Dr. Nicole Browne of Rejuvenating Fertility Center and I discuss ALL THINGS adenomyosis, repeat implantation failure and endometriosis. 

***

SEE TRANSCRIPT BELOW OR CLICK ON THE IMAGE ABOVE FOR THE FULL VIDEO.

Aimee:

Hello, hello, how are you guys? Happy Friday. It's a gorgeous almost spring Friday here on the East Coast and I am loving the weather. I am coming to you live to do a live with Dr. Nicole Browne, she's the newest doctor at Rejuvenating Fertility Center. We are going to talk all about adenomyosis or adenomyosis to really give you guys more information on this condition and how it's impacting your fertility. I'm going to bring Dr. Browne on now with me. Dr. Browne, I think I see you there. Let me see if I do this. Oh, I'm going to invite you to join, Dr. Browne, so your … You should see something pop up on your … Let me see. Why don't I see you? Let me just see. I'm going to click your name. Dr. Browne, are you still here watching because I don't see you on my viewers? Let me see. Oh, you did it. Technology, it's not always everybody's strong suit. Let's see that it works. I've accepted her to join me live, let's see. Oh, it worked. Look at that.

Dr. Nicole Browne:

Hi.

Aimee:

Now turn your phone around so we can see your beautiful face.

Dr. Nicole Browne:

Oh, thank you.

Aimee:

Let's see. There you are. All right, you did it.

Dr. Nicole Browne:

How are you, Aimee?

Aimee:

I'm good, how are you?

Dr. Nicole Browne:

I'm doing well. Good to see you.

Aimee:

You too. Are you at the clinic right now in Connecticut?

Dr. Nicole Browne:

I am. I'm here seeing patients today.

Aimee:

She took a break out of her very busy doctor schedule to come and discuss. Do you say adenomyosis or adenomyosis?

Dr. Nicole Browne:

I say adenomyosis.

Aimee:

That's what I say, adenomyosis as well. We were just talking briefly on the phone before we went live. My first question to Dr. Browne was, I … Or comment. I was like, I feel like I'm just seeing so many more women being told that they have it more than ever before. And I asked you, do you think it's we're getting better at diagnosing it or do you think it's been there all along? And I liked your answer. If you remember you said about endo so go ahead and share.

Dr. Nicole Browne:

For a long time endometriosis has been under-diagnosed. You'd be surprising, Aimee, by how many women actually have endometriosis. And I think because we've gotten better at diagnosing endometriosis we've now sort of keyed in on, or honed in on adenomyosis too which can affect fertility.

Aimee:

Tell us, what is adenomyosis?

Dr. Nicole Browne:

Sure. Adenomyosis is actually a common gynecologic condition that affects a lot of women of childbearing age. And so, Aimee, adenomyosis is just endometrial tissue that lines the uterine cavity but it gets displaced into the muscular wall of the uterus and it grows. And it's hormonally responsive so it responds to our monthly hormones just like the normal endometrial tissue in the uterine cavity. It can grow and it can shed and bleed into the muscular portion of the uterus. So you can only imagine, Aimee, how painful that can be. And it can contribute to a lot of significant abnormal bleeding.

Aimee:

And then also implantation issues, right? Because that patch of tissue, if you will, or adenomyosis, will … Is not implantable. That's my thinking. Is that correct thinking?

Dr. Nicole Browne:

That's correct. So remember, adenomyosis is normal endometrial tissue that should actually be in the cavity of the uterus but now it's growing into the wall of the uterus and that's not where implantation happens, it should happen in the uterine cavity. So implantation can't happen in the setting of adenomyosis or lower implantation.

Aimee:

If that's the uterus and that's the lining, then adeno is happening in here or something like that. Is that what it is? It's going into the muscle layer, am I-

Dr. Nicole Browne:

That's exactly right, that's exactly right.

Aimee:

And so then this whole patch is like sorry, nobody can live there, basically. Right?

Dr. Nicole Browne:

You can think of it that way, yes.

Aimee:

I've described it before but I think I'm wrong in my description. The way I picture it in my head is almost like … I say this. A patch of desert in the uterus where it's just like sorry, nothing can live here, it just can't implant. Maybe desert isn't the right … It's like a patch of a jungle almost, it's more like it's chaotic, if you will, it's in the muscle. And that also probably causes the uterus I'm sure to cramp and maybe be somewhat distorted in its shape, right?

Dr. Nicole Browne:

That's exactly right. Actually, everything that you just said, Aimee, are some of the reasons why we think that implantation is lowering women with adenomyosis. One potentially can distort the uterine cavity so it can interfere with the interaction of the sperm, and the egg, and the subsequent movement of the embryo into the uterus. There's also some thought that there's abnormal steroid production in the endometrium of women with adenomyosis and abnormal steroid hormone receptors so the response to hormones can be exaggerated, especially with the hormone estrogen and the setting of the adenomyosis. And that can affect implantation.

Aimee:

I have to think of the exact case. I think I was talking to her yesterday. I'm like you sometimes where I'm like I have so many cases and I remember the cases. I like to be able to picture the person it helps me tell the story. Anyway. She was saying since doing rounds of fertility treatments that have not worked, unfortunately, now her period is super heavy and painful, and that's made one doctor think that it was endometriosis. That basically the stim meds have exacerbated the endo. But would you also then say, “Well, maybe that's reason to think for adeno as well or we would just”-

Dr. Nicole Browne:

For sure. For sure. The symptoms associated with endometriosis are pretty similar to those associated with adenomyosis. Adenomyosis, remember Aimee, is endometriosis it's just tissue, it's endometriotic tissue growing in the wall, the muscular portion of the wall of the uterus so it behaves just like endometriosis. But then you also have to rule out other factors that can sort of mimic the same symptoms as endometriosis and adenomyosis, specifically uterine fibroids, okay?

Aimee:

Or myomas or something like that, right?

Dr. Nicole Browne:

Exactly.

Aimee:

What do you think is the best diagnostic tool for endo or adeno?

Dr. Nicole Browne:

Okay. Taking a thorough history and performing a pelvic exam … Because sometimes on physical examination the uterus is enlarged in the setting of adenomyosis and it can have a globular shape to it, a globe-like shape. And-

Aimee:

Yes. Instead of more of a heart-like shape, right?

Dr. Nicole Browne:

Exactly.

Aimee:

Okay, okay.

Dr. Nicole Browne:

Exactly. After taking a history and doing an examination, then what we would recommend is doing a pelvic ultrasound. And you can readily do a pelvic ultrasound in a fertility doctor's office. But on ultrasound, some of the things that we're looking for is asymmetry between the top and bottom wall of the uterus, you can see that with adenomyosis. Sometimes you can even see striations from the lining of the uterus going into the muscular portion of the wall of the uterus. And you can also see sometimes cyst-like structures in the muscular portion of the uterine wall.

Aimee:

And they're long, right? They're not round they're these elongated ones. So the striations would be differentiated because it's not trilaminar, right? We're typically looking for the trilaminar.

Dr. Nicole Browne:

You can have a trilaminar appearance. You can also have a very heterogeneous lining or a homogenous lining to the cavity of the uterus. But it's pretty significant when you start to see this linear striation go from the endometrial lining into the muscular wall.

Aimee:

Goes in deeper almost.

Dr. Nicole Browne:

It goes in deeper. Exactly. You can think of it that way. But I think the best imaging modality is going to be an MRI because you're specifically looking for a thickening of something called the junctional zone. The junctional zone is the interface between the lining of the uterine cavity and the inner portion of the muscular wall of the uterus. When the junctional zone is thickened then that is usually evidence of adenomyosis. So MRI is really the best imaging modality to make the diagnosis.

Aimee:

Cool. And then I just want to clarify what I'm hearing because I've always seen them as two separate. Adeno is basically endo but in the muscle layer. Can one exist without the … I know we can have endo and not have adeno, but can we have adeno and not have endo?

Dr. Nicole Browne:

You sure can. You sure can. You sure can.

Aimee:

We know adeno and the presence of it, obviously, is going … Could change the structure of the uterus, would also impact implantation. Will it cause or does it cause an immune response in the uterine environment? Or is that, again, hard to say generically, if you will, for everyone?

Dr. Nicole Browne:

Good. And remember, adenomyosis is just a form of endometriosis, it creates an inflammatory environment, okay? There's an abnormal inflammatory response in endometriosis … With endometriosis and with adenomyosis, in part because of a specific type of white blood cell called macrophages. And when these macrophages are activated they release a lot of pro-inflammatory markers.

Aimee:

All kinds, yeah.

Dr. Nicole Browne:

Those pro-inflammatory markers can increase free oxygen radical species that can affect the egg, the sperm, and the embryo. So you can think of these inflammatory markers as being toxic to all three of those things. Yes, adenomyosis is a … Has a very heightened immune response.

Aimee:

You've just made me want to ask this question which I didn't tell you I was going to ask you. In response to that free radical uptake, if you … Or uptick due to the endo or the adeno, we could then say … Bear with me. That not all your eggs are bad but the environment in which they're being fertilized or growing could impact the quality versus … I mean, you know the story, you do this for a living. Most women are told, “Oh, sorry, it's just all your eggs are bad” and no one's really considering how the environment is impacting egg and sperm quality as they implant and then develop. I don't want to put you in an uncomfortable position. I'm more just thinking, the endo and the adeno-

Dr. Nicole Browne:

Aimee I'm-

Aimee:

Frozen. Can you hear me? I froze or did you freeze? Did you get all that or no because you were frozen?

Dr. Nicole Browne:

Yes, I can hear you now, I can hear you now. I heard some of that, Aimee. To answer your question, you're right. We know that egg-quality fertilization and implantation rates are lower in women with endometriosis. You're probably right, it's probably due … There is a component that is due to the abnormal immune response associated with these conditions.

Aimee:

I just think more that blanket response, all your eggs are bad, is more like well … But we haven't really looked at the environment. My work, right, we're really focused on lowering inflammation, regulating the immune system, improving uterine blood flow, right, so to improve the environment which then … From what I can see improves pregnancy outcomes. We'll never quite know, but it's like is the work improving egg quality and embryo quality, or is the work actually improving the environment and then the embryo now has more of what it needs to survive versus … The endo and the adeno I think create more of a toxic environment, that's how I would just generally see it.

Dr. Nicole Browne:

I completely agree.

Aimee:

So then if you suspect, your first line of next steps would be pelvic MRI, not lap.

Dr. Nicole Browne:

Not a laparoscopy. Surgery is a last resort for adenomyosis, especially for patients wanting to have a child. Because the only way to treat it, ultimately treat it, is a hysterectomy so that's not going to be an option for patients wanting to have children.

Aimee:

That now I'm remembering the story that I was sharing before that I couldn't remember. I just had a patient too who she was told by this doctor, “We suspect endo and maybe adeno based on your poor response to the fertility treatments.” And it was pretty high stims. They were given her 300 Gonal, and priming her with estrogen, and things of that nature. And the doctor said that she would do a lap plus go into the uterus and remove some of the adeno. I was like don't touch your uterus. She's like “And then it would be a six-month recovery, then you could get pregnant.” And I was like, “I would not do that.”

Dr. Nicole Browne:

I agree.

Aimee:

You agree. I would go and do the lap, remove the endo, and then do compression for two months, right? And somewhere in the middle do a retrieval or two to collect some embryos, right? What would you do in a case like that? How about that?

Dr. Nicole Browne:

Good. Doing a laparoscopy to address any endometriotic implants to try to lower inflammation is fine, okay, prior to the start of an IVF cycle. I do suppression therapy after a patient … Well, banks embryos, okay? Because the suppression therapy, I usually recommend three months of Depot Lupron before undergoing a transfer to really quiet down the inflammation associated with adenomyosis and even endometriosis. We were talking before, Aimee, about altered hormone production and the responsiveness of the endometrium to the more … To estrogen production in the setting of endometriosis and adenomyosis. So this is where hormonal suppression really comes into play. People have looked at this and they've seen higher pregnancy rates in the setting of adenomyosis after doing three months of Depot Lupron. Again, because we know it's a hormonally responsive disorder, we know that the higher levels of estrogen can also affect receptor expression in the lining of women who have adenomyosis. This suppressive therapy with Depot Lupron, a few months before undergoing an embryo transfer, can actually help with implantation and potentially even lower miscarriage rates. It's a hormonally responsive disorder so suppressing it=

Aimee:

You got to suppress it, right?

Dr. Nicole Browne:

With hormones is cool.

Aimee:

But you want to be careful with the suppression, I guess, especially in our later 40 girls because we could put them in … So suppression basically means we're putting you into menopause if you will. That's what you would maybe, in the layman's terms, see it as, right? We're suppressing all of your hormones so that this stuff stops growing, the uterus has time to heal, and then become, I guess, healthier that … Then it can receive the embryo. And I've had plenty of patients go through it where … I've never had a patient not come back though, I will say that. I've never had her not come back to cycling. I just did a story of Hope, she's 45. She has a five-week-old, she did suppression, her period came back. She's still in the game if you will.

Dr. Nicole Browne:

It's like a pseudo-menopausal state with Depot Lupron.

Aimee:

Pseudo-menopausal then.

Dr. Nicole Browne:

Yeah. Definitely not true menopause, a pseudo-menopausal state. This is why I encourage patients to bank embryos before being committed to this 12-week course of Depot Lupron to really make sure that they've amassed a certain number of embryos before they're ready to undergo a transfer because the effects of Depot Lupron can stay on for a couple of months after the last injection.

Aimee:

Okay. So then in your opinion, do you push for the endo surgery for the lap or do you just prefer suppression across the board?

Dr. Nicole Browne:

Good. I think depending on symptoms. If you have a patient who has excruciating periods, and they haven't responded to hormonal treatment in the past, and they're looking to get pregnant, I don't think it's a bad idea to undergo a diagnostic, possible operative laparoscopy to remove any endo. Because again, it creates an inflammatory condition that can affect implantation. I recommend surgery in that setting and then going right into a treatment cycle followed by a course of Depot Lupron before undergoing a transfer.

Aimee:

Oh, I just had another question, what was it? It escaped me. Oh, yeah. So in the endometriosis setting, say we see an endometrioma or something like that … I think it's a little more obvious like okay, there's endometriosis here. This is the question I had. So what about women who, say, are making genetically normal embryos, healthy embryos, they have a good reserve, not getting pregnant, right? We're transferring, we're transferring, transferring, we're not getting pregnant. Would it be something that you'd go in and try to rule out adenomyosis or recommend … So would you then go to a pelvic MRI? Do you think it's always showed up on a pelvic MRI? There's no way it's to be missed on a pelvic or can it be missed?

Dr. Nicole Browne:

It potentially could be missed. MRI is a pretty sensitive imaging modality. What you're describing-

Aimee:

Do you think it's possible-

Dr. Nicole Browne:

It's definitely a possibility. What you're describing sounds like recurrent implantation failure where, let's say, no concerns about a quality sperm quality or even embryo quality, but for some reason, a couple, they're just not getting pregnant. There's no general consensus on what causes recurrent implantation failure but adenomyosis should be included in the differential. At that point, yes, you're right. I would spend time studying the uterus, okay? And there are different ways to study the uterus. There are many endometrial function tests that allow you to look for specific receptors that are absolutely necessary for implantation to occur. And we do know, in the setting of adenomyosis, that there's lower integrin receptor expression.

Aimee:

[inaudible 00:20:35] B, right? Isn't that it?

Dr. Nicole Browne:

Exactly. And without integrin receptors, even the most beautiful embryo won't implant into the uterus. And Depot Lupron has been shown to potentially upregulate those receptors.

Aimee:

And then what are some of the other endometrial function tests that you like to run?

Dr. Nicole Browne:

I will also do an ERA study. I think there's utility to doing ERA for some patients. I do Receptiva and ERA.

Aimee:

Okay. What about the [inaudible 00:21:05]? What do you think about that? I know it's not really … She's pointing us to endo or adeno but do you see utility in that test?

Dr. Nicole Browne:

I haven't used it, haven't used it.

Aimee:

You'll do the endometrial biopsy though to rule out endometritis?

Dr. Nicole Browne:

Oh, I'm so sorry, I didn't hear what you said, Aimee. Endometritis. Actually, there's a part of the Receptiva assay that's one of the things that is screened for. Endometritis, it's very treatable. We treat it commonly with doxycycline for a couple of weeks.

Aimee:

So if we're having repeat implantation failure and there's no other concerns, if you will, I think looking at the uterus is a smart thing to do. Let me just see. I know why we had a list of questions. Oh, yeah. I was saying, at what point do you put somebody in the repeat implantation failure category? Is it three transfers of healthy normals? I don't know, you tell me.

Dr. Nicole Browne:

Good. There's no general consensus on the definition of recurrent implantation failure. But I think it's fair to say that if after three failed attempts of a transfer attempt with high-grade embryos, you probably have the diagnosis of recurrent implantation failure.

Aimee:

I mean, I know the practice you work with, and I know Dr. Merhi and Dr. Marco's if you will … Their standard operating procedures. They're big fans of the hysteroscopy, right? Do you feel similarly? I think we look at it very similarly, we've had many conversations about this. Every embryo you work your ass off to create. I think it's-

Dr. Nicole Browne:

That's right.

Aimee:

Highly valuable and really important. So before we go and do a transfer, right, I'm a big fan, especially if there's been no pregnancies … I see these cases a lot, right? They have a baby, now they're trying secondary infertility, they're not getting pregnant. I always think well, we should probably check the uterine cavity because isn't that … But then also we have these women with unexplained infertility, and they've done all the things, and still five IVFs later it still hasn't worked. I believe you're in agreement of doing that … Those endometrial function tests sooner than later in a lot of cases. Would you agree?

Dr. Nicole Browne:

Definitely. We can't forget that the uterus does play a role in our ability to get pregnant and to stay pregnant so you always want to evaluate the uterine cavity whether it be a water ultrasound or a hysteroscopy. Because remember, what someone may call normal there could be an abnormality that just wasn't detected but could put you at greater risk for a miscarriage if it goes undetected. So for sure, evaluating the uterine cavity with a hysteroscope is never a bad idea. Especially in the study-

Aimee:

I feel like too because-

Dr. Nicole Browne:

Of recurrent implantation failure.

Aimee:

What I've seen on my side is the saline sono can miss what the hysto typically doesn't miss, right?

Dr. Nicole Browne:

Exactly.

Aimee:

You would agree I think, I mean, the hysto is … You have to go under anesthesia, it's a much bigger procedure, right? I mean, I get all that. To me, the pros far outweigh the cons. I mean, that's typically what I say. One question was, can an MRI diagnose endo? I believe the answer is yes. A pelvic MRI is another way to diagnose the endo besides a laparoscopic surgery.

Dr. Nicole Browne:

Sure. That's correct. If you have severe stage endometriosis, chances are it's affecting nearby organs like the ovaries. So you can get an endometrioma, which is endometriosis in the ovary that forms, and that can determine the diagnosis of endometriosis.

Aimee:

Someone else said that their doctor was recommending Orilissa. How does that compare to Depo Lupron?

Dr. Nicole Browne:

Okay. Orilissa is a GnRH antagonist so it also suppresses the ovaries. And remember, estrogen contributes to the growth and development of endometriosis and adenomyosis. So potentially Orilissa and Depo Lupron can be effective here to really shut down the inflammation associated with adenomyosis and endometriosis.

Aimee:

But the research has been mainly on the Depo Lupron for implantation failure which is why I think that's the default.

Dr. Nicole Browne:

That's exactly right. And the pregnancies have been reported with Depo Lupron.

Aimee:

Yes, exactly, exactly. Side effects are about the same. They can't be very different if you will, they're both going to do that pseudo-menopausal thing.

Dr. Nicole Browne:

Exactly.

Aimee:

Which, by the way, I'm going to use that term forever now, pseudo-menopause. In our world the word menopause scares the shit out of all of our girls. Although you guys are rocking that boat a bit which I love. Okay.

Dr. Nicole Browne:

Thank you, Aimee.

Aimee:

So let's see. So anything else you want to add that you think is important for girls to know? If they're maybe thinking oh, maybe I do have adenomyosis … I guess this is one more question that I have. Could a woman have adeno or endo, and/or, which I know they're of the same root, and not have heavy, painful periods?

Dr. Nicole Browne:

You can. I mean, there are women who have advanced-stage endometriosis and they never knew about it because they were always asymptomatic. So yes, it is possible. You know, Aimee, I would just encourage women to remember that the uterus does play a role in our fertility. I think we spend a lot of time talking about the egg, and the sperm, and the embryo but don't forget the uterus. There are endometrial function tests. There are things that can be done sooner than later to try to make the … Establish the diagnosis of adenomyosis then. If it's present you definitely want to treat it to increase your outcomes.

Aimee:

And I see it a lot where … And I know you guys do too because you're getting girls that have been at other clinics, where doctors are just refusing to do those endo … Those uterine function testing. Or refusing to do the hysteroscopy, refusing. They say there's not enough data to support looking for the endometritis and treating it. I see it as a big part of my job of arming them with the script or with the … Empowering them to go get another opinion then. I don't know. What would you say to women that are facing those challenges with their doctors?

Dr. Nicole Browne:

Keep advocating for yourself. We are here at Rejuvenating Fertility Center.

Aimee:

Boom. That's it. Yeah, because you're a huge advocate for women which I mean, I appreciate so much. I could cry right now saying it. But it's just like you guys fight for women in such a beautiful way. I think it's fairly obvious that it's a uterine issue but yet the blame still falls typically on the woman regardless of her age and her egg quality.

Dr. Nicole Browne:

That's exactly right.

Aimee:

We're here to move the ball forward and empower you guys with the information so you can ask the right questions and get to the bottom of it. And I think it's just keep pushing and advocating. And then also don't forget to get other opinions. And then someone commented, “Go to RFC they're the best. My baby is here because of working with them and with Aimee. They're great.”

Dr. Nicole Browne:

Thank you so much that means a lot.

Aimee:

Okay. This was so lovely. I loved doing this we'll have to do more of these. Do you have anything else you want to add or you feel good? I feel like we covered a lot.

Dr. Nicole Browne:

I think we did. Patients should be well-informed after our talk today about adenomyosis, fertility, and recurrent implantation failure Aimee.

Aimee:

Okay. Sounds great. Thank you so much, Nicole. Go enjoy the rest of your day. I think I'll be in on Friday. Oh no, today is Friday. I'll be in on next Friday, I'll see you then.

Dr. Nicole Browne:

Looking forward to it. Have a nice weekend.

Aimee:

Goodbye. Bye, you too.

Dr. Nicole Browne:

Bye-bye.

Aimee:

Goodbye, everyone, thank you.

END TRANSCRIPT.

Interested in working with Aimee? Join her 6-month Functional Fertility program: aimeeraupp.com/coaching 

Get Aimee’s fertility books here: aimeeraupp.com/books 

Grab my FREE fertility starter kit here: aimeeraupp.com/fertilitystarterkit 

How to do castor oil packs: https://aimeeraupp.com/get-pregnant-faster-tip-castor-oil-packs/ 

Get my FREE MTHFR guide here: aimeeraupp.com/mthfr

Disclaimer: Please keep in mind that I am not a medical doctor. I have been a practitioner of Traditional Chinese Medicine for over 17 years and I will be speaking from my clinical experience helping thousands of women conceive. The office of Aimee E. Raupp, M.S., L.Ac and Aimee Raupp Wellness & Fertility Centers and all personnel associated with the practice do not use social media to convey medical advice. This video will be posted to Aimee’s channels to educate and inspire others on the fertility journey.