Endometriosis and Failed Implantation: Why High-Quality Embryos Don’t Stick | Dr. Sadikah Behbehani

If you’ve ever been told your embryos are “high quality” but your transfers keep failing, this episode will change how you think about implantation.

In this powerful and science-forward conversation, Dr. Erica Bove sits down with Dr. Sadikah Behbehani — board-certified Reproductive Endocrinologist and fellowship-trained Minimally Invasive Gynecologic Surgeon — to unpack one of the most overlooked causes of IVF failure: endometriosis.

Up to 50% of women undergoing IVF may have undiagnosed endometriosis. Yet many are told everything “looks normal.”

In this episode, we explore:

• Why high-quality embryos fail to implant

• The role of inflammation in recurrent implantation failure

• Silent endometriosis and unexplained infertility

• When to consider laparoscopy

• Excision surgery vs. Lupron suppression

• How endometriomas impact egg quality and ovarian reserve

• Adenomyosis and its effect on embryo transfer outcomes

• Natural pregnancy rates after endometriosis surgery

• What REIs may miss — and when to advocate for deeper evaluation

Dr. Behbehani explains why endometriosis is not just a pain disorder — it is an inflammatory disease that can distort anatomy, disrupt egg development, and interfere with implantation, even when embryos are genetically normal.

This episode is essential listening for anyone navigating IVF, recurrent failed transfers, diminished ovarian reserve, chronic pelvic pain, or a diagnosis of “unexplained infertility.”

If you’ve felt like something is being missed in your fertility journey, this conversation offers clarity, nuance, and a path forward grounded in both love and science.

About Dr. Behbehani

Dr. Sadikah Behbehani is a nationally recognized OBGYN and one of the leading endometriosis doctors in Los Angeles & Newport Beach, specializing in Reproductive Endocrinology and Infertility, as well as Minimally Invasive Gynecologic and Robotic Surgery. With double fellowship training, which is an achievement held by only a handful of physicians in the country, Dr. Behbehani offers a unique blend of surgical expertise and fertility care. As an experienced endometriosis excision surgeon and pelvic pain specialist Los Angeles, she is highly skilled in treating even the most complex gynecologic conditions affecting fertility, such as endometriosis and uterine fibroids. Her advanced training allows her to address these challenging medical conditions with precision, helping patients achieve better health outcomes and improved quality of life.

Find her:

Instagram: dr.sadikahbehbehani

Tiktok: dr.behbehani

As always, please keep in mind that this is my perspective and nothing in this podcast is medical advice.

If you found this conversation valuable, book a consult call with me using this link:

https://calendly.com/loveandsciencefertility/discovery-call

Also, be sure to check out our website: loveandsciencefertility.com

Follow us on social media:

IG: www.instagram.com/loveandsciencefertility

FB: www.facebook.com/profile.php?id=61553692167183

Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.

In Gratitude,

Dr. Erica Bove

Transcript:

Hello, my loves, and welcome back to the Love and Science podcast.

I have been waiting to record this episode for a while, and I have a really wonderful guest with me today.

Dr. Sadikah Behbehani, and she is a friend, she is a colleague. She is the expert nationally, internationally, from my perspective, on endometriosis and reproductive surgery.

And she is both an REI and a MIGS-trained (minimally invasive gynecologic surgery) physician. And so it’s this beautiful combination of somebody who sees the pelvis through the eyes of an REI. And it’s just amazing.

So let me tell you a little bit more about her.

She is the founder of the Center for Endometriosis and Fertility in California. And we actually share a number of people together. She has patients who become my clients, and it’s this beautiful teamwork that we share together.

And so welcome Dr. Behbehani. It’s so wonderful to have you.

Thank you so much for having me here, Dr. Erica. I’m excited to be on your podcast. I’ve listened to a bunch of your episodes and I’m glad that you’re out there raising awareness and educating women on the fertility journey.

Yes. And you know, thank you so much. And I think it does take the love and the science and I see the love with what you bring to your patients and it’s so beautiful. And I think your patients just feel so loved and held.

And you have that double edge, sort of being able to, like literally the scalpel, right? You are able to take out the endometriosis, you’re able to restore normal anatomy, you’re able to improve their chances.

And so, you know, I would say as an REI, some of the most questions I get are pertaining to endometriosis, silent endometriosis, like all of these questions. You know, why are my high quality embryos not taking? Maybe it’s endometriosis.

So let’s start at the basics, right?

Say you’re listening and you’re like a cardiologist and you don’t quite remember all this stuff from medical school, and plus, I mean, science has advanced. We know a lot more about endometriosis than we did even 20 years ago.

Can you tell me a little bit about what is endometriosis?

Yes, and first of all, let’s backtrack a little. You said cardiologist. I bet you even OBGYN residents have very limited information on endometriosis. MFMs, urogynes, we’re all GYNs, but we get very little training in endometriosis in general residency and OBGYN residency.

So it really takes subspecialty training or advanced training in order to properly understand the disease and be able to manage it.

You and I are both REI. We did an extensive training program to learn about infertility and learn about how to retrieve eggs, do IVF, egg quality issues and all that. But we didn’t really learn how to become endometriosis surgeons because it is a whole different training set, it’s a whole different technique. And it takes years to become an expert in endometriosis.

And so like you mentioned, I saw that struggle when I was in REI. So I did my REI fellowship first, then my surgery MIGS training. So I saw that struggle when I was in REI.

We would suspect patients have endo, we would even potentially diagnose them with endo. It’s on their chart everywhere, but we didn’t know what to do about it because we weren’t surgeons.

We would have to send them out to the surgeon for treatment and it takes months to get an appointment and to get in to have surgery and that delays their childbearing.

So to go back to your original question, what is endometriosis?

Endometriosis is the presence of tissue that is similar to the lining of the uterus outside the uterus. So it’s ectopic tissue. It’s tissue that shouldn’t be there.

Women always ask, well, how did I get that tissue to grow inside of me? Is it something I did wrong?

So first of all, to be clear, it is absolutely never your fault that you have endometriosis.

Women are born with this sort of tissue. During Müllerian development, during congenital development, as the uterus grows, some of those deposits get left behind in areas where they shouldn’t be.

And then as women get their cycles and their periods with hormone stimulation, those implants become more active. They start to produce inflammatory deposits, and then they can cause pain, they can cause fertility issues, they can cause issues.

So by definition, endometriosis is the presence of tissue that’s similar to the lining of the uterus outside the uterus in areas where it shouldn’t be.

How can that affect a woman in general?

It can cause pain. So pain is the commonest symptom of endometriosis. It can cause pain with bowel movements. It can cause pain with urinating. It can cause pain with sexual activity.

Depending on where those implants are located, how long they’ve been exposed to hormone stimulation, how much activity is in that implant determines the level of pain.

However, some women have early stage disease and a lot of pain and other women have really advanced stage disease and no pain. So the disease severity does not correlate with symptom severity.

Yeah, it’s so interesting. I mean, would you say that maybe not all endometriosis is created equal?

Absolutely. And some women are trying to find reasons, why did my endo grow so fast?

And I recently came across a patient who has a twin sister. Their mom had endometriosis and she had really bad endo. And they’re identical twins. They come from the exact same genetic material.

One has really easy, flawless periods, no issues, forgets she’s even on her period. And the other twin sister is in bed calling in sick for a week, can’t get out of bed, can’t function, can’t do anything.

They lead very similar lifestyles. They live in the same city. They came from the same genetic background. They were raised in the same household and they grew up the same way, but yet they display different symptoms and different disease progression.

So it’s really hard to tell why some women have more symptoms than others.

However, lifestyle factors come into play as well. So women who are on an anti-inflammatory diet who try and stay active and healthy are less likely to have pain symptoms and may have better management of their symptoms compared to women who are exposed to inflammatory markers consistently like alcohol, caffeine, smoking, or are pro-inflammatory in general with their diet and lifestyle.

It is not to say that going on an anti-inflammatory diet will kill your endo, will stop your endo from growing. It’s probably still there. It’s just to manage your symptoms.

And that brings me back to the woman going through her fertility journey, right? Because this is what I do every day.

I would love to educate women and talk more about the role of endometriosis and fertility. It really bugs me when my young women patients see their doctors and get told, “You have endo, you’re probably not going to be able to get pregnant. You’re going to have infertility.”

And then they get reckless with contraception and all of a sudden they’re pregnant and they’re like, “Wow, my doctor said I can’t get pregnant. What’s going on?” Right.

Right. So let’s talk about statistics.

70% of women with endometriosis can get pregnant naturally. Only 30% of women with endo have infertility.

So the majority of women with endometriosis have no issues getting pregnant. And that’s why if you have children, it doesn’t mean you cannot have endometriosis. You can still have endo and get pregnant naturally because that’s what the majority of women with endometriosis do.

However, if we look at the infertility population, so you and I both work in fertility clinics. So let’s look at our patients who walk through our doors for fertility training or fertility treatment, 50% of those women will have endometriosis.

So that’s a huge statistic. It means that the woman going through IVF, all our patients going through IVF, there’s a 50% chance they have endo. And it’s because of what you just called silent endometriosis.

And I hate calling it silent because—

Yes, I do too.

Yes, because to me, infertility is a huge symptom, right? It’s not silent if the woman is struggling to conceive. That’s a huge symptom.

And if you ask the right questions, you’re more likely than not going to pick up on subtle symptoms that this patient has always had that she thinks is normal.

For example, just being bloated consistently on your period, having pain with bowel movements on your period, having diarrhea on your period, or having really bad cramps, but it’s just for two days and then it gets better with Advil. That’s not normal.

Women should be able to function normally on their period. They should not have to plan things around their cycle.

I have so many women who tell me, well, my daughter’s soccer tournament was on a weekend where I was on my period, so I was really bummed I had to miss out on the entire tournament.

Because they plan in advance, they know, oh, this weekend I’m not gonna be functioning. I’m not gonna be there for my children.

And this lady has kids already. So having children doesn’t mean you can’t have endo.

Having symptoms that you have normalized because that’s your normal over the years doesn’t mean it can’t be endo.

But in some women, endometriosis can cause infertility to be their presenting symptom.

So some women present to you and me just here for a workup for fertility, and they may not mention any symptoms that you and I suspect to be endo related.

We go through IVF cycles like you mentioned, and then we do transfer after transfer, and they don’t get pregnant.

The commonest cause of unsuccessful implantation is inflammation. The commonest cause of inflammation in the pelvis is endometriosis.

So please listen to your body.

Sometimes you have to encourage your doctors to look and investigate for endometriosis because for a lot of REIs, it just sometimes is a numbers game and they want to just keep going with transfer after transfer, especially if you have a great number of embryos in storage.

But also every embryo we want to give its best chance at implantation. And if there’s disease and inflammation in the pelvis, then that’s not helping you get pregnant.

And if we don’t do anything about it, we’re going to keep getting the same results because the definition of insanity is doing the same thing over and over and expecting different results.

The definition of insecurity, yeah.

Yeah, yeah, no, absolutely. And I think I have not done a MIGS fellowship. And you know, in my REI training, it’s like, oh yeah, a third of patients get this diagnosis of unexplained infertility. It’s because we’ve looked at everything and everything checks out.

And then, you know, it’s interesting to, I’m like, okay, so I’m studying for my boards and I’m like, huh, isn’t it interesting that, you know, if people don’t want to go right to IVF, that, you know, people do clomiphene and IUI for unexplained infertility.

And that’s also the standard of care for endometriosis. Huh, that’s really interesting. Why does it work out that way?

And you know, and then I started putting the pieces together. I’m like, oh, it’s probably because a lot of those people with unexplained infertility actually have endometriosis and we haven’t looked hard enough or diagnosed it or whatever else.

And so I do think that we could really reduce that percentage of people with unexplained infertility a lot more if we thought about endometriosis. But also sometimes it can be a challenge for people to get that diagnosis.

So let’s talk a little bit about diagnosis of endometriosis and how you think about it.

With your perspective, how do you think about when people come to your office?

You’re absolutely right, because it is a difficult diagnosis to make.

Endometriosis, we suspect you have it if you have symptoms that are commonly seen in endometriosis, but we can’t really put a formal diagnosis unless we’ve done surgery, removed tissue specimen, and have the pathologist look under the microscope and say, “Yep, I found tissue that looks similar to the lining of the uterus, should not be there.”

So endometriosis by definition is a pathological diagnosis. You need pathology to diagnose endometriosis.

And so when you look at the workup for infertility, the very bottom of the list is always going to be a diagnostic laparoscopy. And that is to look for and treat endometriosis.

So when I was a fellow, there was this study that we kept quoting, number needed to treat is 12, meaning that for women with unexplained infertility, if you take 12 women to the OR for diagnostic laparoscopy—and I don’t know why they call it diagnostic, because it’s not enough to just pop in a scope and say you have, or we see lesions that look like endo, you really need to do something about them.

But one out of 12 will get pregnant by just treating the endo.

So that just shows you the power of treating the endometriosis and getting rid of the inflammation.

So now this is like a really old study. This is how you and I were—

Yeah, yeah.

—the data we had looked at when we were in training.

But if you look at the more recent data now, there is so much data to support excision of endometriosis in order to help improve pregnancy chances.

So let’s backtrack a little.

We talked about how diagnosis of endo can be tricky because it requires surgery. However, I don’t think of the surgery as simply being a diagnostic tool. I think of it as being both diagnostic and therapeutic.

Why? Because now we have the strong suspicion of endo. You have all the symptoms of endometriosis. You have pain with your period. You have pain with bowel movement. You have pain with intercourse. Or we highly suspect you have endo because you have unexplained infertility, we’ve done two embryo transfers and you’re not pregnant yet.

So there’s a strong suspicion for endo. The only way to confirm it is surgery. However, when we do surgery, we’re not just saying, yes, we found endo, we are treating the endometriosis.

Treating the endometriosis means cutting that inflamed tissue, getting rid of those cells that shouldn’t be there. So it’s excision, we cut it out.

And sometimes we look at it and we see just a tiny spot, like looking at the tip of the iceberg, but you need to really dissect it. You need to really look at it because once you start cutting into that endo, many times it’s actually deeper than you think. It’s actually more fibrotic than you think.

Any fibrosis, any disease you leave behind is inflammation that you’re leaving behind. So you need to be very thorough with your excision surgery and that requires skill.

This is why I don’t recommend getting a diagnostic laparoscopy with your local OBGYN because they may be able to put in a scope and say, “Uh-huh, we found those abnormal lesions,” but they are probably not skilled or trained to cut out those lesions.

And that’s where surgery becomes important.

You want one surgery, you want one and done, you want one good thorough excision surgery to say, “Okay, we’ve reset the clock for you. There’s no more inflammatory cells in there. Now let’s go and get pregnant. Should we try naturally or should we go back to IVF?”

And our women who’ve had unsuccessful transfers, the data, Dr. Erica, is very, very interesting because more and more studies are now being done on women who have had surgery to clear out their endometriosis and are told, okay, let’s give you a chance at natural pregnancy and see what happens.

And the interesting fact is 30 to 50% of those women will get pregnant naturally. That is huge.

So there’s a study done by a group in France that really focus on endometriosis data. They publish a lot. I love their papers because the numbers that they have in there are very large because they are multi-center trials.

But they looked at women who had two unsuccessful IVF transfers with ICSI embryos. So two embryo transfers unsuccessful. And then they had surgery for endometriosis. 30% of those patients got pregnant naturally. So two failed IVF ICSI’s, surgery, natural pregnancy, and 30% of these will.

Wow.

And then there’s another data that looked at women with infertility who just wanted to have surgery for endometriosis. They’ve not done IVF, they just wanted to have surgery for endometriosis. 50% of them got pregnant naturally.

That’s a huge number.

So this is just to show how much of an impact this inflammation from endometriosis has on fertility and how we shouldn’t ignore it because your pregnancy chances are going to be improved both naturally and with IVF.

Obviously not everyone’s a good candidate to try naturally after surgery. Some women lose their tubes, some women have frozen embryos that are stored already, they’re older, their egg quality is lower.

But if we do excision of endometriosis first, then do an embryo transfer, we have an extremely higher chance of implantation than if we were to just ignore the endo and try and force the embryo to stick.

Because with local inflammation around the pelvis, that’s not gonna happen.

And I say local, it doesn’t only have to be endo around the uterus, ‘cause some women ask me, “Well, what if my endo is away from my uterus?” It doesn’t matter.

The data has shown that even diaphragmatic endo, so endo on your diaphragm, causes enough inflammation to impact implantation rates with fertility.

And I wanted to talk about, and I actually was not aware of that study. Thank you so much for bringing that up about the natural fertility after IVF. I will check that out.

But let’s talk a little bit more. I’m sure curious minds want to know the pathophysiology of what is happening with endometriosis. Why is it so bad for fertility?

You mentioned, you know, obviously inflammation, it can be far from the pelvis, like thinking about egg quality, environment stuff. Let’s talk a little bit more about that.

That’s a great question.

So when we talk about endometriosis and its impact on fertility, we have to look at the big picture here.

How can endo reduce our chances of pregnancy?

One, is it can distort the anatomy. So when we’re talking about endo, there’s a lot of scarring, there’s a lot of fibrosis.

And actually the ASRM staging system for endometriosis was put in place to determine the chances of fertility with every stage. It is not to determine the chance of pain because with stage one endo you have little deposits, with stage four endo you have massive scarring, distortion of the anatomy, lots of endo deep into the organs.

So when the anatomy is distorted, pregnancy chances drop. So one method how endo can impact fertility is distortion of anatomy.

The second is through the ovary.

So when you have ovarian endometriomas, which is considered deep infiltrative endometriosis of the ovary, DIE. When you have deep endometriomas on the ovary, that is a whole different issue and problem to tackle with fertility.

Because now you’re creating inflammation, just like you said, around the egg where the egg is growing. All that ovarian cortex will be exposed to inflammatory deposits from this huge endometrioma.

It’s a space occupying lesion. It’s squishing and pushing all those healthy follicles, not giving them place or room to grow.

And then also it’s impacting your ability to stimulate that ovary for IVF because now the ovary is large. It’s not where it’s supposed to be. It’s stuck somewhere. It’s either stuck to the bowel, stuck to the uterus, or stuck to the pelvic sidewall high up.

And then the ovarian cortex around it is not going to give you the healthy eggs you’re looking for.

So ovarian endometriomas can affect the egg quality by being just so close to the healthy eggs and ruining the environment for those eggs to grow.

And then third, just in general inflammatory deposits.

So those endometriotic implants produce prostaglandin, cytokines, all those inflammatory markers.

There’s even a test that we conduct in REI, the Receptiva test, where we get a biopsy from the lining of the uterus to look for BCL6 marker, which is an inflammatory marker.

So we all agree that endometriosis is pro-inflammatory and there’s a lot of newer testing modalities that are being studied right now to try and figure out a more accurate way to diagnose endo without actually having to do surgery, but unfortunately none of them are perfect yet.

I’ve had a lot of issues with those tests where women say, “Oh, I tested negative. I cannot have endo,” but they have all the classic symptoms of endo and I go in and do their surgery and they 100% have endo. They have stage three endo. They have not even early stage tiny endo.

So we cannot rely on those tests.

But what I’m trying to say is inflammation is agreed upon with endometriosis. We all agree there’s inflammation. We’re just trying to figure out how to get rid of the inflammation or how to test for the inflammation without going through surgery.

And I’m sure someone’s thinking as they’re listening to this podcast, Lupron, Lupron, can you talk about Lupron? Can you talk about suppression?

Because a lot of REIs don’t want to operate. Like we talked about early on, our training in fertility was not focused on surgery.

Yes, we did surgical rotations, we followed our MIGS surgeons around, we operated with them, we definitely gained more surgical knowledge during REI than we did with general OBGYN residency. You know, you built upon that skill, but it still was not enough for endometriosis and how to treat advanced endo.

So REIs sometimes recommend Lupron, right? It makes sense. There is data to support Lupron.

What is Lupron? Lupron is a GnRH agonist. It shuts down hormone stimulation.

We talked about how endo deposits feed on hormones. Endo deposits grow every time you have a period, every time there’s estrogen. They may make their own hormones too. Those endo deposits have receptors that can make their own estrogen, but they also respond to exogenous hormones and exogenous estrogen.

And so as your body is producing its own hormones, or sometimes women even worry about going through IVF stimulation, I’m getting all those drugs, all this estrogen, those endo implants are reacting to hormones.

So what Lupron does is it shuts down hormone production in your body. So you’re no longer producing estrogen, you’re in menopause because of the Lupron, and those endo deposits suddenly have nothing to grow or feed them. So then they just stay dormant and they are inactive.

Do they go away? Does it cause regression of endo? Absolutely not.

Lupron does not cause endo to disappear, I mean, to go away.

But when we look at fertility data, there is benefit to giving women Lupron over not doing anything.

Now, let’s compare Lupron and surgery.

Is there an advantage to doing surgery over Lupron? Many advantages.

One, you actually get a diagnosis. When we give you Lupron, we have no idea if you have endo or not. We suspected, we give it to you hoping that this Lupron is going to be enough to suppress your endo, but we’ve never actually made an official diagnosis.

Number one.

Number two, we never actually got down to the root cause of the problem and cut it out. It’s like putting a band-aid on the problem.

We’re like, okay, there’s inflammation. Let’s get rid of the inflammation momentarily just until we do your embryo transfer. Then if it comes back in two years, well, not my problem, you’re pregnant, you had a baby.

But then women continue to struggle with pain after their children are born.

I have patients who say, “I can’t get out of bed on my period.” So I always ask them, “Well, how are you going to take care of a newborn?”

You can’t afford to be down in bed for a week on your period when you have a little baby to take care of.

And pregnancy does not cure endo.

Okay?

So that’s another big myth is when you get pregnant, it doesn’t mean that your endo is going to go away.

Pregnancy is a great break, again, because you’re not producing hormones—you’re producing hormones, but you’re producing enough progesterone to counteract the estrogen where the endo deposits are not doing anything. Happy, they’re dormant.

But then you give birth, your periods come back, and for many women they come back to being just as bad as they were before pregnancy.

So Lupron can decrease inflammation momentarily, maybe it’ll help enough to get implantation to happen, but if it doesn’t, then we’re back to square one.

And now you need surgery to get rid of the disease.

So my recommendation is always to consider surgery over Lupron just because it gives us a pathological diagnosis, we get rid of the disease for sure.

And now if implantation doesn’t work, we have to think of other things because we got rid of the endo.

So now we have to think of things like—and I don’t want to mention it because we’re not here to talk about it—but just very quickly, adenomyosis. Don’t forget.

I was going to ask you—so great. I guess we are talking about it then. Yeah, tell me.

So I mean that they’re often concomitant, right? So let’s talk a little bit about adenomyosis.

Yes, perfect.

So adenomyosis, I like to call it the evil twin sister of endometriosis. They often like to hang out and we see them together many times.

However, there are cases where you can have only adenomyosis with no endo.

I see that in my surgery patients a lot when we’re doing a hysterectomy because again, how do you diagnose adenomyosis? The only way to diagnose it is pathology.

What is adenomyosis?

It’s basically endometriosis of the muscle layer of the uterus.

We talked about how the lining of the uterus can travel outside the uterus, but if it just travels to the muscle layer where it shouldn’t be, then that causes swelling and inflammation in the muscle layer of the uterus.

There are distinct ultrasound and imaging findings of adenomyosis.

So just like we suspect endo based on symptoms, sometimes even ultrasound findings, we suspect adeno based on symptoms and ultrasound findings.

So adeno can cause crampy, heavy periods, and then on ultrasound, you can see distinct features in the myometrium that make you suspect adeno. The uterus is boggy, it’s swollen, it’s enlarged.

We see it often in our IVF patients, and as women get older, the adenomyosis becomes more pronounced in those who have it.

When you’re younger, you’re less likely to have severe—you can have severe adeno—but you’re less likely to have severe adeno when you’re younger.

But if you have— you can’t say that—

I was just gonna say, and just like you said about endometriosis, sometimes your only symptom can be infertility, and so I wanted to mention that as well.

Correct, absolutely. So adeno, we see it a lot in the infertility population. But as REIs, we actually recognize it when we do the ultrasound. Like, this uterus doesn’t look really nice. This uterus looks boggy and swollen. So you suspect adeno.

But if you suspect adeno, the patient probably has endo too. That’s the problem. They often co-occur together.

So if you’re confident in your ultrasound skills, you see features of adeno, you don’t know how to look for endo, you should just let the patient know, I suspect you have adeno. If you have adeno, you may also have endo.

But back to adeno and its effect on fertility.

Adeno is actually harder to treat because the only way to get rid of it is a hysterectomy. That’s the only way to get rid of the inflammation in the muscle layer.

And in our patients who are trying to get pregnant, that is absolutely not an option. We want to help them get pregnant and carry their own kids.

Obviously, if we try and resolve the issue and that doesn’t happen, there’s always the option of surrogacy, but most of our patients would like to try first with their own uterus.

So how can we make that happen?

That’s when I prescribe Lupron.

That’s when, to me, Lupron becomes essential because that’s the best current medical management we have for adenomyosis.

So what I typically do is I go and surgically excise all the endometriosis, remove everything and anything that I can without actually doing a hysterectomy.

Also sometimes they need to have their tubes removed if they have hydrosalpinges, right? Because a dilated fallopian tube is not compatible with implantation. We have to remove a hydrosalpinx before we do an embryo transfer.

So I oftentimes will surgically clear everything and then do Lupron prior to embryo transfer.

And I actually recommend Lupron/Letrozole/Norethindrone, the whole combo, because Lupron will put women in menopause, letrozole will also shut down estrogen production, and then norethindrone adds back so that women don’t feel miserable and don’t have all those menopausal symptoms.

So I do that for two to three months and then do an embryo transfer.

So adenomyosis in itself can cause fertility issues. It can cause implantation failures. And we need to try our best to reduce inflammation in the muscle layer of the uterus before attempting an embryo transfer.

And if that’s unsuccessful, I’ve actually had—my patients who’ve utilized surrogacy have been my worst adenomyosis cases.

That’s interesting, yeah.

Not all adenomyosis can be suppressed enough where implantation happens. And sometimes we’ll have to think outside the box and use other options.

Yep, no, I would agree with that.

I wanted to ask, so okay, so for clarity’s sake, what is the way that you think about people and when to evaluate for endometriosis?

Obviously we’re always listening with our ears and the history and those sorts of things, but like, did I hear you correctly that like, if they have a lot of symptoms of endometriosis when you first talk to them, then you’re likely to book a laparoscopy?

Maybe they don’t and you’ve done two transfers and that doesn’t work, then you do a surgery.

Is that kind of how you think about people on the fertility journey?

So when I say they’ve done two transfers, it’s not with me because I don’t usually do two transfers without—okay, let’s backtrack a little.

So you asked, how do I manage my patients?

First of all, because I’m an endometriosis surgeon and I’m an REI, I have a special subset of patients that come to see me.

They come to see me because they’ve had the two unsuccessful transfers and now they’re thinking of what else it could be.

Unfortunately, Dr. Erica, not everybody thinks about endometriosis and I do.

I have a lot of patients who have seen other REIs that are just trying to force more and more IVF cycles on them because that’s how an REI clinic functions. They’re only there to do fertility treatment and IVF and if the patient needs surgery, they’re not the ones who offer surgery.

So then it becomes complicated to send them out for surgery, wait for them to get surgery, then come back.

So ideally they would like to fix the problem by just helping them get pregnant faster. And that usually means doing more and more cycles, right?

So when patients come to see me, they’ve already done those IVF cycles that have been unsuccessful. They’re here to see me for a second opinion because they feel like something’s wrong with their body and no one’s listening.

They’re here to think about what else could it be? Could I have something that someone else has missed?

And the other group of people that come to see me is because they have really bad pain and no one’s listening. They’re pain with their periods and they’re not really trying or focusing on getting pregnant today. Yes, they’re of childbearing years and they want to have children at some point, but they’re just so focused on feeling better now that children doesn’t seem like it’s a possibility.

So those are the type of people that come see me because my office is called Center for Endometriosis and Fertility. So it’s women who are looking for endo management and fertility.

But when they come see me, regardless of why they’re here, whether it’s pain or fertility, I ask all the questions about possible endometriosis. And most of the women are here to see me because they suspect they have endo. Most of the women check off those boxes.

Yes, they have pain. Oh, they’ve always had pain with their periods.

Yesterday I did a case on a patient who has had pain with her periods for the first 15 years and then all of a sudden they got better. ‘Cause she got older, probably hormones, actually she has a diminished ovarian reserve, her ovarian reserve dropped.

She did four IVF cycles, banked some embryos, and her periods are now better.

And she’s like, “Do I really need to worry about endo? My periods are better.”

Her embryos are very precious because she’s not able to make more embryos.

She has diminished ovarian reserve, a low egg count, which we haven’t talked about, but actually is one of the presenting symptoms of endometriosis. There’s a huge correlation between endo and low egg count.

So if you see someone with a low egg count, you have to think of endo. And if you see all the endo patients, you have to evaluate their ovarian reserve to make sure they don’t have a low egg count.

But anyway, back to this patient, she said, my pain is better. I just had pain with sex. That’s the only thing that I still have, but that’s not bothering me. I’ve learned to work around it. We change positions. We avoid, you know, and of course, sometimes if it’s really uncomfortable, but it’s fine. I’m not bothered by it.

But I told her, we can’t ignore the fact that you probably have endo. You’ve had it your whole life. You had really bad periods at first. Yes, they’ve gotten better. We still have that lingering pain with sex.

Yes, it could be other things like pelvic floor myalgia. I often talk to my patients about other pain generators.

But you have those precious embryos that we can’t go back in time and make more of. So I recommend surgery, laparoscopy.

And we did her surgery and she had tons of endo. She had endo on her bladder, she had endo on her uterosacral ligament, she had—

But if we hadn’t done the surgery, we might not have really known she has endo or not because we could have suspected it and then be like, okay, you know what? You’re not bothered by it. That’s fine. Let’s just work on getting pregnant.

And then if her embryo doesn’t stick, then we have to go back in and worry about the endo and treat it.

So I like to do that preemptively beforehand, before we have unsuccessful transfers.

I also talk to my patients about natural pregnancy, like I mentioned.

So if they come see me for infertility, they have unexplained infertility, the partner’s sperm is normal, we have a good egg count, they are young, then I tell them we can do surgery for endo, get rid of the endo, have you try and get pregnant naturally for six months, a year, depending on how old they are, and then if you’re not pregnant, do IVF.

Or if you’re interested, we can bank your eggs, bank embryos, do an egg retrieval, bank eggs, bank embryos, so that now there’s no pressure in getting pregnant. Do the surgery, help you feel better, and then you get pregnant whenever you’re ready.

And if it doesn’t happen naturally, we have your eggs.

There’s so many ways of making it happen, but I don’t usually ignore—so if someone has suspected endo, I don’t usually ignore it and do IVF and then say let’s worry about it later only if your embryos don’t implant.

I usually try to address it beforehand.

Because also think about our poor egg quality endometriosis patients, right? Or poor quality oocytes, poor quality embryos in our endometriosis patients.

The big question is, does surgery help improve egg quality?

It’s a big debate that I don’t have a clear set answer on because there are two things that happen with surgery.

One is your egg count will drop. You have to expect that when you’re doing ovarian work.

If I’m not working on their ovary, I have zero concerns about their egg count dropping because I’m not touching your ovaries. I’m working around them.

And I usually can gauge ovarian involvement with my ultrasounds. So I do my endometriosis mapping ultrasounds.

As an REI, Dr. Erica, both you and I have done hundreds of ultrasounds, right? So we have the technical skills. You just need to know what you’re looking for when you’re looking for endo.

And I kind of trained myself over the years, but I can gauge on the ultrasound whether or not I expect we’re going to do ovarian work or not.

If I’m not going to do ovarian work, I am very comfortable and confident doing their surgery with a very low AMH.

But if I expect we’re going to be taking out cysts from their ovaries, the ovaries are attached to the back of the uterus, we’re going to be messing around with those ovaries.

And they have a low egg count, I try my absolute best to get eggs out or make embryos before.

And because I do that, I have come to evaluate the quality of those embryos. And they’re usually not great.

You don’t get good eggs, you don’t get good embryos, but we say at least we tried.

And then we do surgery and some of my patients get pregnant naturally after surgery. So they have to have improvement in their egg quality.

And then sometimes some of them have to do another IVF cycle after surgery and we get less eggs.

I always tell them I’m going to get less eggs after surgery, 100%.

But could they be better quality eggs? Possibly.

So that’s what the data shows is maybe we get better quality eggs after endo excision, especially endo of the ovary where there’s those big endometriomas that are affecting your egg quality.

Yeah, that makes a lot of sense.

So what I’m hearing you say is, if you suspect ovarian involvement, then it’s really a judgment call, right?

You say, okay, well, you know, is it better to try and get eggs now, understanding that the quality might be worse, or is it better to operate, especially because you have the skill that you do, and then do an IVF cycle, right?

Whereas if somebody does not have ovarian disease, right, then you might be more likely to do surgery first, preemptively, because you know you’re probably not gonna be touching the ovaries.

And I will say, I’ve learned a lot since graduating fellowship, right? These are things we don’t necessarily learn.

Maybe you can talk a little bit about some of the nuances of the things like, you know, the sliding sign and the cul-de-sac.

And like there’s other ways that I’ve learned since leaving training where I can say, “Oh, I think this whole pelvis is involved,” or I think, “I think this is maybe isolated.”

So I think people might be interested to hear about that because like I said, even in my own very excellent REI training, these are things I needed to learn post-training.

Absolutely, I agree with you. I also learned that post-training.

So I did my REI fellowship at McGill in Montreal where IVF was publicly funded. So we did tons of cycles. It was really busy. We had 80 ultrasounds every morning, three fellows. We would divide our ultrasounds, you know, 20, 20, 20, 25, 25, you know, busy days. We’d do 30 ultrasounds every day.

So I got really good at quickly putting in my probe, measuring the lining, measuring the uterus. You know, we measure the ovaries, we measure the follicles, and we’re done. I don’t look at anything else, right?

But we do it a lot, we’re really good at it. We learn to find the ovaries, ‘cause as you know, not all ovaries are easy to see, right? So you know what things look like in there. But we’re not really looking for anything outside those three structures.

And I realized that a lot of the REI offices also utilize nurse practitioners and ultrasound techs, right? And that’s all they’re looking for too. No one’s looking at the big picture.

I see patients who’ve had cycles of IVF, they’ve had many ultrasounds done, and no one has mentioned the word adenomyosis to them. No one has mentioned the fact that their ovaries are attached to the back of the uterus.

Yes, yes, right?

I’ll tell you what I look for, because that may also help you in clinical practice.

So those are things that I picked up with time.

Like I said, being a surgeon and being a sonographer, I get the privilege of scanning my patients and then seeing what things look like in the OR and comparing and learning from that dynamic.

So the number one thing I look for always is a sliding sign. Okay, so I clearly mark it on my ultrasound report. Sliding sign positive, sliding sign negative.

What does that mean?

When we look at the back of the uterus, where the cul-de-sac is, where the bowel touches the back of the uterus, you want to push with your ultrasound probe to see if that uterus slides off the back of the bowel.

Because if there is sliding sign, that means it’s healthy, it means the uterus is not stuck, ‘cause the bowel is like a bag of worms. It’s just floating, free-floating bowel that shouldn’t be stuck to anything.

So if the uterus and the bowel are sliding off the back of each other nicely, then that reassures me that this is going to be a stage one to two endo excision rather than a stage three to four endo excision.

Next thing I look at is the ovaries.

Where are the ovaries located?

Okay, so we are moving from our ultrasound to the ovary. The ovaries should be nicely nestled on the sides and there should be a clear utero-ovarian ligament. So we watch that vessel.

And then once I get to the ovary, again, I should be able to mobilize the ovaries. The ovaries are free-floating structures. Yes, they have an IP ligament attached to them, but they’re not densely stuck to anything. The ovaries are nicely moving.

So then I check their location.

Many, many times I come across ovaries that are tucked to the back of the uterus. So then I move them around, ‘cause sometimes PCOS ovaries, when they’re big and heavy, they do that, but then you move them around. You push them a little with your probe. Are they moving or are they attached?

I can’t tell you how many endometriosis patients have ovaries that are displaced. They’re not where they should be. They’re attached to the back of the uterus. And no one said anything about it. That’s not normal.

We’re not born with ovaries that are stuck to the back of the uterus. That happens with time due to disease process, due to inflammation and scarring.

Then we look for kissing ovaries, right? Those are the worst. It’s because the ovaries are now stuck to the back of the uterus. Now the other ovary is stuck to the back of the uterus. And now our ovaries are touching each other.

So you could have both ovaries attached to the back, both ovaries kissing, usually with disease in between.

So anytime I see scarring, that’s a sign of endo.

I have then graduated into actually recognizing endo lesions on ultrasound. So I scan the uterosacral ligaments, I turn my probe 90 degrees, go up and down behind the uterus, and I can see little deposits on the uterosacral ligaments.

I look at the bowel. I can often see bowel implants. I see bowel nodules that could be attached or tethered to the back of the uterus.

Again, you can have a positive sliding sign, and I call that my partially negative sliding sign. You could have a positive sliding sign really low, but then as you go up, you see a point, there’s a point, a tethered point, like a mushroom cap, where the bowel nodule is stuck to the back of the uterus.

So that indicates bowel disease and more advanced disease.

And some women say, well, should I get an MRI? Is an MRI better?

In my hands, I disagree. I tell them that I can see just as much with the ultrasound as I can with the MRI.

If anything, the ultrasound allows me mobility so I can see what’s stuck, whereas with the MRIs, I still image, so I don’t get MRIs on my patients.

But sometimes I have patients who come see me because their REI ordered an MRI to see if they have endo or not.

And MRI is not the best tool to diagnose endometriosis because you could have completely normal imaging and still have stage one to two endo.

And I’m happy to send you the data on fertility and endo excision because even removing stage one to two endometriosis, early stage disease, can help improve natural pregnancies.

They’re actually the ones that have a better chance of natural pregnancy than stage three to four, because the anatomy—oftentimes, especially with stage four, those are the worst, most advanced cases—the anatomy is often so distorted that even after excision, the tubes are compromised, the ovaries have low ovarian reserve, they’re more likely to need IVF.

Right, and that makes total sense, yeah.

And I’ve seen the data and I think most people don’t want to need fertility treatment either. I mean, yes, surgery is treatment, but most people would prefer not to have to go through IVF.

And so I just want to stress one more time the importance of seeing somebody with the expertise and the perspective of somebody like you.

There’s not very many people that I know of. You are the expert, right? Who can see the pelvis the way you do, who has the skills.

I mean, people say, if I do surgery, if I have an OBGYN, like, am I going to lose an ovary?

And I’m like, if you go to a skilled surgeon, you’re probably not going to lose an ovary, right?

And so I just want to just highlight your skills, your knowledge, your expertise, and your surgical skills.

Thank you for acknowledging that.

I actually—so let me tell you why I did this, okay?

So I was happy in REI. I loved treating infertility and helping women start a family, but I saw how the women that needed surgery were not being directed appropriately.

Like they would go back to their general OBGYNs and we’d say, okay, go get rid of your fibroid, then come back, or go treat your endometriosis, then come back.

And they would be gone for months because it takes a while to get into OBGYN.

And then they come in, like exactly like you said, with a missing ovary or with half the ovary gone and you’d be like, oh my God, what did I just do? Now I have no eggs to work with.

So not all surgeries are the same.

General OBGYNs are awesome at doing a lot of things, but not advanced GYN surgery.

Just like if you had, God forbid, cancer, you wouldn’t go see a general practitioner to treat your cancer. You need to see an oncologist.

Same with endo. If you have endo, you need to see an endo specialist.

And because I’m an REI, so that’s why I did MIGS, because I felt like those women were not receiving the appropriate care they deserved, and someone needs to be able to understand both fertility and do surgery.

So then I did a second fellowship at the Mayo Clinic in minimally invasive surgery, which was extremely busy too, because it was a big referral source from all over the country.

We did crazy cases, and I got to work with cancer doctors, I got to work with bladder doctors, I got to work with bowel doctors.

And that’s how I learned to manage endo, because endo is not just in the pelvis. Endo is not just on your ovaries and your uterus.

You have to work on the bladder, the bowel. I work on the diaphragm, the muscle that helps you breathe. So I’m working all over the place everywhere.

And that’s what I have to do when I operate on my endometriosis patients.

But back to your question on skills and training.

There are certain measures we have to undertake to preserve those fertility organs.

I inject vasopressin, which is a blood vessel constrictor around the ovary to reduce blood loss from the ovary before I touch the ovary.

I don’t use energy. I don’t burn. I don’t coagulate.

I suture the ovary oftentimes to put it back where it’s supposed to be and keep it nice and close so I can retrieve eggs from it later.

There are lots of things I do as a fertility specialist to help maintain the integrity of the ovary, the uterus and the tubes, because my goal is also to help women get pregnant.

And after, I’m not going to ship them to an REI and say, okay, here she is, she’s your problem now. I’m going to be the one who has to manage the fertility aspect.

And I want to make sure that I’m setting myself up for success.

So if you do a really good surgery, you preserve your organs, then you have a better chance of achieving pregnancy, whether it’s natural or IVF.

And then the other thing is the fallopian tubes.

I teach minimally invasive GYN surgeons, so fellows. I operate with them, I give them lectures.

And the tube is a whole big deal because you and I may know how to do tubal reanastomosis or do a neo-salpingostomy, opening up a new fimbria.

We can evaluate what tube looks normal, what tube looks abnormal, but most GYNs can’t.

So we can’t just do the surgery and say, “Oh, your tube looked fine.” You really need to be comfortable saying, okay, this tube is functioning.

I suspect you’re going to have a great chance of natural pregnancy with this tube. Or this tube looks ugly. I don’t think this tube is going to do anything to help you get pregnant. Let’s remove it or let’s fix it.

So you also have to make those judgment calls during surgery.

That’s why I counsel my patients on all those possibilities before surgery because I tell them I want surgery to be one and done.

I want to get rid of the endo. I want to optimize your chances of fertility.

And then when I see you after surgery, I want to be able to confidently tell you, you have a good chance of trying naturally, or don’t waste your time. I don’t think this is gonna happen naturally.

Let’s talk about fertility treatment.

Amazing. And thank you so much for doing what you do. I mean, your training was unbelievably long and hard. And you just provide such a service to women who are in this situation.

And I send people to you across the country because I believe in you and I believe in what you’re doing.

And so thank you again.

And what I would say is people need to find you too. So we’ll put all your information in the show notes.

But can you say for the listener, where can people find you?

Yeah, absolutely. First of all, thank you for trusting me with your patients. I care about women. I want to help them.

I do this because I want to help women understand what’s going on with their body, help get rid of the issues that have built over time that people have ignored.

Okay. We should not ignore pain. We should not ignore endo pain with intercourse, pain with periods. That’s not okay.

So I’m here for you. First of all, I’m here to listen to you. I’m here to help you understand what’s going on and I’m here to help give you a plan.

I have a lot of patients who travel from out of the country, out of state.

I’m happy to coordinate with doctors like you, Dr. Erica, on your fertility care if you just need help with endo surgery.

But you’re right, I’m one of the very few REIs who are also fellowship trained in MIGS. So I hold board certification in REI and I’m an AAGL-accredited MIGS fellow.

So I’m happy to see you. I’m in Southern California.

People can find me online. I’m at the Center for Endometriosis and Fertility. You can go on our website. You can find me on Instagram. I’m very active on Instagram.

I try and educate the young generation on what’s normal and what’s not normal so that they don’t have to be in your situation.

You know, you’re the adult woman who’s now watching this podcast because she’s trying to get pregnant.

Because if we had treated this at an early stage, we may not be here today.

So I’m happy to provide my contact information, but feel free to reach out to me on social media, email the office, call our office, and I’ll be happy to see you anytime.

Amazing. And thank you, Dr. Siddhika Behbehani.

Like I said, we’ll put all your information in the show notes.

And thank you for educating and empowering.

Thank you so much for being a guest on the Love and Science podcast.

Thank you for having me. You’re welcome.

And to my listeners, you know how much I love you. Until the next time. Bye.