What is endometriosis? Endometriosis is defined as a complex, full body inflammatory condition driven by immune dysfunction and chronic inflammation. 

To better understand this, here's some context:

Endometriosis tissue is similar to that of the endometrial lining. However, it grows outside of the uterus and depending on the individual, it can be found near the fallopian tubes, the ovaries, the bladder, on the bowel, and in some cases, on the lungs. It can be tied to genetics, blood sugar problems, compromised gut health, estrogen dominance, and mitochondrial anomalies. While endometriosis research is still limited, there is growing interest around endometriosis and the relationship to immune dysfunction and bacterial toxins. The immune connection explained: Endometriosis tissue that is present in body creates chronic inflammation. Why? Because there is an increasing amount of immune cells produced by the body in an effort to clear the “invader." Simply put, the immune system goes on high alert because it does not recognize the tissue - and in an effort to manage this, it mounts quite a response. 

Unfortunately, despite the body’s best efforts to protect itself, the tissue can’t be cleared like this. This results in a chronic and maladaptive immune response. And, the immune system becomes progressively more dysfunctional in this environment. 

When the gut barrier is compromised, bacterial contamination also plays a role. And with poor circulation and detoxification problems likely already present, these issues together can further complicate the condition.

What should you do if you suspect endometriosis?

The most important thing is to get a good care team together. This can look like a combination of an OBGYN or primary care doctor, an herbalist and acupuncturist, a functional medicine doctor or nutritionist, and a reproductive mental health expert. While it is difficult to diagnose without a laparoscopy, there are some non-invasive tests available that may help inform a well-trained practitioner on how to approach your care. If you're already working with a reproductive endocrinologist, you can speak to them about the ReceptivaDx test as well. This tests looks at BCL6 which is a marker associated with endometriosis. Note that this will require an endometrial biopsy. There are also vaginal microbiome tests that may detect whether a specific bacteria, common in those with endometriosis, is present.

You can also speak to your reproductive endocrinologist or licensed medical professional about laparoscopic surgery, which is currently considered the gold standard for diagnosing endometriosis. Make sure you understand any risks of the procedure and whether laparoscopic surgery is right for you.

How can I support my body in the meantime?

There are very complex and cyclical immune and chemical processes at play when it comes to both the development and progression of endometriosis. That is why working with a licensed medical professional should be your first step.

To best support your body, talk to your care team about how to improve gut health and the microbiome, increase movement for circulation, support detoxification and liver health, and manage blood sugar. Eliminating environmental toxins and focusing on nervous system support are also essential.

There are also specific IVF protocols to address endometriosis prior to embryo transfer, so be sure to discuss this with your entire care team once you have a proper diagnosis.

Sources Institute for Menstrual Health, and Katie Edmonds, (F)NTP, “Endometriosis: A Modern Understanding and Approach.”

Received baseline lab results with little explanation? Here is your guide to optimal ranges.

FSH. Test on day 3.  

• 3-5 mIU/mL or <6 mIU/mL on days 2-4 of menstrual cycle. 6-9 mIU/mL is very good.

• There are caveats here based on estradiol levels.

LH. Test on day 3.  

• Follicular range: 1.9-12.5 mIU/mL or <7 mIU/mL

Estradiol. Test on day 3. 

• 25-75 pg/ml or less than 80 pg/ml on day 3

AMH. Test on day 3, but only for convenience.  

• Higher than 1 ng/mL can be considered good, while above 3 ng/mL may be considered high. 

• This is age dependent and taken alone is not a reflection of overall fertility status. Many studies, including those published by ASRM’s medical journal and the NIH have shown that, "AMH has a poor predictive value for natural pregnancy, and that low serum AMH levels are not associated with reduced fertility."

Keep in mind:

1. If you fall outside of any of these ranges, that is okay. Baseline levels are only a snapshot.

2. No single result alone will reflect or predict your overall fertility status. Results can simply indicate what areas need a little attending to.

3. Prolactin, SHBG, and a full thyroid panel are also important markers that should be included when possible.

4. Always reach out to your doctor with questions, or feel free to contact me to learn more.

Exposure to xenoestrogens in the environment, such as BPA, can signal a stress response in the body and can impact egg quality and maturation. Here are some practical tips to best avoid the implications of BPA during conception and beyond:

• Use a stainless steel or glass water bottle.

• Take care when using plastic, even if BPA free, by choosing PP or HDPE plastic and washing by hand.

• Avoid BPA and plastic marked as PC, or with the #7 in the recycling symbol. Safer types include polypropylene (PP / #5) or high density polyethylene (HDPE / #2).

• Say no to receipts when possible.

• Packaging labeled BPA-free can still contain chemical compounds, so be mindful of any plastic-lined packaging.

• If you can't be perfect, the biggest takeaway is to avoid acid, heat, and liquid in plastic.

Expert tip: Folate from natural sources may also help with some of the negative effects of BPA, so think about adding organic berries, oranges, avocado, spinach, broccoli, cauliflower, kale, and asparagus to your plate.

The best clinic for you will depend on a variety of factors and on your unique set of circumstances. To get started, here are a few questions to bring to your consultations:

• Does the clinic use it's own lab vs. an outside lab? Note that not all labs are equal.

• How often does the clinic both freeze and thaw eggs and embryos? And what is the cryo-survival rate? This refers to the success rate of thawing your eggs and embryos.

• What are the rates of fertilization and your blastocyst conversion rates?

• What percentage of good quality blastocysts are seen on days 5 and 6? Does the embryology allows embryos to progress to day 7 if needed?

• How often do your PGT-A or PGT-M biopsies return inconclusive?

• Does the clinic do retrievals and transfers on the weekends?

• What tests are required before I begin a retrieval or a transfer?

• Is the financial department available for a consult before beginning treatment to understand costs and insurance benefits, if applicable?

When using SART for clinic research, here's an expert tip: Labs should be able to make great embryos using donor eggs, so look at donor eggs as your starting point.

Choosing a clinic can be overwhelming. If you're in need of additional support, feel free to schedule a session.

Source: Fertility IQ

In 2015, ACOG published a report stating that menstruation should be recognized and understood as a vital sign of overall health. If you're experiencing irregular ovulation or irregular or missing periods, your body may be diverting energy away from the reproductive process in order to attend to another area of your health.

Period irregularities are overt, which is a good reason to listen to them. Often times, cycle irregularities are a clear message to us that something else in the body needs some support. But in order to tune into these messages, we need to first understand what is and isn't optimal when it comes to our cycles.

Here’s what an optimal menstrual cycle looks like:

• 3-7 days of bleeding, but how much bleeding the and quality of your blood matters too.  

• Ovulation that occurs between cycle day 12-21. Remember, ​​a true period must always be preceded by ovulation. 

• A total cycle length of 25-35 days, with a consistent length cycle-to-cycle being the most important

• 11-14 days between your ovulation and start of your next cycle, but pregnancy can occur with shorter luteal phase as well.

• No two cycles are alike, so your own fertility awareness is key.

A failed retrieval brings grief. However, we often avoid feeling into it by focusing instead on regaining the control that our systems have long been lacking. Avoiding what is uncomfortable, we retreat to a familiar space - one of urgency and planning. We quickly find ourselves asking - should we do it again? If so, how soon? What should we change? Will the outcome be different? Do we have the emotional or financial resources to do this again? Will I be supported in my decision to keep going - or to stop?

Here, it’s not uncommon to find ourselves suddenly swallowed whole by the tension between our options and our limitations - and our hopes and our fears. And, in this quest to find control and avoid the unknown, we begin to move farther away from ourselves and our intuition - looking for reassurance or answers in the places we're least likely to find it.

If you’re in the freeze of indecision, here are some tips to help you move forward with ease:

• Start with self-regulation. The energy you gave to the process and the potentiality of your retrieval is a lot to mourn. Find a simple practice that allows you to connect back in. Acknowledging the space you came from will bring more ease to deciding where you're going.

• You have permission to pivot. That might mean doing the retrieval you said you would never do, or taking the pause you said you would never take. You can lock in a new boundary or expand it. You're allowed to constantly shift your vision of what this process can look and feel like.

• Try to avoid the internet searches. This can take you out of your own narrative.

• Try on each of your options for one day. How does each one feel?

• Advocate for yourself. Ask your doctor to clarify anything that is coming up for you.

• Lastly, speak to your embryology team. There is a lot to learn from your day-by-day results, informing a better path forward. Here are some examples: 

  • Can you share what was seen each day? What specifics can you tell me about how the embryos looked on days 1-3 vs 4-7?

  • Did the eggs look dark or sticky?

  • Am I outside the range of lab averages for fertilization, blastocyst conversion, or embryo grading?

  • What day did the embryos stop developing?

Whether you choose to become a mother via IUI or IVF will depend on your unique set of circumstances. However, if both are an option to you and you aren't sure where to start, here are some quick notes on each:

IVF

IVF may be the place to start if you have: fertility coverage, frozen eggs from a previous cycle, have tried IUI more than 3 times without success, are considering multiple children and have age related concerns, or if you have been diagnosed with a condition that impacts ovulation. If this is the path you choose, I'm here to support you through each step.

IUI

While IUI still requires monitoring and can include medications, IUI generally feels less invasive for many. IUI success rates can also be higher for a single mother by choice who is not being treated for a fertility related condition, compared to IUI success rates for those being treated for a fertility condition.

Of course the success rates and the chosen path will vary person to person, so protect your own narrative, and know that the right choice is the one that feels right for you. If you want support understanding each option better, please reach out.

Source Smith (JAMA) and Fertility IQ

If you’ve chosen a frozen embryo transfer with PGT-A and/or PGT-M testing, here’s a timeline of what to expect.

Day 1: Retrieval Day Eggs are retrieved, and fertilization happens today.

Day 2: Fertilization Report You’ll receive a fertilization report. Not all retrieved eggs will be mature, and not all mature eggs will fertilize—this is normal.

Days 2-6: Embryo Development Fertilized eggs, now called zygotes, will start dividing. By Day 3, a healthy embryo typically reaches the 8-cell stage. By Day 5 or 6, the cells should form a blastocyst—a structure with a fluid-filled cavity, an inner cell mass, and a trophectoderm. Many clinics will monitor embryos until Day 7.

Days 5-7: Blastocyst Freezing and Biopsy You’ll get a report during this time. Embryos that reach the blastocyst stage are frozen and biopsied. The biopsy samples, taken from the trophectoderm, are sent for testing.

PGT-A Results Results usually take 7-14 days, depending on the lab.

*Note that there can often be nuance when it comes to genetic testing and embryo grading. Grading can vary across clinics, and it can be subjective. If you have questions about your embryo grades or PGT-A results, it's best to speak to your embryology team and genetic counselor.

75% of people who pursue medicated cycles do not have fertility coverage. If you need financial guidance around affording your treatment, here are some trusted resources to get started: Fertility IQ offers a comprehensive and detailed list of grant organizations Resolve offers a list of resources and tools around grants and scholarships Fertility Within Reach is a non-profit that works to make fertility treatments more accessible and has compiled a list varying grant foundations When you are doing your research, keep in mind that there are local, state, and national grant programs with a different set of eligibility requirements. Pay attention to whether the programs provide a flat amount, a certain number of rounds, and whether they will cover medications.

Building your family with the support of a sperm or egg donor can be a difficult decision to land on. If it is something you're considering, or already pursuing, there is promising news: for those with male factor and women over the age of 42, studies show that donor sperm and donor eggs greatly improve IVF success rates.

What is a hysteroscopy? A hysteroscopy is a quick procedure often used in the IVF context to diagnose or rule out fibroids, polyps, adhesions, and other irregularities. This procedure requires the insertion of a speculum and a small telescope that allows your doctor to see the inside of the uterus.

Do I need one, and when is it completed?

Fertility clinics often recommend a hysteroscopy before an embryo transfer and consider it good for one year. Clinics will vary on whether they require this or recommend it - many require this at your first workup or before a transfer, and some may only suggest one if they suspect any of the abnormalities listed above.

This typically occurs between days 5 to 12 of the menstrual cycle, ideally once bleeding has stopped. If you're schedule for a test and it falls outside of this window, let your clinic know.

What can I expect?

Due to the nuances in the structure of our bodies and in our perception of pain, no two individuals will experience this procedure in the exact same way. However, in my own experience and the experience of many I've worked with, it most often causes a burning, cramping sensation that subsides once the procedure is complete. While some experience only mild cramping, others will experience more discomfort. Additionally, some clinics will do the procedure under anesthesia - so this is important to note. Always make sure you have clear directions from your doctor about how to properly prepare, and make sure you are aware of what activities you will need to avoid post-procedure, such as bathing, swimming, and intercourse. Expert tip: Come prepared with a breathing practice that resonates with you. This can help with any discomfort or nerves during the procedure.

Frequently asked: Why should I consider PGT-A testing on my embryos if I have already completed a carrier screening test? Here’s the short answer: The carrier screening you completed on yourself and your partner (if applicable) only looks at whether you and your partner inherited any recessive gene disorders from your parents. It cannot give you any information about your embryos. PGT-A testing differs greatly from carrier screening done on the prospective parents. PGT-A tests for chromosomal abnormalities of the embryos you create. Even if you and your partner do match for or even carry any inherited recessive gene disorders - considering PGT-A testing on embryos (in most cases, not all) is still highly recommended as the test can indicate whether the embryo is viable for transfer.

Genetic testing is an individual choice and there are specific cases in which it makes sense to opt-out. If you have questions, reach out or schedule time to speak with a genetic counselor at your clinic.

Here are some tips for your progesterone in oil injections, commonly referred to as PIO:

• Ask your clinic to draw you a target before your first injection.

• Heat the oil under your arm, in your shirt, or in your bra.

• Don’t ice the glute. Instead, try some lunges or squats to warm up the muscle. You can also try a heating pad. 

• If you're doing the injection yourself, there are two positions to try: one is sitting down and crossing the injection leg over, and the second is to lean over a counter and shift your weight onto the non injection leg, allowing the injection site to relax.

• After injection, apply gentle pressure with a gauze. Then, re-apply the heating pad and massage gently for 10-15 minutes with a soft yoga ball. Repeat your squats and lunges, or take a walk around before bed. This can help the oil disperse. 

If you're experiencing any pain or discomfort, contact your clinic.

A failed retrieval can raise a lot of questions. The decision to pursue another round can be entangled in emotional and financial obstacles. However, if it is an option for you, know that it is possible to find success in cumulative attempts. According to this retrospective cohort study, those who did not have an embryo available to transfer in their first cycle still had a 34% chance of conceiving in subsequent cycles and more than 50% of women under the age of 40 went on to deliver a child after 3 cycles. Source: Dong, X., Xue, X. Live birth rate following a failed first in vitro fertilization cycle with no embryos for transfer. Sci Rep 13, 8343 (2023). https://doi.org/10.1038/s41598-023-35221-5

Fertility challenges can often lead us to feel scattered, fragmented and overwhelmed. There are endless techniques to self-regulate, but the best place to start is with the basics.

The body needs to feel safe to prioritize reproduction. Safety in the body can look and feel like a number of things - and depending on the unique set of biological and emotional circumstances, each person will need a different roadmap and strategy for bringing the reproductive system back online. However, there are basic practices that can universally sooth the adrenals and ease the nervous system, thus bringing more balance to the hormonal body. Overtime, these practices can help the body become more adaptive to future stressors. Here's some tips on how to get back to the basics:

1. Nourish your body daily with high-quality protein, healthy fats, and colorful, fiber-rich vegetables. Adding high quality minerals to your water is also important.

2. Practice good sleep hygiene. This means creating a regular routine, avoiding caffeine after noon, limiting screens and noise, and sleeping in a cold room. This is easier said than done for many, so please reach out for support if you need it.

3. Move your body regularly - and in nature when possible. Find movement practices that feel good for you. Long walks can be very grounding during this time - especially mid treatment cycle.

4. Somatic practices or breathwork. Start small and find a practice that resonates with you. Slow, deep breathing can be a quick way to find center, while leaning into somatic work will help the body to release stored trauma and find safety.

Several studies have provided a reassuring observation about the lifespan of mothers who give birth later in life. The NIH published findings from one particular study titled, "The Long Life Family Study" which found "a positive association between older maternal age and greater odds for surviving to an unusually old age."

Additionally, the NIH includes that an "analysis of New England Centenarian Study cohort data revealed that women who gave birth to a child after the age of 40 had four times greater odds of being a centenarian compared to women from the same birth cohort who had their last child at younger ages."

Read more here from the NIH.

Source: Extended Maternal Age at Birth of Last Child and Women’s Longevity in the Long Life Family Study (NIHMS608549), National Institutes of Health.

While bacterial infections have been understood to be associated with endometriosis for many years, a new paper explores whether bacterial infections, namely those caused by the gram-negative bacteria, Fusobacterium, could be the cause of endometriosis in certain women. Read the abstract here.

If you suspect endometriosis, you can talk to your doctor about testing for the presence of Fusobacterium. You can also find a healthcare provider through reliable microbiome testing companies, such as Invivo.

Source: Khaleque N Khan, Dominique de Ziegler, Sun-Wei Guo, Bacterial infection in endometriosis: a silver-lining for the development of new non-hormonal therapy?, Human Reproduction, Volume 39, Issue 4, April 2024, Pages 623–631, https://doi.org/10.1093/humrep/deae006