On this episode of The Egg Whisperer Show, I’m joined by Dr. Karli Provost Goldstein, a renowned expert in endometriosis and minimally invasive gynecology. Together, we dive into the challenges of diagnosing and treating endometriosis, a condition that is often misunderstood and underdiagnosed. Dr. Goldstein shares her expertise on why endometriosis frequently goes undiagnosed for years, the differences between surgical approaches like robotic and laparoscopic surgery, and the connection between endometriosis and infertility.
We also discuss how to identify experienced endometriosis surgeons, the role of lifestyle changes and medications in managing the condition, and the importance of fertility preservation for patients with endometriosis. Plus, we answer viewer questions, exploring topics like the relationship between endometriosis and ovarian cancer, genetic risk factors, and the best ways to manage symptoms and navigate treatment options.
Here’s what we cover in this episode:
- The complexities of diagnosing endometriosis and why it’s often delayed
- Advances in minimally invasive gynecology for treating endometriosis
- The critical role of fertility preservation for patients with endometriosis
- A comparison of robotic and laparoscopic surgical techniques
- The link between endometriosis and ovarian cancer
Resources:
Dr. Karli Provost Goldstein’s website: Esse Care
Dr. Karli Provost Goldstein on Instagram
Get Dr. Aimee’s Fertility Essentials
Join The IVF Class with Dr. Aimee
Full Transcript:
Dr. Aimee: I am going to be talking to Dr. Karli Provost Goldstein today. It would be weird for me to say I’m excited to talk about it, but what I’m excited about is that there are doctors like her, doctors who will listen to your symptoms and try to solve problems. She’s an endometriosis expert, she’s a surgeon, and she performs fertility restorative surgeries. I’m really looking forward to having her share a lot of her wisdom with us.
Hi, Karli. How are you? Can you just share a little bit about yourself?
Dr. Karli Provost Goldstein: I am an endometriosis surgeon. I do minimally invasive gynecology. I also do wellness and functional medicine for patients after surgery and before surgery, patients on a fertility journey, in menopause, and I have a collaborative team that I work with in nutrition, with acupuncture, even hypnotherapy, physical therapy, and just really pool all of the resources around patients so they have the support they need whatever their journey is, whether it’s gynecology, menopause, endometriosis. I don’t do obstetrics, but I do these other things.
Dr. Aimee: Where can patients find you, where do they see you?
Dr. Karli Provost Goldstein: I’m in New York, Connecticut, New Jersey, and I also operate in California in the LA area.
Dr. Aimee: I am going to be talking to Dr. Karli Provost Goldstein today. I have patients that come from all over, West Coast, East Coast, and it’s great because they can see you, they can get consultations, they can talk to you, they can go and see you whether in California or New York. I think that’s fabulous. Thank you for making yourself so accessible.
Let’s talk about endometriosis. Why is it so underdiagnosed?
Dr. Karli Provost Goldstein: It’s quite difficult. We talk about this all the time. It takes about ten years, unfortunately, there’s a delay to diagnosis for most endometriosis patients, which is awful. Endometriosis in early stages (stage one and two) is not visible on most imaging, on MRI and ultrasound. There’s a couple of clues they can find on MRI, so we often do a pelvic MRI before surgery just to see if we can see any of those clues. Most endometriosis that is in its early stages will not be seen on imaging, so it’s very difficult without having any real tests to point to before doing a surgery.
Most gynecologists or OBGYNs that are seeing patients will say, “You may have endometriosis, you likely do with your symptoms. Let’s do some birth control or some medication. There’s nothing to do about it.” Or, “We don’t recommend surgery. Let’s do meds.” Unfortunately, a lot of patients are not really given a true diagnosis for many years until they go through the gamut of medications, and they don’t feel well, they miss work, they miss school, they have surgery that didn’t really help, they go through multiple things before finding someone that really specializes in endometriosis.
Dr. Aimee: Do you feel like we’re seeing more patients with endometriosis now than we did 10 years ago?
Dr. Karli Provost Goldstein: I think so, but I think as the awareness picks up and people are talking about it more, then people are saying, “That sounds like me. I do have problems with my cycles,” and they’re looking into it more. That’s been great.
Dr. Aimee: Right. I think what’s frustrating for me is sometimes patients report their symptoms, they go to someone who they think is an expert, and that person is not really guiding them in the best way. They have surgery, for example, with someone who is not an excision surgeon and they’re not getting the right kind of surgery. Can you talk about how patients can look out for themselves? How do they know if the person they’re seeing is really the right provider?
Dr. Karli Provost Goldstein: That’s a great question. Unfortunately, every major academic institution has an endometriosis center now, and it’s very hard because you trust these big names and you often do think they’re the best. The reality is there’s lots of quick tips for patients that are seeing a consult with an endometriosis surgeon or a department. It’s good to ask them how many surgeries they perform in a day, how often they do endometriosis surgery, if they’re doing this every week or a couple cases a year. How many surgeries they do a day, what happens if the endometriosis is more involved than they plan, do they intend to have colorectal and urology and other surgeons on standby in case it’s necessary.
I think that’s very important and it speaks to the team that’s involved. There should always be a team available even if they’re not in the room. For my patients, especially with extensive disease, the team is in the room. For my patients when I suspect mild disease, they are always down the hall. That’s very important because otherwise patients will have incomplete surgery and they’ll say, “We saw endo on the bowel, we saw endometriosis on the bladder and the ureters, but we just took a few biopsies from the pelvic side. You should be fine. Let’s go back on birth control.” That doesn’t really help.
There’s a lot of incomplete surgery that’s happening. There’s surgery where patients are consenting to have their ovary removed in case things go bad. That’s a very bad sign. I never consent my patients that I’m going to likely remove an ovary, unless that’s their intention and they’re close to menopause and they want that. There’s not an emergency that I can’t control, knock on wood, surgically with suturing the ovary and controlling bleeding that I should have to remove the ovary. Unfortunately, this is happening at a young age. They get into bleeding and they take the ovary out. That’s not a great sign.
Those are things that you can ask. The workup ahead of time, if they’re really doing extensive imaging, MRI, bowel workup, bowel prep, these are all signs that person is experienced with endometriosis and they know that it involves the bowel all the time and they might get into trouble, so you prepare the patient accordingly. I would say if things are not well planned and they’re acting like the surgery may take five minutes or 30 minutes, that’s a very bad sign for endo surgery. Typically, the minimum time is about an hour and a half to two hours if you’re being very thorough.
Dr. Aimee: What’s involved in the surgery, what actually happens to the patient? You hear things like robot and laparoscopy. What’s the difference between the two?
Dr. Karli Provost Goldstein: It’s minimally invasive surgery either way, robotic camera and laparoscopy camera. Laparoscopy has two different size cameras, 5 and 10 millimeters. Robotic cameras are 8 millimeters, so kind of in between the two. Hopefully, soon there is a new smaller robotic camera coming out, which should be cool.
How I like to explain it is they’re both a minimally invasive approach with small incisions. The robotic camera is being held by the robotic arm, so the platform itself is very steady. I can control the robotic camera with my foot pedal, so I can zoom in on whatever I want to see and have very fine control over that. The laparoscopic camera has to be held by an assistant surgeon, whether it’s an attending surgeon, a resident, or a PA, so there’s less control by the primary surgeon on the camera itself because you have to tell that person what moves to make and what to do next.
That’s the only thing. The team is great regardless. If you really like your assistant surgeon, then it’s perfect. But that can be a little frustrating at times if the camera hand is shaking or you need to go a certain place and someone is looking another place. That’s the difference with that.
Dr. Aimee: Do you have a preference?
Dr. Karli Provost Goldstein: I have been using robotics more lately. I can sit down and operate, so on long cases that take six to nine hours, it does help me at times to be able to sit down. When I had surgery and I was in my own recovery, I could still operate sitting with the robot. Endometriosis can famously be anywhere from two hours to nine hours, so it is a nice platform to be able to use. I am learning that with robotics I can have a PA in the room and not have as big of a team because I’m self set up and the team can all be nearby if needed and on standby. That’s great.
Dr. Aimee: Why do you work so closely with fertility doctors, what’s the connection between endometriosis and fertility?
Dr. Karli Provost Goldstein: You can correct me if I’m wrong, but endometriosis seemed to cause unexplained infertility where you can’t find out the cause, you have normal fertility labs, and they’re coming to you and everything seems perfect and we don’t know what’s happening and why they’re not getting pregnant. In those patients, we can see 40–50% of them may have endometriosis. In fertility patients, it’s often called silent endometriosis. A lot of the patients don’t have symptoms. I sometimes find a deeper probing, literally, with the sonogram, no pun intended, and with intercourse they do have symptoms, but just kind of pushing down their symptoms a little bit. Their goal is to get pregnant, so maybe the symptoms take the back burner.
Dr. Aimee: The way I think about it is it robs young women of their fertility. You can think you have fertility levels of someone your age, and then if you have endometriosis, it makes them act biologically older than your chronological age. It can also affect implantation. It certainly is one of the most common reasons behind “unexplained.” I hate that term. Unexplained is it could be endometriosis, so they need to find someone like you.
If someone is suspecting it, but their fertility doctor doesn’t believe in it, are there signs that you can see on ultrasounds, like the way the uterus is tilted or how they ovaries are maybe attached to the uterus? Are there any things that are telltale signs that someone might have it?
Dr. Karli Provost Goldstein: Yes, definitely. We can see ovarian attachment to the back of the uterus so the ovary doesn’t move with ultrasound. That’s a very good sign that there is adhesive disease around the ovary, whether or not it comes from endometriosis, that the ovary may be stuck and very painful when they’re going to get their ultrasound. We can also see abnormalities in the uterine cavity, so heart-shaped or arcuate uterus, didelphic, bicornate, any kind of uterine anomalies that happen from birth are higher risk of endometriosis, so that’s a little clue. A lot of patients may have retroverted retroflexed uterus and a lot of pain. Any kind of slight shift or abnormality with the uterus could put them at higher risk, we can see that on ultrasound.
We can see sometimes rectovaginal nodules on ultrasound if the stenographer is good. We can see a lack of what we call a fat plane or space between things, and that can signify that things are stuck. You can also palpate some of this if it’s at the back of the vagina. We can also cysts on the ovaries, endometriomas. We can see disease inside the uterine walls, adenomyosis, which is a sister disease of endometriosis where there can be more cystic lesions within the walls of the uterus that could be a sign of disease.
Dr. Aimee: What about for patients who are really scared of surgery? I have those patients that under no circumstances do they want to go into the operating room. Is there anything that they can do with lifestyle or medications that you think could be helpful?
Dr. Karli Provost Goldstein: Do you mean for fertility or just for life in general with endo?
Dr. Aimee: Life in general with endo and fertility.
Dr. Karli Provost Goldstein: For general endo patients, if they’re worried about having surgery, I do work a lot with acupuncturists. They can try hormonal birth control to reduce the amount of bleeds that they have in a year, do continuous birth control that’s often given. There can be a certain type of medication that we take before the period to reduce the amount of uterine cramping they have with a cycle. Then acupuncture, low inflammatory lifestyle, low inflammatory diet, finding out their food triggers, what bothers them, and working to reduce those, reducing processed foods, added sugars, colors and dyes, the chemicals that we’re putting in ourselves and our diet, can help reduce some of the symptoms.
I like to say that especially the week before the period, if you focus on the low inflammatory things in that week, and the yoga, and the deep breathing, and the right diet, that can help your upcoming period to be a little bit less painful. I do see a lot more painful cycles after the holidays, for instance. That’s when I think a lot of indulging is happening, everyone does it, but I can see that the sugar and inflammatory foods can cause an uptick in the pain afterward.
Dr. Aimee: Your patients who have had surgery, do they have to worry that it’s going to come back and they’ll need more surgery? How often does that happen?
Dr. Karli Provost Goldstein: I see patients down the road, typically, in their 40s or so. By that point, if they come back, typically they’re coming back for the uterus itself. If I come back and do a hysterectomy for someone that’s already been through their fertility years, they’re done having periods, they’ve had their kids or decided not to have them, at that point when I go back and do a hysterectomy, I find very little recurrence of endometriosis, maybe one or two new spots. The overall recurrence is quite low.
There are some subset of patients, obviously, that have a more aggressive disease. They may have more increased recurrence. Also, estrogen stimulation can cause a recurrence or an uptick in lesions or disease. That’s why it’s very important with fertility experts and sending them to someone like you that does modified protocols and watches what’s happening to the patient and monitors them over time. Basically, even in menopause treatment for endometriosis, we don’t want to give unopposed estrogen because that can be a stimulant for disease if they’re not balancing the hormones out for menopause.
All of these things are important things that could cause a recurrence. Obviously, if the patient is really symptomatic, I always believe them and we always look into try all of the different things first. Nutrition, acupuncture, pelvic floor therapy, exercise, all the different things we can do first. If all of those are not working, then we may look back at that time, but I don’t typically have to look in every year or two.
Dr. Aimee: Do you recommend fertility preservation, freezing eggs or freezing embryos, for patients who haven’t gotten pregnant yet but they’re coming to you for endometriosis?
Dr. Karli Provost Goldstein: I think it’s a great option. It’s something that I wish I had when I was 20 that I did not have. I went through this whole journey with endometriosis and infertility. By the time I was diagnosed with endo, I already had ovarian failure, so it was already on the fast track. I think that is a tool that we have now that we didn’t have 20 years ago even. It’s something very important that if we diagnose endometriosis at a younger age, I like for them to have a fertility consult and at least have that as an option, have awareness about it and know their options with that, and then plan it timely if they’d like to, before their 30s, if they have the option to do that. Just not be scared, but be well informed.
I think that’s really important, considering what are their goals, what would they like to do in the future, are they going to go to medical school and be in school for 10 or 12 years. These are important questions. I think it’s a great idea to have a fertility consult at a young age.
Dr. Aimee: When someone wants to have their fallopian tubes removed and they go to the hospital, they have to sign sterilization consent forms. I feel like when someone goes in for an endometriosis surgery, especially because we can’t vet every single surgeon out there, because they could remove an ovary, I feel like there should be a fertility preservation consent form that they sign saying, “I’ve been told that going through surgery could potentially reduce my ovarian reserve.” It can, especially when you’re removing big cysts. I often wish people would get their AMH levels checked before surgery, find out what they are, depending on the level, get their eggs frozen first, and then do endometriosis surgery, because the IVF stim can also stimulate endometriosis.
Dr. Karli Provost Goldstein: Absolutely. It’s important you say that. ASRM doesn’t even say that stim can cause endo. The fact is I’m always happy to coordinate that. You do the egg retrieval first and then we go up and do damage control and cleanup afterward. Then if there was endometriomas, I’ve seen very talented reproductive endocrinologists retrieve eggs without rupturing the endometrioma or very little rupture, and then if we time the surgery quickly after, we can go and remove the endometrioma right after without it rupturing all over the place. I think the timing is very important.
When patients are interested in fertility, I’m happy to send them. I do a full fertility workup and hormone workup for all of my patients, even if they’re not interested in fertility. I always do a hormone panel with thyroid, check their vitamin levels, check their CA125 marker for ovarian inflammation, and that can be elevated in endometriosis, and I check their AMH. Then I like to follow them post-op with the same things to see how we’re looking afterward.
Dr. Aimee: What CA125 threshold are you looking for, what would you consider positive? That’s scary when people Google CA125, they see it’s a cancer test, and if it’s elevated, they freak out. What is elevated for endometriosis patients?
Dr. Karli Provost Goldstein: Anything above 35 is considered elevated in most labs. With endometriosis, I often see 40s or 50s. With big chocolate cysts, I can see levels in the hundreds. I’ve even seen severe adenomyosis with levels above 300s and 400s. Typically, a visit to the oncologist is promoted at a level above 200, but I have seen plenty of endometriosis cases where the levels are close to that or even above it and it’s all endo and adeno. I’m happy to collaborate with the GYN oncologist, send them for a consult, and let them say, “I’ll be nearby if you need me, but this looks like endo.” Then everybody is reassured, we do the case and move on if needed or do it in conjunction with them if necessary.
Dr. Aimee: Is there anything genetic about endometriosis? If my mom had it, am I at higher risk of having it, too?
Dr. Karli Provost Goldstein: Yes. We think that in twin studies there can be about 50% chance that the daughter-offspring would have endometriosis if the mother had it. We also see it closely related in aunts, cousins, and other family members. If the patient has a family history or if someone says, “My mom had a hysterectomy. I don’t know if it was endo, but her periods were terrible. My grandmother did, everybody in my family had their uterus out,” that’s a big sign that something was going on. Or a history of miscarriage, a history of infertility, trouble with pregnancy, difficult or complicated pregnancies, those all can be signs of endometriosis in the family.
Dr. Aimee: I just want to be clear. If you have endometriosis, it does not mean you cannot get pregnant. There are people with severe diseases who are able to get pregnant. Can you tell us a little bit about that?
Dr. Karli Provost Goldstein: That’s what I always want to be clear with patients. Just because we have severe disease or a very low AMH or something, it doesn’t mean it’s impossible. There are many patients that will get pregnant with endometriosis and carry to term and deliver with uncomplicated and healthy delivery and they’ll be okay. We can’t say that because you have endometriosis you’re doomed. We don’t need to say that. We don’t need to scare people into surgery just saying things like that.
I certainly think it is a cause for thinking further about the situation, having the fertility workup and knowing all of their options, and just being more informed about everything.
Dr. Aimee: Let’s talk about the fallopian tubes a little bit and what endometriosis can do to the tubes. When my patients have tubal factor, I don’t think that they got that from chlamydia. It’s most likely scarring from endometriosis. There’s also this connection between endometriosis and ovarian cancer that I don’t think people really know enough about. I don’t think OBGYNs when they do an endometriosis surgery are saying, “When you’re done having kids, be sure to remove your fallopian tubes to reduce your risk of ovarian cancer.” Can you talk a little bit about the role of the fallopian tubes and then a little bit about ovarian cancer?
Dr. Karli Provost Goldstein: Absolutely. With endometriosis, I have seen fallopian tubes where a fertility patients comes and they have a hydrosalpinx or a fluid-filled fallopian tube, and it prompts their fertility doctor to say can you look at this patient, check them out for endo, or can you remove that tube for me. That’s part of that fertility restorative surgery that I do.
Even if they don’t have endometriosis, I will look inside if they’ve failed a lot of rounds of fertility. I’ll look inside and do a very good hysteroscopy video, take pictures of the whole thing, test the endometrial lining for chronic inflammation, flush the fallopian tubes, check them inside and videotape it with laparoscopic or robotic, put blue dye in the fallopian tubes to check and see that they’re working. If they’re not working or if we see a very strong delay, I investigate all around the tube, see if it’s swollen. I’ve seen hydrosalpinx where the tube is completely twisted and caught under the ovary with a bed of endometriosis there.
I do think that a lot of times these tubal factors there is something happening inside the pelvis. That’s quite common. I like to say when we have something like that happening on HST and you’re having trouble, not investigating inside the abdomen and the pelvis is kind of like buying a house because you see a blue door and you love that blue door and you never look inside the house and never do an inspection. That’s kind of like doing a pelvic exam for infertility and never looking inside the abdomen if the patient is repeatedly failing. There are so many ways and things that can happen around the ovary, around the tube, around the back of the uterus, around the rectum, all around the abdomen that can cause inflammation and affect that egg quality, that transport up the tube and transfer into the cavity for a successful pregnancy. There are a lot of little steps along the way that could be affected and that we can help with.
With ovarian cancer, there’s new data coming out as of July this Summer that the advanced cases of endometriosis stage four, deeply infiltrating disease, are associated with 18-to-19-fold increase in ovarian cancer. It’s still quite rare overall, ovarian cancer associated with endometriosis, and that’s important to remember. The ones that are associated with it are quite hard to treat, so it is better to have everything removed at an earlier stage, obviously. Removing the fallopian tubes is a great strategy. That is risk-reductive surgery and that can reduce the risk of ovarian cancer by at least 20%. In someone with endometriosis, it could reduce pain or inflammation of the endometrial cavity if they’re having trouble with implantation.
These are options that can be considered. I always talk to patients that when they are nearing menopause, we talk about risk-reductive surgery as an option for them if they’ve had a family history, they’re concerned, or they really don’t want to deal with these things years and years further into menopause.
Dr. Aimee: How would you react to a patient that comes to you and says, “My fertility doctor does not believe that endometriosis impacts fertility.”
Dr. Karli Provost Goldstein: I would say get a new opinion. I think it’s very important that patients have a second and third opinion with fertility. There’s so much to learn and so much creativity. Even for my patients on the East Coast, I say, “Why don’t you see Dr. Aimee and just have another opinion?” It’s like having another opinion and another way to cook something. It’s so important to have creativity in the field and to try different options and not just be doing the same protocol ten times in a row.
I find patients with endo respond well with natural embryo transfers where they let their body clear of the hormones and then they don’t have as much estrogen stimulation. Many patients have success with that after a lot of failed trials. Thinking all different ways around the endometriosis and the hormone response is very important.
Dr. Aimee: You’re a lot nicer than I am. I say they’re wrong. We have enough data to show that it absolutely impacts fertility.
I’ve gotten a lot of really nice questions sent in, so I’m going to start reading them. Someone said, “I just finished Letrozole, Depot Lupron a month ago. Period has not come. Doctor prescribed Provera. Finished five days ago, still no period. I’m scared it’s not coming back. Thoughts?”
What I would say there is I don’t know what you’re waiting for in terms of the period. If your goal is getting to a frozen embryo transfer, you don’t need to wait for a period. You can just go right into your transfer prep, either doing a controlled cycle, I also prefer a modified natural cycle, but I don’t need to wait for a period. Waiting for a period can take a really long time. Don’t you think?
Dr. Karli Provost Goldstein: Absolutely. They can always do a sonogram to check if the lining is actually thickened or if the lining is thin and they’re still suppressed by those. Then that gives a clear answer that there’s nothing really to worry about, the lining is still suppressed, it’s still thin.
Dr. Aimee: Exactly. I find when doctors tell their patients they have to wait for a period, they clearly don’t have enough experience with these medications to guide patients because waiting for a period is counterproductive because you’re waiting for an ovulation, and that’s just more time that has passed.
The next question says, “Is it true that once you have endo it never goes away completely, even after an excision surgery?” What would you say to that?
Dr. Karli Provost Goldstein: I would say it’s not necessarily true. It depends on the surgery that you have and if you really try to get to the root of all of the disease. I’m a very good example, I had a lot of endo surgery myself. I did years of IVF and years of infertility treatments. I’m happy to say that the last two surgeries I had, one for the uterus itself, there was really no endometriosis recurrence in my own case. In a lot of patients, I do see that.
I don’t think that you’re doomed to have endometriosis forever. I think that sometimes you may still have a sensitive bowel for certain issues, inflammation and things that you react to stronger with the bowel. There are other things systematically that can happen that make people feel like it’s endo back. It’s not always necessarily a recurrence. Again, some patients genetically have a stronger chance of recurrence, and they have a more aggressive disease to start with.
Some patients have a very aggressive disease and they still want to get pregnant, so they say, “I don’t want you to do anything drastic. I don’t want you to take any blood supply to the uterus or take any blood supply to the ovaries,” so there is a little bit of disease left there, 5–10% of the disease is left, and then we go on to try to get them pregnant and work together with you, but we know there is still residual disease. That’s very different from having a recurrence.
Yes, there are patients that can have recurrences. I would say that’s not the norm. I would say 80–90%, and this is my own experience with patients, not a study, most of the patients I see do not have a big recurrence. But there are some patients that have very deeply infiltrative disease into the rectum, the posterior vagina, the other organ systems that probably, I think being totally honest, they probably have some residual small disease somewhere.
Dr. Aimee: What about adenomyosis? The next question is can you do surgery for adenomyosis?
Dr. Karli Provost Goldstein: I would say that’s a big if. You can do surgery for it, yes. That’s the short answer. Should you do surgery for it? That’s a more complicated answer. I think that in that case I always like to work together with a team. I would certainly go in on those cases to look for endometriosis, excise all of the endometriosis, look at the tubes to make sure they’re okay, look at the environment, do a good hysteroscopy.
As far as adenomyosis itself, if the adenomyosis is diffuse and all along the back wall or the front wall of the uterus, you cannot go and excise 20 focuses of adenomyosis and have enough healthy uterine wall to repair. There’s always a risk versus benefit for adenomyosis surgery. If there’s a solitary focus of adenomyosis or an adenomyoma, sometimes this can be easy to take out and repair. Or if it’s close to the surface of the uterus, then that’s okay. If it’s very deep adenomyosis, I do find that those patients do better with a suppression protocol with their fertility doctors rather than going in and aggressively removing it and repairing it, and then the uterus does not heal well and puts them at risk for uterine rupture.
Dr. Aimee: I agree. Next question says, “If someone has stage four endometriosis and had a laparoscopy, should the individual plan to repeat surgery? If so, how soon?”
If they had it removed, should they plan on one day needing another surgery?
Dr. Karli Provost Goldstein: I don’t think you have to plan on that. I think that depending on their goals with fertility, what they do and when their symptoms occur, and if their symptoms never come back, then maybe they don’t need anything else, or they’re a candidate for risk-reductive surgery down the road.
I like to follow my patients once a year with an ultrasound. Even if they’re back home or somewhere else, I give them a prescription for one and they go for an ultrasound. We’re just checking on the ovaries and the uterus, making sure everything is okay.
Dr. Aimee: The next question says, “What about Letrozole and Depot Lupron before embryo transfers?” I offer patients three types of suppression. Orilissa with Letrozole, Norethindrone, Letrozole with Norethindrone, Depot Lupron, and then for patients who are worried about the mood side effects, birth control with Letrozole. Does that sound pretty similar to what you would recommend?
Dr. Karli Provost Goldstein: Yes. Definitely those severe adenomyosis cases, there is better data on that for a three-month suppression protocol and add-back therapy. I like to say the data for endo is a little bit more murky on how much benefit it has. I do see higher rates of success with actually excising the endo and then doing your protocols, whereas adeno, that suppression can really work.
Dr. Aimee: The next question is, “For early stages of endo, can medication treat it, or is laparoscopy the only way to completely treat it?” I get that question a lot. Again, people want to avoid surgery, so they’re thinking they’ll do medication instead. Is that as good? What do you think about that?
Dr. Karli Provost Goldstein: Medication does not remove endo. Medication can suppress the symptoms of it and turn the lesions maybe to a white color and don’t have as much pigmented bleeding in the lesions at that time, so it can kind of deactivate the lesion for a little bit. But it does not remove the lesion. The only way to remove the lesion is to actually remove it, to pick it up and cut it out. Lupron, Orilissa, and these long-term medications may suppress the symptoms for a while, and they may buy patients some time if they’re planning something, but they’re not magic fairy dust, they don’t just get rid of all the endo. I wish they worked that well. Unfortunately, sometimes they have a lot of side effects, and they don’t actually remove the disease. I always outweigh those things with my patients.
Dr. Aimee: Someone is asking, “What are the effects of PRP for people who have stage four endo and high FSH?” I’ll just answer that and say I have definitely treated patients with ovarian PRP with both of those things to see an improvement, but there’s no guarantee that it could work for them.
I have a nice comment here that someone sent in, “My life post-surgery is so drastically improved. In the right hands, surgery can be so life-changing. Thank you, Dr. G, and thank you Dr. Aimee for helping me find her.” That’s a very sweet comment.
Here’s a question, but we kind of already addressed it. “I recently saw an article that people who have advanced endo have a much more increased risk of ovarian cancer. What can we do to mitigate this risk?” That’s a good question. Is surgery the only thing that people can do? Would birth control pills maybe help?
Dr. Karli Provost Goldstein: Birth control is shown to decrease the risk of certain types of cancers, and ovarian cancer is one of them. That could be a low dose birth control, if well tolerated, it could be an option for them. Watching things over time and making sure that endometriosis doesn’t keep recurring and doesn’t go back into infiltrative disease of the bowel or something like that is very important, to not let those things sit.
I had a patient with vaginal endometriosis recently, and she was told by her OBGYN they removed it in the office. They got the biopsy back and it was positive. I said, “If you have endometriosis invading the vagina, there is a big storm behind the vagina, in the abdomen, of endo.”
Dr. Aimee: Where do you think it came from first?
Dr. Karli Provost Goldstein: Unfortunately, there was a huge storm. That surgery took six hours to clean everything and reconstruct the back of the vagina and remove it all.
I think for these patients that have that deep infiltrative disease, being very closely followed and having a follow up every year and just making sure that everything is status quo and no symptoms are returning and things like that, I think we’re staying ahead of the game that way.
Dr. Aimee: Have you seen a high correlation with the MTHFR gene mutation and endometriosis?
Dr. Karli Provost Goldstein: I could let you answer that one. I see a lot of MTHFR. I think it’s quite common in the population that I see.
Dr. Aimee: We thought MTHFR was a big deal like 20 years ago, there was this gene and it can cause miscarriage, it can cause all these things. Now we’ve learned that a lot of people have it and it’s not a big deal.
Dr. Karli Provost Goldstein: Right.
Dr. Aimee: The next question says, “Can you say more about endometriosis and low AMH specifically?”
Dr. Karli Provost Goldstein: That’s a good question about the chicken before the egg with AMH and endo. Some patients have normal AMH with endo, and they still have some trouble with egg quality or with the disease. Some patients have low AMH as a result of chronic insult on the ovary, whether it’s endometrioma or adhesions or scar tissue, or they independently have dysfunction in the ovary where there’s decreased or premature ovarian insufficiency. I think that’s quite common in endometriosis patients, and that’s probably as a reaction to the chronic inflammation, the inflammatory environment that endo causes. I do see those commonly.
I don’t know if you’ve seen this, but I see an elevation in AMH falsely with a big cyst, and then it will actually come back down to a normal level after the cyst is cleaned. I’m always like, “it’s a good AMH,” but it might not be that high in real life when that big cyst is not there. I have seen a false elevation with large cysts. I have seen AMH recover over time after surgery, actually even improve or go back to baseline after six months to a year. The first few months after surgery, it can take a little bit of a hit, and then afterward it can recover.
AMH does not always reflect if they’re going to get normal blasts, in my opinion. They can still have a great result with the egg quality if they were failing on getting blasts and normal blasts before. Even though the AMH number or the number retrieved is actually lower, they may have better results on the quality itself.
Dr. Aimee: I get this question a lot. If the patient has an endometrioma on her right ovary and I’m doing her egg retrieval, she’s often worried that maybe the eggs on that side aren’t going to be good. I just reassure her and say as long as I’m not touching the endometrioma, I’m not getting any endometriosis fluid or any of the chocolate cyst fluid inside my tubing, there’s still a good chance you could have good eggs. Do you have an opinion about that?
Dr. Karli Provost Goldstein: I think it’s always good to try either way. If they’ve failed retrievals and get no blasts, then we can look at both situations. I think it’s important to try beforehand and see. Again, I have seen normal blasts even with an endometrioma in there.
Dr. Aimee: The next question asks, “What is your recommendation if the lining is not shedding properly, short periods of two days, and thick baseline with fluid. I suspect endo. My doctor said symptoms don’t line up with endo.” Thick baseline with fluid, I would look at the fallopian tubes to make sure you don’t have a hydrosalpinx and check your hormone levels. Sometimes if your estrogen is really high at the beginning, that can also prevent your lining from shedding completely, and that would explain why you have a thick lining.
We lost Karli. I’ll see if she’s up for coming back on and answering more of your questions. This was so fun. I will probably have to have her come back because you guys asked so many great questions that I think will help a lot of people. Thank you, everyone, for joining.
