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Playing the Lottery: Egg Count

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We’ve all been there before: lying in bed, listening to the local newscaster call out the Powerball numbers, hoping this may be your night! And while you may be a lottery regular, most of us hold out on playing until the pot is big. Really big. And if it gets super big, you might not only buy one ticket, but go in with your officemates for a bunch of them, because the more tickets you have, the better your chance of hitting the jackpot. The same can be said for egg number and good-quality embryos—the more eggs that are retrieved, the better your chance of having a baby!

Whether you’re an IVF newbie or have been through many retrievals, you know that numbers matter. Whether it’s from your fertility Facebook group or your fertility doctor, the numbers are a big deal in the land of fertility treatment. Not only does lower egg count reduce your chances, but also for many women, lower egg quantity is often linked to lower egg quality. For most women, both decline with age, and when low, make having a baby much harder.

Therefore, the more eggs that are produced during an IVF cycle (thank you, hormone shots!), the more embryos that can be created in the lab. The more embryos, the better the chance of having a baby. In many ways, it’s no more complicated than simple math. More leads to more leads to best leads to BABY!

And while the daily shots are no one’s idea of fun, they’re actually pretty essential to the process. The fertility medications serve as the “multiplier” in this mathematical equation—they take what’s already there and make them grow! Without this stimulus, it’s nearly impossible for the ovaries to produce multiple eggs.

So, although it’s fairly unlikely that any of us will even come close to winning the lottery, for many, it’s pretty likely that we’ll win the baby lottery. Because in the egg Powerball, even when you buy only a few tickets, with the right fertility clinic and fertility doctor, you have a serious chance of winning! And while we never encourage cheating, this is one place where a little help counting your cards (a.k.a. your doctor) is strongly recommended. Winning this game requires a strong and supportive team!

The 5 Most Important Questions to Ask When Looking for a Fertility Clinic

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While fertility clinics aren’t as prevalent as Starbucks and Duane Reade in New York City, there are definitely many options to choose from. From uptown to downtown, the east side to the west side, you have a choice. And unless your BFF or your OB/GYN points you in a certain direction, deciding where to direct your care can be difficult. Whom you see and where you go can be the difference between walking away with a baby and walking away with nothing more than a big bill.

Here are the five questions you should ask before deciding where to do your thing!

  1. Success Rates:
    Fertility medicine is moving fast. To quote our friend Ferris Bueller, “Life moves pretty fast…if you don’t stop and look around once in a while you could miss it.” The same goes for fertility treatment! As a result, you need to make sure wherever you go for treatment not only knows this but also practices fertility medicine on their toes. Being up to date with the newest techniques and latest procedures translates into success. Furthermore, you want to check the success rates of the clinic you are visiting and what they are doing to get those success rates—say, are they putting in multiple embryos to get a pregnancy, or can they achieve those success rates with a single embryo transfer? Although your goal may be to have a brood one healthy baby at a time is the safest way to go.
  2. Practice Styles:
    While we all went to medical school followed by a residency and fellowship to become board-certified Reproductive Endocrinologists, the way physicians practice medicine can be very different. Some are talkers, and some are quiet. Some like to chat on the phone, and some prefer to email. Some move fast, and some move slow. Make sure that whom you select as a doctor matches your needs and personality. These partnerships can be lengthy; you want to make sure you find someone who has the “death do us part”-type of feel. While you can certainly get a divorce if things get rocky, starting over puts you back at square one (minus some valuable time).
  3. Take a number; we’ll see you in an hour:
    Unfortunately, many fertility clinics have started to resemble factories. Patients are shuttled in and out like cattle going down an assembly line. Waiting rooms are littered with patients, and you can go an entire IVF cycle without seeing a physician who knows you by name. Before you commit to a specific center, ask around about how the clinic functions and what previous patients who have been treated there have experienced. While it may not change your decision about where you decide to be treated, it will prepare you for what lies ahead.
  4. Availability:
    We all have busy lives and schedules. Trying to squeeze in time to chat with your mom can be a challenge. Therefore, it’s important that you know when both your doctor and fertility clinic will be available not only to speak to you but also to see you. Just like personalities, you want to make sure that your schedule can effectively merge with their schedule.
  5. Honesty is key:
    Sugarcoating the situation when it comes to your ability to have a child can become a “sour” situation. You need to make sure that the physician you are seeing is honest with your prognosis, the chance of the treatment being successful, and the clinic’s ability to help you achieve your goal of having a baby.

     

If Your Friend Jumped off a Bridge, Would You Do It, Too? Altering your lifestyle for fertility.

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How many times do you remember telling your parents, “I did it because Susie did it”? And how many times do you remember your parents saying, “If Susie jumped off of a bridge, would you do it, too”? This usually was met with a muffled “no” and a trip to your room. Bottom line, the “because my friend did it” response never got you anything more than a grounding. And while our moms may no longer discipline us, our doctors do. And telling us that you have picked up bad habits because Susie has them is not going to go over well.

Saying that habits are hard to break might be the understatement of the century. They become a part of us, our routines, our cultures, and the essence of who we are. Whether it be smoking, drinking, drugging, or doing lots and lots of exercise, they become a part of who we are and how we see ourselves. Because of the latter, it makes them really hard to taper or totally take out. Even the best of habits (exercise, eating healthfully, or engaging in some sort of activity) can become excessive, and while they may not need to be eliminated, they may need to be reduced.

Substituting is a great concept and often works well. For cardio junkies who can’t turn up the torque during IVF stimulation, we recommend a long stroll in the park or an inclined walk on the treadmill. You don’t have to lie on the couch and eat bon bons (although it is nice to give yourself a break!); you can still do something that will build a sweat.

While some habits can be halved or quartered, smoking and drug use need to be out out completely. There is no healthy amount of smoking or toking; it’s got to go. It’s not good for your ovaries or any of your vital organs, so take this as an opportunity to go cold turkey.

When it comes to alcohol, we are definitely more lenient. I think someone said a glass a day will keep the doctor away. Although this is probably more wishful thinking than reality, a glass of wine from time to time (it even rhymes!) is nothing to stress about. You don’t have to cork the bottle when you’re trying to get pregnant.

Food is a fairly big issue when it comes to fertility. Although nothing has been proven definitively, there is a lot out there on the internet and blogs, as well as in friendly conversations, about what is best to eat. Should I can the carbs, should I forget about fat, should I say goodbye to gluten? We say no, no, and no, not unless you have been diagnosed with celiac disease (true gluten intolerance) or have been directed to follow an anti-inflammatory diet.

Dietary variety is a good thing. We need proteins, fats, and those carbs (we have such a love-hate relationship with the lattermost). While everything in moderation is the right way to go and no one ever overdosed on fruits and veggies, eliminating foods to boost your fertility probably isn’t the best idea.

What works best for you and your body may be very different than what worked best for your BFF or your pseudo BFF. As much as we may think our bodies are the same, they are not. Yes, we all have bones, brains, and muscles, but after the basics, there is a lot of variety. So while Sally had to cut out sugar and Georgia had to remove gluten, you don’t necessarily need to follow their menu plan.

Despite what you hear, fertility treatments do NOT mean you have just seen the finale of your favorite things; telephone is a dangerous game! Exercise, caffeine, and alcohol plus are okay when trying to conceive. While we may ask you to tone it down, we will infrequently ever ask you to turn it off completely. Although your friends and those who have made the fertility journey before you are a good source of information, they do not have the final word. Just because they were told to do something or had to change something doesn’t mean the same applies to you.

Don’t Break My Heart: The Impact of Fertility Treatment on Heart Disease

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Be still, my beating heart: Does fertility treatment increase your risk for heart disease? The latest results from a large Canadian study made everyone’s heart skip a beat with its recent findings. The data showed an increased risk in heart disease in women who required fertility treatment to get pregnant. And while this study got a lot of press, before you have a heart attack, here are five things that you should know:

  1. Even with the increased risk reported in the study, the absolute numbers are very low (a.k.a. the number of women who experienced cardiovascular events was pretty small). While we aren’t turning a blind eye or a deaf ear to the results, we are interpreting them with caution.
  2. IVF in the 1990s and IVF in 2017 are VERY different. The treatment protocols and techniques have changed more than the fashion trends (#bellbottoms). Therefore, it’s nearly impossible to study the aftereffects of treatments given then to the aftereffects of treatments given now. Our medications are different, our stimulation styles are different, and our dosages are different. In fact, it’s hard to find anything that’s the same!
  3. When analyzing any research study, it’s important to distinguish between correlation and causation. Although they may sound the same and start with the same letter, they are very different in what they suggest and what they mean for you. When you think of causation, think of cigarettes and lung cancer: We all know cigarettes cause lung cancer. When you think of correlation, think of cigarettes and infertility. Cigarettes do not specifically cause infertility, but they have been associated with infertility. In this study, fertility treatment has been correlated with heart disease (to a modest effect), but fertility treatment has not been demonstrated to cause heart disease. And although the distinction may seem insignificant, it’s actually pretty important!
  4. Anyone who is going to undergo fertility treatment should be in good shape. While you don’t need to join us for regular 5:30AM workouts, you do need to be in good health. Pregnancy is no walk in the park; you want your body to be prepared for those nine months and the many months that follow!
  5. The primary outcome studied was “adverse cardiovascular events.” The authors lumped stroke, TIA (think of it as a temporary stroke), MI (a.k.a. heart attack), and heart failure altogether. And while they all may affect your heart and your brain, they are not all the same. By opening up the floodgates (or adding more diseases to the primary endpoint), you will almost certainly capture more women who fall into the “I got that disease” category. So, while more women who took fertility medications may have gotten the primary outcome, the primary outcome was pretty expansive.

Your heart is as important as your ovaries, your uterus, and your fallopian tubes to us fertility doctors. While we may seem to have a one-track mind (#makingbabies), we are not only focused on your fertility but also your future health. Therefore, we will keep following the latest scientific breakthroughs and bring them to you hot off the press. We cross our hearts!

Where to Place Your Bet: The Difference Between Egg and Embryo Freezing

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Who doesn’t love a good pre-game? Standing in a parking lot with the sun beating down on your back, relaxing with your friends: life couldn’t be better. While you may don a Giants jersey and your friend Eagles green, your pregame rituals are pretty much the same. Good food, good drinks, good times. When you enter the stadium, that’s when things start to change.

The same can be said for the difference between freezing eggs and freezing embryos. The “pre-game” part is pretty much the same—you take injectable gonadotropins (hormones) on a daily (sometimes twice daily) basis. This doesn’t change whether you are freezing eggs or embryos. Additionally, in both cases the medications and the morning visits will most likely start with the start of your period and go on for about 10 days. Therefore, in terms of the stimulation (a.k.a. the pre-game process) the two are pretty much the same. It is not until the eggs are retrieved that you run to opposite sides of the field.

If you’re rooting for team egg freeze, here’s what your game plan will look like once we start to play ball. Shortly after the eggs are retrieved, they will be evaluated for their stage of development (mature versus immature). Those that are mature will be frozen immediately. And this is where the information about your eggs and your fertility ends. You will know nothing more about your frozen friends other than quantity. We cannot tell how many will be “good” (a.k.a. make a baby) and how many will be bad (a.k.a. do nothing). But as most American possessions go, the more, the better. Women who have more eggs frozen will have a better chance of pregnancy from them in the future.

And in the blue corner, we have team embryo freezing! For those that choose to embryo freeze, after the eggs are extracted they will be fertilized with sperm. The resultant embryos will then be watched over the next several days in the laboratory. How they grow, how they divide, and how they develop is very telling for their health. Some, if not several, will drop off along the way—those that can’t hack it in the lab would definitely not hack it in the uterus.

In many ways, the lab is like the ultimate test of survival, or natural selection. At the end of the game, you may only have a few players on the field, but these players are tough, resilient, and really know how to play the game. They have weathered the storm and are your true MVPs.

In many ways, egg freezing is like drafting a player who has demonstrated potential in college but has not yet played in the big leagues. They should be good, but you can’t know for sure. It’s also hard to survey the newbies in spring training and know who and how many superstars you’ll have at the end of the season.

In the same vein, if your ovarian reserve tests are normal and there are no red flags in your medical history, you should have some good potential in your eggs. Embryo freezing is like signing a player who has already won rookie of the year. You know more about the player’s (a.k.a. embryos’) ability to hit it out of the park because they have already been vetted. Take it one step further…if your embryos undergo PGS (also called CCS or TE biopsy—the chromosomal analysis of embryos), we have even more information about their ability to make a baby. You have vetted them in the most aggressive way possible.

For many women, embryo freezing is not even an option. Unless you have a partner or chose to use donor sperm, without a sperm source, you can’t make embryos. The lack of sperm and the ability to make embryos are NOT a bad thing AT ALL! And we definitely don’t recommend using donor sperm just to make embryos and have more information about your egg quality. In these situations, egg freezing is totally the way to go! Additionally, even if you have a partner, egg freezing may be a better option for you. Not to be Debbie Downers, but nearly half of all relationships end in divorce. So be careful about who you mix your gametes with!

If you are even thinking about freezing, be it eggs or embryos, you’re being proactive. You are several steps ahead of the game. It’s like you’re planning your roster months before opening day! Either way you do it, you’re giving yourself options and choice. And that’s really why you did this in the first place. So however you get on the field, you are here to play ball—go, girl, go!

Can’t Stop, Won’t Stop: What to Do When Your First IVF Treatment Fails

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Can’t stop, won’t stop; it’s not for nothing that this may be one of our favorite sayings. As overplayed as it might be and as trite as it might sound, it’s pretty much how we aim to live our lives, how we chose to tackle our challenges, and how we hope to make it to the end of a marathon. We push each other, we push ourselves, and we push ahead to get to OUR end.

But life is not a race, and there is no set finish line (except for the obvious one that we won’t harp on). How you end your day, how you end your career, and how you end any struggle in many ways is up to you. You set the start line, the halftime, and the finish line. Much can also be said for how many rounds of fertility treatment you decide to do and how long you continue to try for a baby.

Knowing when to call it quits can be nearly impossible. Whether professionally or personally, it’s hard to know when enough is enough. In terms of fertility treatment, specifically IVF cycles, how much is too much? How many is too many? When do you move on to something else?

A recent study from England published in a very prominent medical journal (JAMA) recently addressed this question. It got a whole lot of press and found its way into the New York Times, the Wall Street Journal, and all of the morning talk shows. It basically showed that women who hung in the game were more likely to get pregnant—quitting after a couple of failed IVF cycles was not the right move. Although they didn’t find a magic cutoff number after which patients should be told to exit stage left, they did find that nearly 70% of women under the age of 40 got pregnant after six IVF cycles. While about 30% of women got pregnant on the first cycle, many took longer to cross their finish line.

The results were less promising for women older than 40; while they also got pregnant at a higher rate after more IVF cycles, the total number did not exceed 30%. Bottom line, even though this study got as much press as a Kardashian wedding, it’s important not to misanalyze the data.

This study is NOT giving the green light to endless IVF and fertility treatments. This study is NOT saying that multiple IVF cycles are always the way to go. This study is NOT saying everyone who does multiple IVF cycles will get pregnant. This study is simply saying that, if you can emotionally, physically, and financially (unfortunately, finances come into play big time) swallow the treatment AND your doctor believes you are a good candidate, it’s okay to keep on keeping on.

Knowing when to bow out is nearly impossible. Unfortunately, there is no magic number. But here’s the CliffsNotes version from girls in the know… For starters, we use age, pregnancy history, and ovarian reserve testing to decide when enough is enough; these initial parameters can shed a lot of light about what’s to come.

Additionally, we use IVF response as a gauge of how much gas you have left in the tank—are you responding to medications, are you producing follicles, is your estrogen level rising?

Last, we use embryo development and, if available, embryo genetic testing results (PGS/CCS/TE biopsy, which tests for aneuploidy) to help patients decide whether further treatment is a go. For example, if patients have done several IVF cycles without any viable or normal embryos, we are hard pressed to recommend continued fertility treatments with your own eggs. And while no, history doesn’t always repeat itself, in these cases, it comes pretty close.

We are not dictators, czars, fortune tellers, or goddesses (although we wish we were)—and we are not afraid to admit that. We can’t tell you that more will be better; it may just cost more money, cause more physical discomfort, and evoke more emotional anguish. But quitting too early can be a real shame.

Just like in sports (from two women that love to pound the pavement!), there should always be a day for rest, always a moment to breathe, and always a time to stop. Without a break, you get injured. Without a day to sleep in, you get fatigued, and without days off from work, you get frustrated. In cases where there is no definable finish line for you or your partner, you may need your doctor to help you set it. When you collectively find that line in the sand, be careful not to step over it. Things will start to sink quickly on the other side.

The Art and Science of IVF

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As first-year medical students sitting in the back of the Mount Sinai School of Medicine lecture hall, we had no idea what to expect from the Art and Science of Medicine course. We all thought of ourselves as scientists (I mean, this was medical school!). Art was far from most of our minds. Questions like “What will this class be like?,” “Will it be lecture-based or textbook-based?,” and “Will the exams be graded or simply marked Pass or Fail?” flooded our minds. In typical Jaime and Sheeva fashion, poised with pens in our hands (we were both ferocious note takers!), we were ready to transcribe every word uttered by the lecturer to soak up and eventually memorize every piece of data shared. However, what followed surprised us: we would not be note taking, we would not be studying, and we would not be test taking.

We would learn about the art of medicine.

Art and medicine may strike some of you as odd. It did us! Medicine is a practice rooted in science and data, not color or design. The people you knew who became doctors did it because they liked facts, not pictures. However, in reality, how we diagnose a disease, how we treat a problem, and how we formulate a plan are really an art. The many available imaging modalities, medications, and surgical procedures are our colors. How we blend them to get the best outcome for you, the patient, is our art.

For fertility doctors, ovarian stimulation in particular (a.k.a. how you get the ovaries to produce multiple eggs) is our art. What protocol we select for a patient, when we increase and decrease medications, and how to obtain the highest percentage of mature, good-quality eggs is our art (not to be confused with ART= assisted reproductive technology!). Sure, we have scientific data to guide us in our decisions, but what can make one IVF cycle more successful than the other has a lot to do with the art of ovarian stimulation. And we bring you back day after day for blood draw after blood draw and ultrasound after ultrasound not because we like to torture you but because it helps us customize your design, your art.

Don’t get us wrong. There is a lot of science in what we do. The laboratory is our science. The embryologists, the culture system, and the genetic testing are science. And without the science, our art is just some strokes on a blank canvas. It takes both, the art and the science, to treat a patient and to achieve success in all areas of medicine.

So, if you ever wonder why we do what do and how we decide on treatment protocols, they are our art. And when they are combined with science, it can make a beautiful picture!

Round and Round You Go: We Hope It Stops Where You Want to Go!

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Unfortunately, it is more the norm for us to see or hear about couples (and individuals) that have undergone years of fertility treatments without success. Month after month, they take medications, inject themselves with hormones, and hold their breath as they wait for the pregnancy test results. For many of these patients, be it for medical reasons, financial reasons, insurance reasons, or misguided reasons, there is little that is changed between the negative cycles. We like to call this the merry-go-round effect: couples/individuals who continue the same ineffective treatments month after month without redirecting or reanalyzing the situation. It’s a bad situation that we want to help you change.

Let’s face it: after the same treatment, be it timed intercourse, oral medications, inseminations, or IVF, has failed continuously, something needs to change. Whether it be moving on to more aggressive treatments (or, as we say, stepping up the ladder!), tweaking the current protocol, or seeking a second opinion, you need to shake things up. There are many available fertility treatments that can be, and likely should be, utilized.

A patient-doctor relationship should be a partnership with give and take, as well as back and forth. Gone are the paternalistic days of medicine where the doctor speaks and the patient listens. Treatment decisions should no longer be dictated, but rather, discussed. If this is not happening for you and you find yourself in the merry-go-round rut, then you need to put the brakes on. Make a phone call, send an email, or sit down with your doctor to review your case. Bring your list of questions, and ask away.

If you don’t like the answers, don’t be afraid to take them and your struggles elsewhere. At some point, you have to either ask the attendant to stop the ride or simply hop off. Eventually, circling in the same direction stops being fun, exciting, or promising; it also makes you nauseous, dizzy, and loopy!

So be your own advocate, and shut this ride down. The park is huge, with so many more rides and adventures to explore.

How Old Is Too Old? The Age Limit for Pregnancy

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We have all heard the stories, seen the headlines, and talked about it over the water cooler on Monday morning: “66-year-old woman delivers twins,” “65-year-old woman delivers quadruplets,” and most recently, “72-year-old woman delivers baby” (that last one really made us stop in our tracks)! It gets us talking and gets us thinking: How old is too old for a woman to have a baby? Is pregnancy in your 60s really healthy? Is it fair for a child to be born to parents who are 60?

The questions are endless. And although we are not advocating for Congress to raise the age for Social Security or cut Medicare benefits, we do believe (as does the American Society of Reproductive Medicine) that at some point we all must throw in our reproductive towel. Here’s why.

Let’s start by shedding light on how we women in our 50s and beyond (as well as most women in their late 40s) conceive. In nearly all cases, the pregnancies have been achieved with donated eggs. By the time we hit our mid-40s, our egg supply has pretty much gone kaput. And the ones that are still hanging around often lack the ability to make a healthy embryo.

But while the ovaries have waved goodbye to most things fertility, the uterus is still hanging on. It is like that friend you had growing up who could be dared to do anything (you know the kind we’re talking about… “Dare you to eat a worm…”). The uterus is sort of a pushover for anything with estrogen and progesterone. However, like your middle school friend, just because it will do it doesn’t mean it should do it.

There are guidelines released by the American Society of Reproductive Medicine (they’re sort of like the fertility FBI) suggesting at what age people should and should not be pregnant (no matter how willing their uterus is!). This is what they have to say:

“Physicians should obtain a complete medical evaluation before deciding to attempt transfer of embryos to any woman over age 50. Embryo transfer should be strongly discouraged or denied to any woman over age 50 with underlying issues that could increase or further obstetrical risks and discouraged in women over age 55 without any issues.” (ASRM Ethics Committee)

Let us translate. What they are really saying is that it’s okay to attempt pregnancy in women over the age of 50 as long as they have really, really clean bills of health. It is not okay to transfer embryos, no matter how clean their bill of health, if they are over the age of 55. And while they don’t have your phones wired and your Internet tapped, even if you as the doctor or the patient don’t get “caught” doing this, if you violate the rules, you could get hurt.

Pregnancy complications increase markedly as women age. It can be a pretty dangerous nine months for both mother and baby. In medicine, when the risks start to approach the benefits, you have to seriously stop and consider what you are doing. Donor egg pregnancies in women who are above the age of 55 are one of those times. There is an increased risk of pre-eclampsia (pregnancy-induced high blood pressure), gestational diabetes, low fetal birth weight and, in some studies, fetal mortality. Additionally, nearly three quarters of the babies born to woman above the age of 50 are delivered via C-Section—and while we all think of a C-Section as nothing, it is a major surgical procedure.

Pregnancy is somewhat of a conundrum for us doctors. It is the first time and the only time that you have two patients AT ONCE (in the same body!). It is not only difficult medically but also ethically. Donor egg pregnancies in women who are older than 50 bring up the “fair-to-child” debate. This topic is more controversial than who you voted for this election season.

Let’s just say it’s a good thing there are curtains at the polling places and in doctor’s offices—privacy is key! And while medical ethicists could debate this topic for hours (similar to MSNBC and Fox re: presidential candidates) citing studies and data points on both ends, the bottom line is that no one really knows the answer.

There are those who say that it is not uncommon for grandparents to raise grandchildren, to provide economic support to the family/children, and to serve as the parents in a family unit, so what’s the big deal with women getting pregnant in their 50s? Is it sexist to limit a woman’s ability to have a child while allowing older men to keep on keeping on, no matter how old they are? Shouldn’t women be given the same opportunity as men?

On the flip side, there are those who argue that older parents can’t meet the physical and emotional demands of raising a child. And furthermore, there is a fairly good chance that the child will lose one or both parents at a young age—how can losing a parent or parent (s) before adulthood be fair to a child?

It’s a pretty intense debate. And while all the speaking points may get muddled in your head and you don’t really know whose side you are on, what is important to remember is the following: our jobs as MDs is to keep you informed and healthy. If we think something could hurt you, no matter how badly you want a baby, we must hold up a big flashing STOP sign. While we want to make you a parent and help you build a family, our primary duty is to keep you healthy.

When we say no, it is not because we are being ageists, it’s because we are being “aware-ists.” We are aware of what could go wrong and don’t want to see this happen to you. We won’t play truth or dare with your health. Trust us, no dare is worth it.

Putting Out the Fire: Endometriosis Treatment

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Living in New York City, we don’t usually see those forest fires some of you ladies see out West. While we watch it on TV and read about it on the Internet, those days and days of blazes are something of a foreign concept to us. However, what we have taken away from those images are the hoses upon hoses and the buckets upon buckets that those firefighters must use to quell those flames.

Endometriosis (a.k.a. endo) is to your pelvis as a big forest fire is to California. If it is not put out quickly, it can be devastating. The good news is that, just as the firefighters have many tools in their truck, we too have several potential treatment options.

For women who do not have babies on the brain, there are many “hoses” that can help put out your fire. You have both medical and surgical options. When fertility is not in the near future, shutting your own system off medically with hormonal therapy is no big deal. Most GYNs will recommend that you start basic (non-steroidal anti-inflammatory agents/NSAIDs plus hormonal contraceptives).

Go big only when the fire continues to rage. NSAIDs combined with continuous hormonal contraceptives (continuous birth control pills) are usually pretty good at putting out “smaller fires” (mild/moderate endometriosis). It doesn’t matter if you prefer the oral, vaginal, or skin (a.k.a. patch) route for hormonal treatment. They all work the same, and here, it is more a matter of preference than potency. If estrogen is out because of a medical contraindication (clots, smoking etc.), then progesterone can be given in isolation with NSAIDs.

If this concoction is not keeping your symptoms quiet, we start climbing the treatment ladder. Our next step is usually a GnRH agonist (cue Lupron) combo’d with add-back hormonal therapy (estrogen and progesterone). If this doesn’t bring things to a halt, we usually give aromatase inhibitors (think Femara) a try. The aromatase inhibitors work by decreasing circulating estrogens in the body.  Estrogen is like gasoline to the endo fire. It doesn’t take a firefighter to tell you that it’s probably not a good idea to throw gasoline on a fire!

One treatment is not necessarily better than another. Some just work better in certain people. What is different is how they are administered (oral, injection), how frequently they must be taken (daily, weekly, monthly), and how much they cost (a little vs. a lot!). You have to see what works best for you and your symptoms.

When medical treatment isn’t cutting it, surgery is an option—no pun intended. We try to reserve the bigger guns for the bigger flames; starting with surgery is usually not a good idea. In general, the basic tenant of endo is to max out on medical treatment and avoid repeat surgeries—repeat trips to the operating room do not earn you frequent flier miles. It just earns you a lot of scar tissue, a lot of risk, and a lot of anesthesia. It’s not something you want to do.

If you do find yourself needing to make that trip down the runway, make sure your pilot has been around the block several times—no first-timers here. Endo surgery is no walk in the park; you want your surgeon to be experienced.

Gynecology has gained a couple of new subdivisions in the past few years. There are now GYNs who spend years after their residency learning how to do endo surgery. Their second home is in the operating room. Let’s just say that, when you need a tour, they should be the ones to do it! There are a variety of surgical procedures that can relieve your symptoms. The specifics are above the scope of our conversation, but what you do need to know is the following. Know your surgeon, know why they are doing what they are doing, and know how many times they have done what they are suggesting you do. Trust us; it’s super important.

No two fires are exactly alike. Similarly, no two cases of endo are exactly alike. While for some, pain is the biggest problem, for others, it is GI symptoms. Because of the variability in symptoms, in severity, and in life plans (fertility vs. no fertility), the treatment plan that “puts out your fire” will likely vary. What gets you going or stops your endo from growing may be different than what helped your sister or what helps your BFF.

Although we probably won’t ever treat you, we can recommend that you treat yourself with the utmost respect. Be aware of your symptoms and what makes them better or worse. Have your GYN on speed dial—don’t tell them we told you that!—and tell them when things are not going so well. And while we don’t recommend you ringing them on weekends and in the nighttime unless urgent, you should feel comfortable calling them. If their answers are not cutting it, don’t be afraid to remove them from your contacts and find a different doctor.

Unfortunately, endo is a chronic condition. Once the treatment hoses are turned off, the fire will likely return. After your baby days are done, you may elect to undergo definitive surgical treatment (a.k.a. a hysterectomy and bilateral salpingo-oophrectomy: simply stated, ovaries, tubes, and uterus out) to ensure that you never face another forest fire. Until then, let us help you temporize the flames so that you can fight whatever fires, be it professionally or personally, that you choose to extinguish. There is nothing you can’t put out if you put your mind to it!