NaproTechnology Surgery for Endometriosis, PCOS, and Fibroids (Episode 615)

Full Transcript: Episode 615

Lisa Hendrickson-Jack:
This is the Fertility Friday Podcast, episode number 615.
February has been the month of endometriosis. I took the opportunity this month to share several episodes, interviews that really dive into this topic. And on the heels of last week’s episode, I really wanted to share this interview that I recorded with Dr. Kyle Beiter. He is a board-certified OBGYN and NAPRO technology surgeon.
This episode really builds on what Dr. Ken Sinervo talked about in the episode that we did together, because it really shares about how specialized this type of surgery is and really reinforces the idea that when you have a client who’s struggling with endometriosis — or whether you yourself are struggling with it — it really does make a whole lot more sense to search out medical professionals who specialize if you are looking to actually do a laparoscopic procedure for screening, or if you are seriously considering having treatment done.

So even just to identify if it’s there, we certainly want to be consulting a specialist, let alone if you’re wanting to actually undergo surgery to support it. Obviously surgery is not the only approach, but I do think it’s really important if you’re looking at all these different options to be as informed as possible.

So before we dive in, I’ll share a little bit more about Dr. Beiter. He is a board-certified medical doctor with a specialization in the field of obstetrics and gynecology who specializes in fertility. He is a NAPRO technology surgeon. And for those of you who aren’t familiar with NAPRO technology, it’s a specialized form of gynecological surgery whose primary aim is to reconstruct the uterus, fallopian tubes, and ovaries in such a way that it minimizes adhesions and protects the tissues instead of destroying them.

With that said, let’s go ahead and jump into today’s episode with Dr. Kyle Beiter.

Welcome to the show, Dr. Beiter.

Dr. Kyle Beiter:
Hey, thanks.

Lisa Hendrickson-Jack:
Thank you so much for being here. I’d love to start just by getting a sense from you of what inspired you to take this route and to take the extra training. I can’t imagine how, in addition to being a surgeon, going ahead and taking the extra training in the specialized field.

Dr. Kyle Beiter:
Yes. Well, thanks for asking. It is a long road, obviously. I mean, you have college, medical school, OB-GYN residency, and that right there is 12 years.

I did the additional fellowship. I guess I love surgery. I thought about going to general surgery, but in general surgery, you’re taking out organs and you never see patients again. And that’s okay — we need general surgeons, obviously. But I felt like that wasn’t for me. With gynecologic surgery, patients are usually a little bit younger and healthier, especially if they’re fertility patients. It’s really rewarding to have relationships with patients where you help them with their fertility, and then also maybe care for them through their pregnancies and see them for their yearly exams. I thought that was a lot more rewarding for me.

The other reason is I’m very pro-life, obviously. The fertility care system and NAPRO technology is based on Catholic ethics — but not for Catholics only, certainly. I feel like there’s not that many pro-life doctors out there, unfortunately. I felt like I want women to have that option. And since I feel strongly about it, here I am. So that was the second big reason I went into this area.

Lisa Hendrickson-Jack:
I’d like to hear a little more about that. I think when you say pro-life, it conjures up a lot of ideas for people, but specifically with respect to the surgical techniques and how it comes from a basis of protecting and supporting the tissues. I’d love for you to talk a little bit about how that philosophy of medical care differs from mainstream traditional medical care.

Dr. Kyle Beiter:
Sure. For example, in mainstream medical care, if you have pelvic pain or even endometriosis on an ultrasound, oftentimes the first knee-jerk response is to put someone on suppressive hormones — birth control pills, Depo-Provera shots, or Lupron injections, for example.

It’s true that studies suggest that for some women, those therapies can help, but what’s the cost? These things do have a lot of potential side effects. Certainly infertility is an obvious one — you cannot conceive on any of those I mentioned. But not only that, there’s a small risk of blood clots and liver tumors, or lack of sexual desire.

One thought is: would you want to eat a steak with artificial hormones? People would probably say no. Well, then would you like to take a pill with artificial hormones on a daily basis? It’s not that appealing, obviously. And there’s also some current concern about Lupron and possible autoimmune issues if you take it for a long time. It’s certainly not the best medication from that standpoint.

One other bias I have is in the area of family planning: why don’t men take the hormones? Women must take the hormones. I think in the area of family planning, it should be something both partners are involved in. I don’t know how much of that overlaps with using hormones so much for pelvic pain, but it’s a little one-sided to me.
And certainly in terms of surgery, those same motivations apply — wanting to get to the underlying problems and to do a good job. When I’m operating, I’m not thinking, well, this patient might be headed for IVF anyway. That’s not a good attitude for any surgeon to have. My goal is to get it all out as much as I can. I’ll admit I can’t always do that — endometriosis can be in difficult places sometimes — but that’s certainly the goal.

Lisa Hendrickson-Jack:
I love your analogy of the steak. I think I might borrow that in the future because it puts it into perspective. And just the approach of really getting to the underlying cause of everything.

You were already a surgeon, trained in surgical techniques. So one of the obvious questions is how much more is there to learn? How did learning this additional aspect of things change your practice or your understanding of the way the body works?

Dr. Kyle Beiter:
In obstetrics and gynecology, training hours are becoming shorter. Work hour restrictions in the United States — part of that is a good thing, getting some sleep during training instead of being up for three days at a time. But the pendulum may have swung too much, where now a lot of graduating OBGYNs don’t have the surgical numbers that people had 20 or 30 years ago.

A lot of the things I do based on my fellowship and my experience, a lot of residents coming out of training would not attempt them, because they don’t have the experience. If they don’t do a fellowship and have no one to show them, it’s going to be really difficult to just pick up a book and try to learn and do it on their own. So it’s really about exposure to a very specialized area of surgery that I would not have had otherwise.

Lisa Hendrickson-Jack:
That makes a lot of sense, having that mentorship and guidance in those areas. Let’s talk a little bit about why a woman might need surgery. What are the reasons why patients come to you for surgery in the first place?

Dr. Kyle Beiter:
Two main reasons. One is pelvic pain and the other is fertility. They can overlap, or you can have both simultaneously. A lot of times a patient has had pain or fertility issues for a long time and may have gone to other physicians who tried to treat them with suppressive hormones, or IVF, or insemination, and those patients have not had success. That’s maybe the biggest reason why they come to me.

Lisa Hendrickson-Jack:
Well, why don’t we break it down a little bit? Maybe we could start by talking about fibroids. Fibroids is something I’ve experienced personally — I didn’t need surgery because they didn’t grow that big. But I know there’s a large percentage of Black women who are affected by it. Maybe you could talk a little bit about fibroids and when surgery might be an option, and why in other situations it wouldn’t be recommended.

Dr. Kyle Beiter:
Fibroids are very, very common — up to about 80% of women have them if they live a long life. But not all fibroids may cause problems. For example, if you have one small submucosal fibroid buried in the muscle of your uterus, there’s a great chance that it may be asymptomatic. Because they’re so common, if you start doing ultrasounds for infertility or pelvic pain, you may see a fibroid. And then the question is: is that fibroid responsible for this pain, this bleeding, or this fertility issue?

They’re very heterogeneous — different sizes, different locations — so that makes it a little more difficult to study. But there are now a number of studies and a loose consensus on when surgery may be a good idea.
For fertility specifically, there’s some consensus that a fibroid five centimeters or larger may cause some problems. Now, I say “may” — there’s no guarantee. Everyone’s different. If I saw a very young 21-year-old with a five-centimeter fibroid and she had no pain and she’d never tried to get pregnant, I’d probably say, okay, let’s just watch it for now. There’s a good chance it may not grow. But let’s say we have a 35-year-old who’s been trying to get pregnant for five years, tried medications, her husband’s sperm counts are fine, tubes are open, hormones look pretty good — in that circumstance, I would likely offer surgery to remove the fibroid if it’s five centimeters or larger, and depending on location.

The closer the fibroid is to the uterine cavity, the more likely it is to cause problems. When you look at studies of women who’ve had fibroid surgery, the evidence is pretty strong that if you take fibroids out of the uterine cavity, that can decrease the chance of miscarriage and increase fertility. And sometimes, if it’s growing into the cavity and it’s not too large, you can remove it through the woman’s cervix without any abdominal incisions — that can be good for that type of fibroid.

In my own practice, for a larger fibroid — five centimeters or larger — I usually have to do that by laparoscopy and make incisions to take it out.

Lisa Hendrickson-Jack:
And for a non-doctor like myself, what is a laparoscopy?

Dr. Kyle Beiter:
Laparoscopy is a style of surgery where you only use very small incisions — typically through the belly button and maybe a couple of other incisions on the abdomen that are about a centimeter or half a centimeter. That’s in contrast to a traditional open surgery, which involves a very large incision, maybe 10 or 12 centimeters at the bottom of the abdomen.

Lisa Hendrickson-Jack:
So in the procedures you’re describing, you’re removing a larger-size fibroid, but you’re not opening up the whole uterus — really minimizing potential scar tissue and those types of things. What are the risks involved? And then the benefits in those cases?

Dr. Kyle Beiter:
For any patient thinking about having surgery, I always talk about the risk of bleeding, infection, and injury — those are going to be risks with any surgery. For fibroids specifically, they can be very bloody surgeries because the uterus is pretty vascularized. The larger the fibroid gets, the larger the incision you’ll need to make on the uterus to remove it, and the more blood loss you can anticipate. That also increases the chance a patient may need a blood transfusion. For a 10- to 15-centimeter fibroid, I would tell patients maybe a 30% chance of transfusion, for example.

Recovery also gets longer as the fibroid gets larger. I might tell a person that recovery might be a month long after removing a 10-centimeter fibroid, whereas if the fibroid was four or five centimeters, maybe two or three weeks.

In terms of injury for fibroid surgery, the main concern is the uterus. Fibroids are usually at the top of the uterus, so there’s very little chance you’d cut into another structure. Could the fibroid be near the uterine blood vessels or near the fallopian tubes, where when you take it out and sew it closed, you might kink or block the tube? Yes, that’s possible. So it’s often a good idea to have a pelvic MRI prior to a myomectomy.

An ultrasound is usually the first imaging test — it’s quick, relatively inexpensive, and a good first-line test. But MRI is a little better at localizing the fibroid within the uterus and showing where it is in relation to the fallopian tubes and other parts. For most patients considering surgery, I recommend an MRI to really see where it is.

We also worry about scar tissue — not only outside the uterus, but inside it. Especially if the fibroid is pressing into the uterine cavity, when we take it out and close the incision, there could be some scar tissue inside or outside the uterus. A very good closure of that muscle is necessary.

In general, when you talk about surgery, the main surgical skill is dissection — can you dissect out structures, get out the bad tissue, and make sure the ureter and blood vessels are safe? But for fibroids, maybe one of the major skills is your ability to close the uterine muscle nicely with stitches and make sure it’s really secure afterwards.

Laparoscopically, that’s very nice for patients because the incisions are small and recovery time is shorter compared with open surgery. But it is more difficult to stitch laparoscopically. You don’t have your hands — you have instruments with a limited degree of motion, and you’re restricted by where your ports are placed. In open surgery, you can reach your hands in from almost any angle and stitch how you want. Laparoscopically, you’re limited. I’ve adopted different techniques of laparoscopic suturing over the years to manage this.

You’ve likely heard of the Da Vinci robot? It basically allows you to do laparoscopy with instruments that can articulate inside — almost like having your hands in there. I have used it before, but I don’t use it anymore because I feel like I can do the same thing with normal laparoscopy. Large studies don’t suggest a difference in patient recovery, blood loss, or fertility outcomes between the robot and normal laparoscopy. The robot also requires more incisions and is much more expensive. That said, if a physician cannot suture laparoscopically well, the robot can help with that.

I know Dr. Hilgers, who pioneered NAPRO technology, really does like the robot and uses it very effectively. One area where I think the robot would be genuinely great is tubal reversal surgery, where you want to put the tubes back together — the robot’s ability to filter out hand tremor is a real advantage there.

Lisa Hendrickson-Jack:
That’s really interesting. So for a woman who has fibroids and is thinking about how to manage them and considering surgery — from your experience now, what is the main difference between a surgeon trained the NAPRO technology surgical way versus one who has not been trained in this way?

Dr. Kyle Beiter:
For many types of surgery, the main difference might be in adhesion prevention strategies. An adhesion is abnormal scar tissue that can develop after surgery — when two surfaces that should not be stuck together become stuck together. Surgery can cause that. Other things can too — endometriosis, or a prior pelvic infection, for example.

Dr. Hilgers did a lot of research himself about how to minimize adhesions, and he stressed several things when he trained us: the way you close tissues, re-approximating them as neatly as possible; gentle handling of the tissues; trying not to make unnecessary peritoneal incisions. He also taught us to use adhesion barriers — either dissolvable or non-dissolvable structures that prevent scarring — leaving extra fluid in the abdomen so tissues float on each other as they heal, and sometimes using temporary suspension sutures. For example, placing a temporary stitch on the ovary to lift it out of the pelvis so that the area underneath heals without the ovary scarring down to it.

Lisa Hendrickson-Jack:
Let’s talk a little bit about endometriosis. From what I gather, it sounds as though it’s a much bigger problem than we think, because diagnosing it is not necessarily easy. Maybe you could start by sharing what endometriosis is, and then how one would go about making a diagnosis.

Dr. Kyle Beiter:
Endometriosis — an easy way to define it would be the presence of endometrial tissue in an abnormal location. The endometrium is the normal tissue inside the uterus — the layer that sheds every month with menstruation, and where an embryo implants when a woman is pregnant. It’s normal for that tissue to be inside the uterus. However, endometriosis is when endometrial tissue exists in an abnormal location — for example, on the ovaries, on the intestines, or on the fallopian tubes. It’s not supposed to be there.

It’s not cancer — it’s benign — but it’s a disease that can be associated with pelvic pain and infertility, or both.

If a patient has endometriosis on imaging but has no symptoms — no pelvic pain, no problems getting pregnant — then I would say, what can surgery do for you? Surgery is going to give you temporary pain and carry temporary risks. So I wouldn’t recommend surgery for all patients with endometriosis, only for someone who has fertility problems, pelvic pain, or a mix of both.

It’s a really strange disease. Some patients have no pain and no fertility problems. Some have one but not the other. You really have to customize whether surgery is right for a certain patient.

If someone comes to me, how do we know if they have endometriosis? First, I start with a physical exam and a good history of their symptoms. I also start with an ultrasound as the first-line imaging test — it’s relatively inexpensive, and you can see a lot. But even if their physical exam is completely normal and their ultrasound is completely normal, that still does not rule out endometriosis entirely.

If they have high-stage disease, many times an ultrasound or physical exam would bring that up — for example, a big endometriosis cyst on the ovaries, or some tender nodularity behind the uterus. But if their ultrasound is completely normal, they still could have disease just out of reach of my hand, or thinly layering the tissue so the ultrasound can’t see it.

So if a patient has significant fertility problems or pain, laparoscopy is the only 100% way to rule it out — to know if they have it — and we can also treat it at the same time by cutting it out.

MRI is another imaging test we can use. MRI is better at seeing intestinal nodules of endometriosis — for example, if a patient has a lot of pain and bleeding with bowel movements, I would get an MRI. But for mild disease, even if the MRI was normal, they could still have a milder form.

Lisa Hendrickson-Jack:
It’s really unfortunate that to get that 100% diagnosis, you would need to have somebody go into your body with an instrument. How can endometriosis negatively impact fertility? In the cases where it’s actually a contributing factor or cause of infertility, what is it doing to disrupt the natural flow of things?

Dr. Kyle Beiter:
It’s something that physicians will probably argue about for a long time because there are a lot of studies and a lot of back and forth. But a couple of things.

Obviously, if it’s high-grade disease where it is scarring the tubes or ovaries and restricting the fallopian tube from picking up an egg from the ovary, that’s an obvious way it can interfere with fertility. That’s probably the biggest way.

Lisa Hendrickson-Jack:
Does that mean the endometrial tissue is potentially growing on or around the fallopian tube itself and kind of warping it?

Dr. Kyle Beiter:
It can be, yes. Or another example: there may be a large cyst on the ovary — say, a 10-centimeter cyst — that has pushed the fallopian tube up out of the pelvis so it can’t come down and pick up an egg. Or there could be scar tissue between the ovary and the back of the uterus, and the fallopian tube is caught in that, restricted in its ability to pick up an egg.

There could be endometriosis on the tissues around the tube, or even on the surface of the tube itself, kinking it or drawing it back, or even scarring the end of the tube closed and causing a tubal obstruction.

The more mild forms of disease are a little more subtle. Endometriosis seems clearly associated with fertility, but exactly how it causes infertility in its milder forms is controversial. One theory is that even if these implants of endometriosis are not on the tubes and ovaries, they can secrete cytokines and other inflammatory molecules. If you take endometriosis fluid and try to grow an embryo in it, the embryo will die quickly — that’s circumstantial but suggestive evidence. There are also studies suggesting the endometrial cavity of patients with endometriosis is different, with different expression of immune molecules that might affect their ability to implant an embryo.

In terms of whether surgery can help: the largest study of its kind included over 300 patients and was done in Canada, I believe in 1997. All 300 patients had stage one or stage two — minimal or mild — endometriosis. Half the patients had their endometriosis looked at during surgery but not touched. The other half had it either cauterized or excised. Over about nine months of follow-up, the patients who had their endometriosis removed had a conception rate of about 32%, compared to about 18% in those who had it left alone. It almost doubled their fertility. A smaller study done in Europe did not show that difference. I would tend to trust the larger study.
Of course, fertility involves many different factors — not just endometriosis, but sperm count, fallopian tubes, hormones, and so on. That’s why I always customize the conversation with a patient. I tell them: it’s not 100% guaranteed, but it can be additive in the context of your overall health.

Lisa Hendrickson-Jack:
So there’s the very physical, obvious obstruction that endometriosis can cause, but also this more underlying issue that sounds like it could have something to do with autoimmunity or changing the way the uterine lining functions so that it’s not as receptive to fertilized eggs.

So from that, I would imagine there are situations where surgery is clearly a good option for a patient, and others where it’s more unclear as to whether it would actually do anything for them.

Now, I have a question that’s coming from pure curiosity: when you go in there and you’re actually looking at the insides — what does endometriosis look like?

Dr. Kyle Beiter:
Good question. Do you want me to show you a picture? I have some pictures from my own patients that I often use to illustrate these issues before surgery.

Here is a picture of a normal uterus and fallopian tubes — no endometriosis there. Endometriosis can look like many different things. It can look like little kind of black, powder-burned spots. It can look like little blisters. If someone has had prior surgery where it was just cauterized, it can look like little implants under the tissue.

Severe disease can start scarring to the bowels — here are the intestines, and it’s scarring there. Behind the uterosacral ligaments — that’s more severe disease. Here is someone’s appendix all really scarred up. You can see the little blisters and vesicles around it.

Here is an ovarian cyst of endometriosis. The ovary is white, but inside there’s an endometriosis cyst. It’s about three times the size of the normal ovary.

And finally, here is a very severe case. Here you can see the top of the uterus — barely — and underneath it you have all of the scar tissue and blood. That was before any surgery even started. It’s hard to tell where the ovary is, where the fallopian tube is, because it’s just so distorted.

This patient had both pain and fertility issues. Thankfully, afterwards she was able to get pregnant and her pain decreased. But I’ll admit hers was a really tough case, and I was not able to get it all out.

I don’t mean to say that surgeons should be sloppy — no, you should do the best you can. But the human body is much more wonderful than we even know. Some women with horrible endometriosis get pregnant without surgery, and that’s really amazing. When you go in and see how bad the disease is, you do the best job you can to take it all out, and you leave the rest up to God, so to speak. Many of these women do conceive. And certainly after surgery we continue to work on their hormones, their husband’s sperm count, and so forth.

Lisa Hendrickson-Jack:
How often does this stuff come back? You go in there, you cut it out — does it come back?

Dr. Kyle Beiter:
I wish I could give you a quick one-second answer, but I can’t. It is possible to cure patients of endometriosis. Authors like David Redwine, and even Dr. Hilgers, have documented that when they go back in for a second surgery sometime in the future, a good percentage of patients have no more endometriosis — it’s all gone. So it is possible to cure patients.

However, I want to make an important distinction between recurrence and residual disease. Residual disease is a lot more common than true recurrence. Residual disease means they had a prior surgery with a doctor who was not able to get it all out — either due to location or surgical skill. If you do another surgery, you’re still going to find it there. It didn’t come back; it just remained.

A true recurrence is where you have endometriosis appearing in a new spot that was not there before. I feel that is relatively uncommon, with two exceptions: the ovaries and the uterine muscle.

For the ovaries — one theory about how ovarian endometriosis, like a big cyst, develops, is that you may have a small spot of endometriosis on the edge of your ovary, and if you happen to ovulate right by that spot, the area becomes bloody and irritated and expands into a big cyst. Endometriomas are noted to recur relatively frequently after surgery. The younger a patient is when they have surgery, the higher their chance of a recurrent endometrioma — possibly because younger patients will have more ovulations until they reach menopause.

The second area is the uterine muscle. There’s a special kind of endometriosis called adenomyosis — endometriosis of the muscle inside the uterus. It’s normal for the endometrium to line the inside of the uterine cavity, but adenomyosis is when it’s deep in the muscle of the uterus, where only myometrium should be. Adenomyosis seems to develop on average in a woman’s late 30s or early 40s. Other types of endometriosis — on the intestines or on the outside of the uterus — tend to form in the late teens or early 20s.

So I may tell a patient: it was pretty straightforward, I really think I got it all out — there’s a small chance you may have it on your ovaries or uterus in the future. Or I may say: you had very bad disease, I wanted to save your ovaries, but you may have a chance of a new cyst forming. Or: I got all your endometriosis out, but there was a big nodule in your rectum, and if you want to address that, we’ll have to go back in with a colorectal surgeon for a bowel resection.

Lisa Hendrickson-Jack:
I wanted to ask you about PCOS, because for PCOS it wouldn’t occur to me that surgery on the ovaries would be a line of treatment. I’d love to hear a little more about that.

Dr. Kyle Beiter:
Polycystic ovarian syndrome — many patients with this syndrome don’t cycle normally. They may have only a couple of periods a year, and defective or deficient ovulations can be a cause of their infertility.
Way back in the 1930s, two doctors named Stein and Leventhal described ovarian wedge resection surgery for PCOS patients. They found that if you removed part of the ovary and sewed it back together, about 90% of women had normal menstrual cycles, and pregnancy rates were 80 to 90%. At the time it was a landmark discovery.
Since then, in the 1960s, they developed medications like Clomid — the first ovulation induction medications — that can help patients ovulate without surgery. And then in the 1980s, IVF came around. So ovarian wedge resection is not given the attention it deserves. I feel it should be offered to many more patients than it is.
My approach is: if a patient has polycystic ovaries and is not ovulating normally, I will use ovulation medications first, because they’re relatively cheap and do not carry surgical risks. Many patients can get pregnant and do nicely on them. But if they’re not ovulating or not getting pregnant after six cycles of ovulation induction, then I feel wedge resection surgery is a consideration. My pregnancy rate in that group of patients is about 50%. Not 100%, I wish it was — but 50%.

The other alternative is stronger injectable medications like Menopur, Follistim, or Bravelle. But with PCOS patients, those carry an increased risk of multiple pregnancies and ovarian hyperstimulation syndrome. Ovarian wedge resection can avoid those risks. I don’t think I’ve ever had a set of twins after ovarian wedge resection — from what I know, all of those have been singleton pregnancies.

I have patients who failed IVF with PCOS and then got pregnant after the wedge. I have one patient who tried for eight years with Clomid and other medications with other physicians. I did the wedge, and she’s had three full-term pregnancies since — without any medications at all. So it can be a really useful procedure.

Lisa Hendrickson-Jack:
At first glance it sounds really invasive to do surgery on your ovary, but if it has the potential to solve some sort of physical issue, and then in the healing process normal ovulation resumes and pregnancy happens spontaneously, I think that sounds like a good option if it’s appropriate.

As we’re coming to a close, the one other topic I wanted to ask you about is ovulatory disorders. Some of my clients who chart their cycles ask me about luteinized unruptured follicle syndrome, or other issues that can happen with the ovary. I’d love to hear your take on that.

Dr. Kyle Beiter:
That’s a great question. It’s a very frustrating disorder. The concept is that someone might have normal menstrual cycles every month — but that does not necessarily mean they are ovulating normally. Their follicle, their egg cell, grows — but maybe it does not rupture. And if it doesn’t rupture, the egg cannot escape the ovary and travel down the tube to meet the sperm. A woman could have this problem and still have monthly cycles and not know it otherwise.

You must do serial ultrasounds to find it. That’s why for all our fertility patients, we track one cycle to make sure they’re actually rupturing.

For most other fertility doctors who do not use NAPRO technology, when they do inseminations, they’ll do ultrasounds until the follicle is a mature size, give a trigger shot, and do the insemination — but no follow-up ultrasounds. To me, that’s incomplete, because the egg still has to get out even if you’re doing insemination.
In our patients, we find that about 10% of fertility patients have this problem. It’s not rare. I feel it’s one of those things that is underappreciated.

It can be frustrating to treat. Jerome Czech — a fertility doctor here in New Jersey — has done a lot of studies on this problem and has shown that ovarian stimulation can help. You can use different combinations of Clomid or injectable stimulation, with different varieties of trigger shots like HCG, or even sometimes a light dose of Lupron. I know I talked about Lupron as a pelvic pain medication earlier, but these are very small doses, and we wouldn’t use it if we didn’t have to.

One other association: luteinized unruptured follicle syndrome can be more common in patients with significant endometriosis. So sometimes that’s worth noting — some patients may need surgery for endometriosis, and this issue may also resolve as part of that.

Sometimes it could be just an enzymatic problem of the ovarian tissue. It can be quite frustrating — not the same treatment works for all patients. You have to go in a stepwise fashion and find what works for each patient.

Lisa Hendrickson-Jack:
That’s really important for women to know. Because you could have a regular-looking cycle, even if you’re charting, and it can look relatively normal — but still, if you have this type of ovulatory disorder, you don’t know that the egg isn’t rupturing.

Dr. Beiter, I just want to thank you so much for going in depth into all of these topics. I’ve really had a ball picking your brain.

After everything we’ve talked about today, what is the one thing you want the listeners to take away from our conversation?

Dr. Kyle Beiter:
I guess the one thing I’d say is that NAPRO technology — this science exists. And it’s not just us; there are other doctors who know these principles and use them too. But I want people to know that there are good, healthy alternatives out there rather than just IVF or insemination.

The second thing is that the human body is very wonderful. My philosophy, and the philosophy of NAPRO technology, is to try to help the body, to optimize the body’s own natural function and to give you the best chances. Many patients have great success that way. We’ve helped patients who failed IVF.

Don’t give up hope. I know the infertility journey can be a long one. Many patients have a very good shot at having a pregnancy. So hang in there.

Lisa Hendrickson-Jack:
Thank you so much. And for the listeners who want to find out more about you or potentially live in your area — maybe you could share where you work and how patients can get in touch with you.

Dr. Kyle Beiter:
I am in central New Jersey at St. Peter’s University Medical Center in New Brunswick, New Jersey — which is kind of between Princeton and New York, about an hour from New York City. My clinic is called the Gianna Center. The Gianna Center is a network of centers that provide NAPRO technology to patients. The goal is to have a nationwide network of Gianna Centers, and that process is slowly being realized. If you just type in Gianna Center, New Jersey, you’ll find our clinic and a number of other clinics like us. Give us a call if we can help you — we’d be very happy to help any patients interested.

Lisa Hendrickson-Jack:
I hope that you enjoyed today’s episode with Dr. Beiter. I will upload to the website the link to the images, if you’re wanting to take a look at some of the things that we talked about. As I mentioned on the episode, I am not a surgeon, so I will never see endometriotic tissue with my own eyes — but it was really phenomenal of Dr. Beiter to provide his presentation and show us what that actually looks like. So if you want more information, head to fertilityfriday.com for episode 615 and have a peek, because it really is mind-blowing.

My biggest takeaways from this episode are similar to what I was talking about at the beginning: it’s really important for your clients to seek support from specialized providers. Endometriosis surgery has really significant implications, because if we don’t actually get at the root of the issue, it can come back. The recurrence rate can vary dramatically based on the surgeon and the type of surgery you undergo.

And it’s already such a significant, traumatic experience for so many women to even get to the point of being diagnosed and thinking about undergoing a surgical procedure. You certainly don’t want to go through all of that only to find that you need multiple procedures because you didn’t know to seek out a skilled practitioner.
If you found today’s episode, or even this February endometriosis series, to be helpful, and you could think of someone who would benefit from it, I would really encourage you to share the podcast. Truthfully, over all of these years, it’s our amazing listeners and our amazing community that has really helped the podcast grow and helped new listeners find it.

And if you’ve never left a review, I would really appreciate it. Reviews on Apple Podcasts continue to help people find the show, and when they do find it, they’re able to see what type of content we share. So the reviews help immensely.

With that said, I hope that you have a wonderful week — whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.