Tired of managing endometriosis with just pain medication? In this episode of Fertility Docs Uncensored, hosts Dr. Carrie Bedient from The Fertility Center of Las Vegas and Dr. Susan Hudson from Texas Fertility Center sit down with guest Dr. Joy Brotherton, Director of Minimally Invasive Gynecologic and Fertility Surgery, to map out how to build your ultimate multi-disciplinary treatment team. Building a collaborative medical team is essential for true root-cause healing. [1] Discover how to strategically combine diagnostic tools like the ReceptivaDx test with holistic protocols—including pelvic floor physical therapy, somatic therapy, and acupuncture—to reduce chronic inflammation, regulate your nervous system, and restore pelvic health. If you are struggling with silent endometriosis, chronic pelvic pain, or infertility, this collaborative, whole-body approach offers a clear roadmap to reclaiming your quality of life.

Episode Transcript:

Susan Hudson (00:01)

You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.

Susan Hudson MD (00:22)

This podcast is sponsored by ReceptivaDx. When fertility questions remain unanswered, ReceptivaDx helps reveal why. Trusted by fertility specialists for over a decade, ReceptivaDx identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, ReceptivaDx helps women and their physicians make more informed treatment decisions and move forward with confidence.

Carrie Bedient MD (00:59)

Hello and welcome to another episode of Fertility Docs Uncensored. I am one of your hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas. And I am joined by my lovely, lively co-host, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (01:13)

Hello everyone.

Carrie Bedient MD (01:15)

And today we are joined by Dr. Joy Brotherton, who is the director of minimally invasive gynecologic and fertility surgery at Marin Fertility Center and is a jack of all trades because she not only works at the fertility center and doing surgery, but she works at the VA with some of the veterans. She works on labor and delivery to keep those set of skills up. You are just all over the place. And we are delighted to have you, Joy. Thank you so much for joining us. And one of the clearly most important things about all of this is that you won a National Yearbook Award for your designing in fonts when you were in high school. And you said that you absolutely love designing things and as people who dive down rabbit holes on a regular basis,

Joy Brotherton, MD (01:45)

Thank you for having me.

Carrie Bedient MD (02:05)

What kind of rabbit hole do you go down when to get you this award?

Joy Brotherton, MD (02:10)

Yeah, I mean, I think it’s for me one of my biggest accomplishments. In tenth grade, I won this national award for my yearbook design. How it translates in today’s world is I’m super judgy about fonts. And like if I’m making any kind of a presentation or an invitation or just sort of anything visual, I’m very into fonts and and how it looks and I don’t like to one up people with that, but it is one of my best accomplishments in my life. So

Susan Hudson MD (02:41)

I do have to say, I actually think I see how this translates into a minimally invasive surgeon because you have an eye for what you want perfect to be, and you want to make it efficient but beautiful and make it work the best it can. And it’s just like doing surgery.

Joy Brotherton, MD (03:01)

Yeah, I mean there’s definitely a huge OCD component to my life and my work. I think I’ve recently diagnosed myself as being on the spectrum. I think we all are a little bit.

For me in the OR and very regimented in how I do things. I used to teach residents for many years. And so that was my quality control, was kind of doing things very the same way every time so that so that you could keep that quality control. Yeah. And that muscle memory is still there. Yeah.

Carrie Bedient MD (03:31)

How does that attention to detail and meticulousness translate to when you travel? You had mentioned you’ve traveled internationally and oftentimes that does not go as planned. How does who you are naturally as a person translate to the outside world?

Joy Brotherton, MD (03:47)

Yeah, that doesn’t go well together. I’m the person who’s at the airport three hours before their flight.

I’m the biggest type A woo-woo person in the world. I’m a triple Pisces. I don’t know if anyone knows what that is, but I am a very woo-woo. I sometimes have to go to my woo-woo side and just kind of embrace the unknown, which is very hard when you’re a type A kind of surgical physician. I have a a big yoga practice that I have to go to most days so that I don’t, smack people in line at the at the grocery store because I’m also a perimenopausal woman. So anyone who’s out there who’s perimenopausal may know that symptom or just things annoy you. You must do a lot of yoga and things to decrease that.

Carrie Bedient MD (04:31)

Do you do you have somebody on speed dial who keeps bail money out for you?

Joy Brotherton, MD (04:36)

Yeah. So my best friend since I was fourteen is this crazy Colombian woman who is also very woo-woo. When I need someone to just smack me back to earth, she is my person.

Carrie Bedient MD (04:47)

All right. So, Joy, because you are an endo expert, we will dive into that in just a second and what kind of community patients can build for themselves, medical community patients can build for themselves and how they get through those some of these challenges. But first, Susan, do we have an endo question?

Susan Hudson MD (05:04)

We do. All right. So this one is obsessed with your podcast. Thank you. Thank you so much for being obsessed. I am a 34-year-old with a two and a half year old living child. No issues conceiving her. Husband’s 36 with quote A plus sperm. I had four losses, one chemical, two ectopics, one chemical with a euploid embryo. Since trying for a second, AMH is 2.86. RPL workups showed TPO antibodies.

Treated with levothyroxine. Celiac suspected removed gluten from the diet. HSG was normal, but left side was slow to spill out. Diagnosed tubal factor, anyways. First egg retrieval results, six eggs, four mature, three blasts, one eploid, one segmental. Euploid ended up in a chemical. My mom recently had a hysterectomy and found silent endo in lots of fibroids. Sis also has endo. I do not want to do another egg retrieval or transfer without more testing on what could be going on in my uterine environment. What would you do next?

So Joy, could you tell us a little bit about families in endo? How how did these things relate? Literally.

Joy Brotherton, MD (06:11)

Yeah, so there are some screening questions that I always ask. I will say the basic ones, painful periods, pain with intercourse, pain with bowel movements, pain when you’re not on your period, ever have to stay home from work or school because of pain. those are the, you know, those are the easy ones. Anyone in your family with a history of endometriosis or infertility, those are big ones. But there’s a good percentage of women now in my fertility life that I have been in for the past couple of years that I realize are kind of silent. My whole MIGS career doing minimally invasive GYN surgery, I typically worked with women who had chronic pain. And now on the fertility side, I see a ton of women who their biggest presenting factor is trouble getting pregnant. I tend to see a correlation with poorer egg quality in women with endo. I see a correlation with lower AMHs. I don’t know if you guys see that. This is just sort of me putting two and two together and some data I think coming out now about that.

Susan Hudson MD (07:15)

Think in last month’s Fertility and Sterility, there was an article all about how endometriosis is both related to egg quality and quantity and potentially earlier menopause.

Joy Brotherton, MD (07:26)

See it all the time. And also for me, why did you have an ectopic? Where did that come from? For me, it’s a history of PID, gonorrhea, chlamydia, which are not that common. What else can cause that endometriosis? I’m always somebody who wants to know why.

Carrie Bedient MD (07:31)

Exactly.

Joy Brotherton, MD (07:42)

And if someone had ectopic, there’s usually a why.

Carrie Bedient MD (07:45)

So how much do you chase that down in a fertility patient like this? What kind of testing do you do?

Joy Brotherton, MD (07:51)

In the olden days we had to take people for a laparoscopy, put them under general anesthesia, put a camera in their belly, look around. I definitely think I am guilty in my early years as a young surgeon of telling women you don’t have endometriosis because I didn’t see it. And in those days, in the early days of MIGS, I don’t think it was as popular to do a bunch of biopsies on normal appearing peritoneum.

That was sort of the old fashioned way of diagnosing it. Four years ago when I got to this fertility practice, my boss was like, you should do Receptiva on this patient. And I was like, What’s Receptiva? It was a test looking for BCL6, which is a surrogate marker for endometriosis. And I was sort of like, How am I a MIGS surgeon? And I’ve never heard of this test. It was kind of hidden in your fertility world. I use it a lot. I really wish that every patient that walked in my door had this test because it gives us so much information.

And you guys can verify this amongst the REI community. It’s not standard really to test this until you’ve had multiple losses. But a lot of my patients don’t have multiple embryos to lose. For me, it’s almost never unexplained infertility. There’s always an explanation, almost always. And many times that explanation is silent endometriosis or not so silent.

Susan Hudson MD (09:13)

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If you’ve been waiting for the right moment to get clarity, this might be it.

Susan Hudson MD (10:20)

Carrie, I have a question for you. In your practice, who do you bring to the operating room and who do you do testing like Receptiva?

Carrie Bedient MD (10:29)

I don’t tend to take people to the operating room very often. In part that’s because I kind of assume everybody’s got endometriosis, at least a little bit, because for the most part, it’s not something that’s going to require surgery to make them feel better. And so for that reason, I don’t really want to take them to the operating room because I’m worried I’m gonna do more damage ultimately.

Even if it’s just the psychological, you need to have surgery here, let me put a camera in your belly and take a look around, as well as the financial and the the nuisance factor of it. My default is I assume everybody’s got endo. When I’m doing a stim and IVF, for example.

I stim with that in mind. If I see any trace of adeno, any trace of hemorrhagic endometrioma, cyst on the ovaries, I assume endo. And if I don’t see a lining that looks good, a lot of the times that’s my my default. I will do additional testing when number one, someone really has a need to know. They’re they’re not comfortable just making some of those assumptions, even if they do have, painful periods or things like that. If someone needs to know, we’ll absolutely do it. If someone really doesn’t want to do a long lupron transfer protocol, for example, we’ll do it because that’s not a it’s not a benign protocol in the sense of it takes an extra two months and infertility treatment, you might as well tell them they have to wait a decade. I have this conversation with a lot of my patients, but I tend to assume that most people have some form of endo going on by the time they get to me. What about you?

Susan Hudson MD (12:09)

Yeah, I I think I remember a statistic one time that if you actually laparoscoped everybody who came into a fertility office, sixty percent of them would be positive. And early in my career, we took a lot of people to laparoscopy. And I did it at that time because the thought process was, well, if we go to laparoscopy and we see that somebody has severe endometriosis, then we know that they are most likely not going to be successful with lesser invasive options like ovulation induction with IUI and that they should go to IVF. Well, being in a non-mandated state, what I found was that information and it didn’t change people’s pathway. Either they were gonna go to IVF anyway, or they wanted to try something less invasive because IVF’s expensive. I mean it’s a big thing and as we always talk about in our podcast, we never say never.

People will still want to do less invasive treatments in the absence of of having something more compelling than just knowing its presence is there. I think in this patient that we’re referring to with the family history, I think Receptiva is a great option. It’s a test that you can do a couple of different ways. If you’re ovulatory essentially we ask you to not try to get pregnant to that cycle and post ovulatory on a certain day you’ll go into the office and we just do a little endometrial biopsy. If you aren’t ovulatory or you’re doing other endometrial receptivity testing for whatever and you need to do a mock cycle, you can do it on the day you theoretically would have had an embryo transfer. And it gives us an idea if that BCL6 is present, then we know that you need to do some sort of treatment to improve your chances of implantation and decrease your risk of miscarriage.

Carrie Bedient MD (13:57)

So, Joy, when you do your Receptiva testing, do you tend to have patients come in and do it under anesthesia? Do you do it in a random biopsy? Are you primarily doing it in the setting of surgery where you’re looking for the metabolic markers in addition to what you may be able to see or not see as the case, maybe? How do you how do you do your biopsies?

Joy Brotherton, MD (14:20)

Just a plain endometrial biopsy in the office. I have started offering it to most patients because I’ve had several patients not get offered it until they failed a few transfers and they were very upset about losing those embryos. So I’m very upfront.

In the beginning, and say, listen, it’s not gold standard to check this unless you failed a couple transfers. However, most people don’t have a lot of embryos to fail. And if there’s something in their history that’s suspicious to me, or let’s say we only have one embryo. We have one precious embryo and we want to do everything in our power to make sure this embryo gives us a healthy pregnancy, most people are willing to do the extra test.

They want to know that they’re not crazy. It’s a simple biopsy in the office. It takes about a minute. I do offer patients, I usually tell them to take some kind of ibuprofen or Tylenol before they come in. In my GYN world, there was just an interesting study that showed that if you took 800 milligrams every eight hours times three doses of ibuprofen before an IUD insertion, then there was statistically less pain. I kind of have extrapolated that study. I will also offer people an anti-anxiety medication and my patients that have a lot of pain, I will even offer them, I call it my cocktail. I literally prescribe one Percocet or Norco and opioid medication with an anti-anxiety medication, but they have to have a driver.

We typically do it at the end of the day because I tell them you’re not gonna go home and do work emails because I cannot be responsible for what you write in that work email after you take my cocktail. But most patients appreciate at least being forewarned. And some patients tolerate it totally fine. Other people, I tell them they can swear if they want. I enjoy swearing. So if that helps them, if that helps them get through the biopsy, but it’s really hard. I just had a patient last week who had a history of an ectopic who did two cycles of IVF, didn’t get any euploid embryos. Ended up going pretty quickly to donor egg, has a child from her untested donor egg embryos and was coming back for baby number two. And first transfer didn’t work. Only has two more embryos left. We talked about testing this. And when it came back positive, the look on her face was just sort of like putting everything together after all these years of infertility. And sort of like, gosh, why didn’t nobody tell me this before? Why didn’t anybody check this before? So I tend to talk about it very early and we don’t have to do it, but I like everyone to have the option and have the information so they can do their own research.

Carrie Bedient MD (17:01)

You had mentioned that you’re more of a woo-woo doctor, especially given you are also a type A surgeon. So with that in mind, what kind of team, if you were gonna build your perfect center so that when a patient came to you, you could with pain, with endometriosis, infertility, the full package, like so many of our ladies have.

Who would you build and who would you be able to say, okay, I’m gonna send you here and here and here and here so that it’s not just you as the surgeon taking care of them, but the whole team. So who’s who is the first person you would bring on that team to build?

Joy Brotherton, MD (17:37)

Yeah. Well I would preface it by saying, and anyone who has endometriosis who has painful endometriosis knows that it’s not a one size fits all treatment plan. There’s nothing more soul crushing than spending hours painstakingly taking out endometriosis implants and the patient doesn’t always feel better. Sometimes they do, most of the time they do, but there’s a great percentage of patients who don’t. I like to use a multi-prong approach. I think surgery plays a role for certain patients at certain times in their life. I think there’s some medications out there that can be very helpful. And then I’m in the Bay Area now, so patients really like to be empowered. First of all, they’re waiting longer to have children in the Bay Area, particularly compared to other places in the country. So that creates a whole other discussion about fertility preservation and being more proactive about that. But people are very into lifestyle here. And so thinking about anti-inflammatory diets. And my dream team, acupuncture, I’m a huge fan of it. I’m a doctor who doesn’t like to take medicine. So I in my life have used a lot of acupuncture. I have found it a great modality.

If you know anything about chronic pelvic pain and trauma when I’m working with veterans, the body keeps the score. Things like alternative modalities, somatic therapy, somatic movement, having a good nutritionist. Yeah, it’s that’s in my my woo-woo life. So if you’re someone who’s very anxious, and I think if you work with patients with endometriosis who have a lot of pain, when your period gets close, you start getting anxious because you know that pain’s coming. Many people have a lot of anxiety.

It’s a very anxious time to be alive. Anxiety feels like that elephant sitting on your chest. In the fertility world, I’m sure your patients come in, they want a baby yesterday, and it has to happen because they have to have this timeline and it’s not working at their perfect timeline. And I get it because I am type A as well, but sometimes you have to surrender to the universe because it doesn’t always give us what we want when we want it.

And I’m have the gray hair to know that that is just how life works out sometimes. But we hold this anxiety in our body. And how do you get that out of your body? Some people meditate, some people walk, some people punch a boxing bag. I have recently discovered somatic therapy.

Can I give a plug? I don’t even know this woman, but I found this woman on social media. It’s called the Workout Witch. And she has these videos where you basically, I thought it was really stupid until I did it myself. And you basically lay in bed and listen to this woman telling you to move your legs to the left and move your legs to the right. And you do these very simple movements in bed.

And I will tell you from personal experience, it really does lower your anxiety levels. Now you can’t then go watch a murder mystery show after you do that. It’s kind of negates the whole thing. Especially here in the Bay Area, there’s a lot of somatic therapy practitioners that will kind of teach you these sort of very simple movements in your body to try to move some of that energy out. And if you’re somebody who suffers from pain.

And you’re sort of the word is catastrophizing in the endometriosis world where you’re just you’re you’re anticipating this month’s period how painful it’s gonna be then that layers on top of each other and so having these alternative modalities for certain patients are a great tool to have in your toolbox.

Carrie Bedient MD (21:11)

That’s fantastic, especially because you have done some of those things yourself. So you’re practicing what you preach, which is always really helpful when you’re advising patients. So you can say, Yeah, I know that this works. And I know you’re gonna feel ridiculous as you’re doing this, but it has the potential to help. How do you work with the nutritionists? You had mentioned an anti-inflammatory diet.

What does that mean. Patients are asking us all the time, what should they eat and how should they eat it? And from a straight fertility perspective, there’s no one diet. We will oftentimes say Mediterranean diet, because that builds in a lot of the antioxidants, the fruits, the veggies, the lean proteins, the complex carbs, things like that falls within an anti-inflammatory diet. But when you say anti-inflammatory diet, what are you thinking? What does it mean? And how strict do they have to be with it?

Joy Brotherton, MD (22:02)

During the pandemic, I actually wrote a chapter for the American Society of Lifestyle Medicine. I helped write the chapter on lifestyle modalities to help with endometriosis. I looked at all the studies. I think I had like 30 or 40 studies that I looked at as a mostly lifelong vegetarian since I was 16.

I wanted to prove, I don’t know why, but I just wanted to prove that a lot of the meat and dairy that we eat in this country is filled with hormones and crap. And we know endometriosis is a hormone driven disease. I wanted to find out is there any correlation between a plant-based diet versus a meat and dairy rich diet. And there’s not a lot of good data. A lot of the data comes from Europe that’s said that there really was no difference. But the way that meat is raised in Europe, I think is probably different than how we mass produce things in this country. The answer is there’s no perfect answer. You have to kind of do your own elimination diet. Every every patient needs to eliminate one food for a week or two, see how their symptoms are.

Okay, so I eliminated dairy for two weeks. Did I feel better? Did I not feel better? We also live in a world where being super restrictive can also limit your joy in life. I don’t want patients to go super crazy with it, but I do think that there are things that they can look at and everybody’s a little bit different. Working with a nutritionist might be helpful for some people to do that elimination and see. I think there’s some really interesting thought process amongst people. There’s no data. There are just individual cases of people using GLP ones now and their endobelly got better. I think there’s a huge potential for studying this. Will it get studied anytime in my lifetime? I don’t know. But women are desperate now.

And they’re willing to try things. And it’s pretty easy to eliminate one or two things and see how you feel for a week or two and go from there.

Susan Hudson MD (24:01)

When you talk about endobelly, what do you mean by that?

Joy Brotherton, MD (24:05)

So a lot of patients with chronic pelvic pain and endometriosis from the pain side will say, I get a lot of bloating around my period, I get diarrhea, constipation, and they will get diagnosed with IBS. That’s one of my light bulbs in the fertility clinic. If someone comes in and says, no, I don’t have I don’t have painful periods. I do have IBS though. I have IBS. Maybe it’s not IBS.

And what is IBS? Nobody really knows. From personal experience, GI doctors don’t really explain it very well, and there’s not a great cure for it. There’s been some interesting I would say, case reports of people using GLP1s. and that kind of bloating got better.

And I’m not endorsing people go use GLP ones. I’m just saying that we have a lot of space for understanding how this is really a systemic disease that affects so many different systems.

Susan Hudson MD (24:58)

Yeah. It’s interesting when we talk about diets. So I have celiac, so I follow a very strict gluten-free diet. You can ask Carrie if something negative happens, it really, really sucks for me. I try to live as healthily as I can and I’m I’m very good at a gluten free diet. And I’ll have patients come in and, first gluten free diets were for celiac.

And now they’re for people with thyroid disease. And those things actually make sense because a lot of thyroid disease and celiac are shared genetically. It makes sense that if you’re needing to manage one with a theoretically anti-inflammatory diet, that the other would be. But I just want to warn people who are like, ooh, I’m going to try to do gluten-free because it’s the hot thing out there and everything is labeled as gluten-friendly and blah, blah, blah. First of all, if you’re following a gluten-friendly diet and that’s what you’re eating when you go out to eat, realize you are probably getting a reasonable amount of gluten if you’re not telling them to avoid cross-contamination and that type of thing. It’s it’s a nightmare for celiacs, but it’s great for everything else. And realize that just because something’s gluten free, doesn’t necessarily mean it’s healthy or anti-inflammatory. And it really, if you’re doing gluten-free and you’re wanting to do a Mediterranean style diet, those things actually marry very nicely together, but you have to be very cognizant of what you’re doing. I want to say this because I see people getting very wrapped up in these diets and if you’re not doing them correctly, then you may be exerting a lot of effort and not actually getting the gain because you’re not actually adhering to what’s potentially going to help you. So that’s my little soapbox as a person who has to do gluten-free and understanding the real implications of a gluten-free diet and understanding that there’s some things that inflammatory-wise may help, but it may not be the panacea everybody thinks it is as well.

Joy Brotherton, MD (27:12)

And I think a big part of that is really rephrasing it to a whole foods-based kind of diet because a lot of the gluten-free stuff is processed non-foods. It’s a good thing now that it’s five million dollars to go to dinner. So stay home and cook. Everything is so expensive right now. Learning how to prepare whole foods in your own kitchen is going to control sort of all of those things. I think it’s something to think about. I also think, because this test only exists mostly in the fertility space, in my ideal world, in my general OBGYN life and my colleagues who are general OBGYNs, they would have more access to doing this testing so that young girls could find out earlier if they have this disease without having to go through a whole big surgery to find out because they could do actionable items like this, like looking at their diet, they’re not necessarily trying to get pregnant at maybe 22, but maybe they have painful periods or they have enough symptoms where they’re wondering, and having that diagnosis early for me can help people plan their life. If you find out at twenty-two that your symptoms of IBS and maybe painful periods and I also see women with endo have a lot of allergies. So when I do surgery on someone with endometriosis, there’s a surgical glue that we often use. I will not use that glue on women with endo because I’ve seen so many of them come back with really bad skin allergies. If we have a younger patient who’s not necessarily looking for fertility right now, having that diagnosis may help them prepare and save money to freeze their eggs or just do some of these lifestyle changes that will empower them to know what’s gonna make them feel their best. I don’t believe in strict diets. I’m a kid from the 80s who was on a diet my whole life, all the weird diets that we were on in the 80s, and that’s not real food. So people have to eat real food and find out what makes them feel the best. So there’s not one thing for each patient. Everybody’s a little bit different.

Carrie Bedient MD (29:23)

So as a patient’s putting together a team, she’s got her surgeon, hopefully a nutritionist, hopefully an acupuncturist, somatic therapy person. Who who else? Physical therapy? Pelvic floor therapy? 

Joy Brotherton, MD (29:36)

Pelvic floor therapy.

Yeah. I don’t know that they’re gonna go find a somatic therapist, but I’m just saying that there’s these are some easy videos that you could do in your privacy of your own home. Pelvic floor therapist, for sure. For me, it’s finding continuity with an OBGYN who can follow you long term, who you can have those conversations with about your fertility. Do you want to have kids in the future? Do you not want to have kids? It really depends on your age.

When it comes to surgery, I used to always put people into three categories when it came to pain. Number one, they’re young, they don’t want kids right now, but they want kids in the future. Number two, they’re reproductive age, typically mid 30s, they wanted kids yesterday. And then category three were women who are done having children and they just want to feel better. So finding an OBGYN who really can work with you throughout your lifespan to focus on whatever your goal is at that point. If you are someone who suffers from really bad pain or are going to undergo surgery, talking to your surgeon about who they work with. Do they have a colorectal surgeon that they work with? Do they have a urologist that they work with? Do they have a comprehensive team? What I have seen so many times in my career is women just go to, the person who delivered their baby. And not that there’s anything wrong with that, but for someone who trained residents for many years, people are becoming more and more specialized within our field. Someone who delivers babies is probably in today’s day and age not necessarily concentrating on doing complex endometriosis surgery. So if you have a complex case, finding the right person so that you don’t get what we call a peek. They put the camera in, you have endo, go see a specialist. Well, that was kind of a waste of everyone’s time and resources. I think in the MIGS world and the minimally invasive GYN surgery world, that is our next hot topic is how do we build a comprehensive team around the country in different places?

Susan Hudson MD (31:31)

So I have a question. You were talking about somebody being a complex patient. And I think one of the hardest things for people regarding endometriosis is that pain does not necessarily relate to the complexity of your actual disease state in your pelvis. How do you know as a listener, hey, I’m listening to this, either I have infertility and I’m worried about endometriosis, or I have pain and I have infertility too, because most likely those are the people who are listening to this. How how do those people figure out, am I simple or complex? Or is everybody complex?

Joy Brotherton, MD (32:10)

I think everybody’s complex in their own way. I think as a general OBGYN who did a MIGS fellowship and lived in the sort of non-fertility world for many years, I think I myself was very naive to the extent that how quickly our age our eggs age.

We see people walking around in their 40s having babies all the time. And everyone just thinks it’s so easy. But I think people are very, very ignorant. I was ignorant to how fleeting our fertility is. If you’re in your mid-30s and you want to have a baby, I defer everything to fertility. And it’s not just thinking about the baby that you want right now, but do you want to have more than one child? If you have endometriosis and you want to have more than one child, you’re gonna really have to think about banking embryos for the future because if you’re having trouble at 34, how is it gonna be when you’re 36 or 37 after you’ve had baby number one? So in my ideal world, an IVF would not be five million dollars, just like going to dinner would not be five million dollars.

Exaggerating, but it wouldn’t be so expensive. In my ideal world, women with endo could bank embryos or eggs if they don’t have a partner, to preserve that fertility and then work on is your most important thing having a baby right now or addressing your pain? I think everybody’s complex in a different way. I think when we look at the teenage population, if you’re a teenage girl and you’re missing school, then that’s not what we want for you. But we also don’t want someone to go in and wipe out your fertility. Cauterizing your ovaries. Everybody’s complex in different ways. It depends really what your goals are and where you are in life.

Susan Hudson MD (33:56)

When we have patients come to see us, one thing they’re always so happy about is how much time we get to spend with them talking about their fertility challenges as compared to what they may have experienced in a general OBGYN’s office. Is that similar when you go see a MIGS surgeon who has a specialty in endometriosis? or is a MIGS’s practice still very fast paced, like in a a general OBGYN.

Joy Brotherton, MD (34:24)

It’s a good question. Ideally, if you’re seeing a MIGS surgeon and you’re talking about surgery, you’re gonna have more than 15 minutes with them. If they only give you 15 minutes, that might not be the right surgeon for you. If they’re checking your incisions two weeks post-op and everything is fine, we don’t need to spend two hours with you. Medicine is very broken right now.

In my general OBGYN world, we are given 15 or 20 minutes to see a patient. And that’s not enough time for you to get your Pap smear and talk about your mammogram and all the things. And talk about fertility. It really has to be a second or third independent visit. And honestly, it should be a referral pretty quickly to a fertility specialist if you’re in your 30s, in my opinion.

Hopefully your time with a MIGS surgeon is going to be more than 15 minutes. And you should really be able to address all of your concerns, what your goals are, and map out your plan. Map out your plan for whether it’s gonna be surgery, whether it’s gonna be going and freezing some eggs before surgery, whether it’s what we call a clean out, and we’re just gonna take everything out and then we need to talk about what your hormone replacement’s gonna be. Depends where you are in your life, but with a fertility focus, I think the last four years for me working in a fertility clinic have been, I just really was so unaware of how fleeting our fertility is. I read it. I heard about it. I kind of did it, but not really to the extent of what you see every day of women coming in in their mid to late 30s. We were supposed to have babies when we’re 16. That’s what I tell people every day. I always say, There’s nothing wrong with you. You’re just not 16, and that’s when we were supposed to have babies. I should be dead by now. We didn’t live this long.

Carrie Bedient MD (36:16)

On that uplifting note.

Joy Brotherton, MD (36:15)

True.

I’m always uplifting, yes.

Carrie Bedient MD (36:22)

Any other words of advice to our patients who are coming in as they’re navigating this journey, figuring out endo? We’ve talked about Receptiva as a diagnostic tool, general surgeries, laparoscopies as a diagnostic tool, all the other different subspecialties, especially in the more woo variety, which is really actually quite helpful because it’s not typical to find a surgeon who’s willing to talk about the things that don’t have a zillion published articles that hold up to the standard of publishable data with power analyses and full statistics and all of that. It’s really nice to have somebody who’s willing to talk about all of that, even though there isn’t a ton of data on it. But anything else that that our listeners should be thinking about as they’re going through this?

Joy Brotherton, MD (37:13)

Well, I would say a lot of my woo is not published. But actually I’m on the editorial board of JMIG, which is our journal of minimally invasive GYN surgeon, but I did recently just review an article about using yoga for patients with endometriosis. I think MIGS surgeons are open a little bit to the woo because we just want our patients to feel better. And, if you can go do some simple movements and feel better, then that doesn’t cost us anything. And it makes you feel better. So that’s the most important thing.

For me, I would say my best advice is if you think that there’s anything in your history that could point towards endometriosis, or if you’re just still confused of why you have to be in this fertility office and you want additional information, I don’t think it’s ever wrong to take 30 seconds or a minute or however long it is, a couple minutes, and take that month off and get a BCL6 and a CD 138 done through the Receptiva. I hate playing Monday morning quarterback after we have an embryo that doesn’t implant and then we go back and find out and we’re like, gosh, we could have improved this environment. I know everybody wants it right now and wanted a baby yesterday, but I always say sometimes it’s faster to go slower.

I used to say that to my residents a lot. Sometimes it’s faster to take your time and do it correctly than have to go back and fix something. I wish like when everyone walked into the office, we do an ultrasound, we do saline sonograms, we do follicle counts, we do all these things. I just wish they could just get a Receptiva when they walked in the door. So I have that information because the more information you have,

then you’re able to make the best decision for yourself. And sometimes if you test positive, that doesn’t always mean that you have to have treatment. I’ve had patients say, I got a bunch of embryos. I don’t want to take that medication. Let’s transfer one. And if it doesn’t stick, I’ll consider taking it next time.

So it’s never always an exact black and white answer for each person, but we do have good modalities to improve that uterine environment for these precious embryos. So in the fertility world with my fertility hat on, I wish that more patients could have this information before they start their journey because it’s just more empowering to have more information, really.

Carrie Bedient MD (39:35)

That’s fabulous. Well, for our listeners, we’ve had Dr. Joy Brotherton, who is the Director of Minimally Invasive Gynecologic and Fertility Surgery at Marin Fertility Center. And thank you so much for joining us and sharing all of your experience across really a wealth of OBGYN subspecialty information. And that is very helpful. So thank you for joining us.

Joy Brotherton, MD (39:59)

Thanks for having me.

Carrie Bedient MD (40:00)

All right, so to our listeners, thanks for spending a part of your day with us.

Susan Hudson MD (40:05)

If you enjoyed this episode, subscribe, leave a review, and send us your questions at fertilitydocsuncensored.com.

Carrie Bedient MD (40:12)

If you want more fertility information, pick up a copy of the IVF Blueprint, which is our practical guide to understanding fertility treatment IVF and the decisions you’ll face along the way.

Susan Hudson MD (40:21)

Before we go, remember this podcast is for education and entertainment only.

Carrie Bedient MD (40:26)

While we’re fertility doctors, we’re not your fertility doctor.

Susan Hudson MD (40:30)

Nothing we discussed should replace medical advice from your own physician who knows your individual history and circumstances.

Carrie Bedient MD (40:36)

Thanks for listening. Bye.

Susan Hudson MD (40:42)

This podcast is sponsored by ReceptivaDx. When fertility questions remain unanswered, ReceptivaDx helps reveal why. Trusted by fertility specialists for over a decade, ReceptivaDx identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, ReceptivaDx helps women and their physicians make more informed treatment decisions and move forward with confidence.