can people follow you on Instagram?

Speaker 2:
59:00

My handle is naprofertilitysurgeon. There you go, and my name I'm sure it's on there too Naomi Whitaker.

Speaker 1:
59:06

Yeah, so is there anything else that you would find pertinent for listeners to hear that would be beneficial for them in this?

Speaker 2:
59:18

journey, you know, finding someone who won't ever give up. Like for my patients, we're going to keep looking. Obviously, within reason there's a time and a place where we get to a point where, mentally, they're done and and then sometimes they just want permission to be done. They've been doing this for five plus years and they, they want someone to tell them they're not giving up but that it's, it's okay, they covered all the bases and then they're at peace, which is amazing. To get to that, you know, no one can ever guarantee you a baby. But to be able to feel like you had a thorough workup, you had support and you found all the answers and you're healthier, and then to close on that chapter, you know, think about the end, Hopefully. Obviously we want a baby and that is great and it doesn't heal the pain of infertility but that's the best outcome we would want. But what happens kind of worst case scenario after working with a provider. Hopefully you at least got answers and healing and peace when you went.

Speaker 2:
1:00:21

Look back, because a lot of closing the infertility chapter is which people don't talk about, because no one wants to talk about. There is a time sometimes when we close trying for that biological baby. But what women want to want to know when they close that chapter is they are going to have peace. They're going to have peace in the moment, knowing we tried so hard to cover all our bases. We did everything within reason. As far as you know, excision Some people don't want excision, right. But whatever, it is within reason for them and they can look back in five, 10 years and say you know, we worked hard and I don't know what a journey that was, but they have a sense of peace. I think that's what people look for when they're closing that chapter.

Speaker 1:
1:01:04

Yeah, absolutely. That's a good point to make, because I think a lot of us, if we're faced with that, it is a really hard thing to kind of find peace with. But if you know that you've done everything that you possibly can with a really good provider, I think there is a sense of peace there Not to say that there's not grieving that happens because I think that's always going to be the case but I do think to have peace, knowing that you did your absolute best to fulfill that dream and that desire. Dr Whitaker, thank you so much for joining me today and just taking the time. Oh, yeah, I mean, this is not an easy topic to talk about and you make it so much easier to highlight this in a way that gives good information. So thank you so much for taking the time to do that.

Speaker 2:
1:01:56

Yeah, so happy to help. Definitely very close to my heart this issue, so thank you for talking about it Absolutely, and until next time, everyone continue advocating for you and for those to help. Definitely very close to my heart this issue, so thank you for talking about it absolutely and until next time, everyone continue advocating for you and for those that you love.