Tuesday, July 17, 2012

the scientist speaks!

A few years ago, two of my co-workers (all of us being educators, of course) were discussing something as they stood a few feet away from me. I wasn't part of the conversation, so I can't rightly say what they were talking about, but I was brought into the conversation when one of the girls spoke up more loudly, and in my direction, to say "let's ask Erika, maybe she'll know. She is a scientist, you know." This was said in complete seriousness.

"Who, me?" I asked, as though there might be several other Erikas hanging out in the room. I'm a lot of things, but I don't really count 'scientist' among them.

"Yeah!" the same girl replied. "Didn't you get your degree in science?...or something?"

"Um...well, I got a Bachelor's of science..." I replied.

"Yeah, exactly. So you're a scientist..." she broke in.

"...in psychology." I finished.

We all three busted out laughing. Because if you've ever obtained a Bachelor's in psychology, then you're probably well aware of how that definitely fully qualifies you to be referred to as a scientist, what with all those rigorous science classes I was taking. It qualifies me call myself a scientist in the same way that my Bachelor's of Arts degree (in Criminal Justice, in case you were wondering) lets me call myself an artist. Scientist, artist...who can really say what qualifies one to call himself by that title? So for today's post, please keep in mind that you can trust me: I am a scientist.

 Because so many of you (and by "so many" I mean, of course, I think...4?) begged for more information, I thought today I would share some of my new-found endo knowledge with you. This is all stuff Dr. S explained to me at my appointment last Friday, and it is his personal 'philosophy' (I guess you could call it that?) regarding treatment of endometriomas in order to preserve maximum fertility. For your viewing pleasure, I am even going to include some sketches and notes from Dr. S himself that he made to illustrate his points. I know. Get excited. Never mind-- that was my plan, but despite saving and re-saving the pictures right-side-up about 15 different times, Blogger will only upload them upside down. Instead of slitting my throat or throwing my computer through the window (both tempting options after 20 minutes of trying to figure this out), I am just going to paint a picture for you with my words.

If you have no idea what endometriosis even is, then you should probably read up on that first, because I don't feel like explaining everything. Google can lead you to lots of different sources of information, but here's one decent explanation I found when I looked.

Alright. Let's start with a discussion about ovarian reserves, first. Basically, females are born with as many eggs as they are EVER going to have, each one hiding inside a little follicle. Your body will never, ever make MORE eggs. Once a female hits puberty, eggs start releasing, one-ish at a time (although multiple follicles/'future eggs' die off each month)...that's your 'cycle.' So from the time you start your period, you're depleting your egg supply with each cycle (unless you suppress the release of eggs with hormones, birth control, or pregnancy...or probably some other things). As the years go by, your eggs are aging just like you are. Younger eggs are more likely to result in healthy pregnancies. Older eggs...well, they're older. That's why older women tend to have more trouble getting/maintaining healthy pregnancies, even if they're still ovulating regularly. Okay. So. 'Ovarian reserve' is basically a measure of how many good eggs you've got left-- eggs that are likely to become fertilized. They 'measure' (and by that, I mean 'guess at') ovarian reserve by assessing the levels of various hormones in your body (FSH and AMH, primarily).

So what does ovarian reserves have to do with endo? "Not much" would have been my answer prior to last Friday. But "much!" would be my answer now. Well, "much" in terms of how you're going to treat endometriomas on an ovary, that is. 

Dr. S drew a picture of the endometrioma (cyst) on a piece of paper. Picture the cyst as a balloon inside a balloon, with the inner balloon being just a tad smaller than the outside balloon. That's the endometrioma sitting on my ovary--THE PLACE WHERE EGGS ARE STORED. Apparently a long time ago, this cyst started life as a follicle(s) that contained egg(s). Over the years it has grown and filled with fluid and endometrial tissue, but trapped between the two layers of the 'balloons' are a bunch of microscopic eggs. The eggs are STUCK there-- they cannot be released (to be fertilized), but chances are-- they're good eggs. After all, they are ones that got "called up" however long ago by their follicle(s)...but then got hijacked (and trapped) by the cyst.

So now let's think about ovarian reserves again. If I have a GOOD ovarian reserve, then that means I probably have lots of good eggs hanging out in my ovaries...making these guys trapped in the cyst not quite as important. But if I have a BAD ovarian reserve, then these guys are suddenly of extreme importance. It's like...when you have a head full of thick, glorious hair, you don't care about the strands pulling out in your brush every day. But if you're a male in your early 40s, starting to notice a little thinness up top...you are very concerned about 10 hairs vacating the premises during your shower. You really can't afford to waste any of them.

The most effective way to halt the spread of endometriosis is to remove the ENTIRE endometrioma during surgery. Leaving any endometrial cells behind will mean that most likely they will just start growing a new endometrioma in the near future...so typically you want to cut out as MUCH affected tissue as possible. If your primary goal for treating endometrioma is pain management, this is the best method. This was what I thought (up until Friday) to be the only philosophy behind endo surgery: get it ALL OUT. In severe cases (and depending on where the tissue is growing, of course), women have various organs removed-- appendix, sections of intestines/bowels, ovaries and Fallopian tubes (or complete hysterectomies). Leaving a speck of endo behind is leaving a seed for future endo to grow from. And if you have severe endo with debilitating pain...you'll do whatever it takes to prolong the pain-free time (and put off your next surgery) for as long as possible.

BUT. Dr. S explained that if preserving/maximizing your fertility is your primary goal for endo surgery, then this might not be the best way to do it. Because if you have low ovarian reserves and you then cut out the whole endometrioma (if it's growing on your ovary), then you lose the (possibly many and good) eggs trapped between the walls of the cyst. And that could seriously hinder your chances of having a good egg available to be fertilized in the future. So in that case, Dr. S prefers to basically drain the inside of the cyst as much as he can-- getting rid of as much endometrial tissue and fluid as possible, without destroying the eggs that are trapped between the walls or banging up the rest of the ovary too much. He said it's a really difficult thing to do, because you can't SEE the eggs, so you're just doing a guessing game about how much more you can keep removing before you're infringing on their territory...but he'll do whatever he can to make sure those eggs are left intact, with a fighting chance to do something important. Now naturally, this method will probably leave more endometrial tissue behind, which means you will probably experience a re-growth of the endo more quickly...but if it gives you a shot to get pregnant first, then it just might be worth the gamble.

So he was saying...it all kind of depends on the ovarian reserve (AMH levels). If you are young (which he graciously still considers me to be) and you have a great AMH level (greater than 3), he'll probably go more aggressively with removing the entire cyst-- after all, you have plenty of good eggs left, so it's worth it to lose a few if it will buy you more time without endo. But if you have very LOW AMH levels (1-1.5), then he would proceed much more cautiously, choosing to drain the cyst rather than remove it entirely. As he said, "we can always treat the endo again (and more completely) later...but you don't have the same luxury of time with trying to get pregnant."

So that was the 'new learning' that blew my mind pretty good. Obviously, he said, it's a woman's choice how she'd rather her endometriomas be treated: if you're not WANTING to preserve/maximize your fertility (because you don't want kids or are done having them, or, I suppose, if your endo pain is SO AWFUL that it is more important to you to slow the growth than to maintain fertility), then there's no reason to bother with any of this at all--just cut those suckers out. But if you DO...then this could be really important. And I'm just a little floored that with as much endo research as I've done, I've never heard anything like this before!    

So like I said at the beginning of today's dissertation: I am a scientist, so you can definitely trust me on this one. In fact, if you have endo yourself, I suggest you name-drop my name a little as you propose your own endo treatment plan based on this new information. I'm sure your doctor will immediately recognize me as a leading authority on the topic and fall in line accordingly. Or...not...which is to say, I'm not a doctor and please don't get mad if all of this information is wrong or mixed up. I did the best I could to catch what he was saying, but ya know...I have a couple of useless liberal arts degrees and I teach four-year-olds, so take all of my science lectures with a large grain of salt. I'm just passing on something I thought was was interesting.


  1. Dr. Bates, I'm really impressed. In fact, I'm going to start e-mailing/texting/calling you with all of my future medical AND general science questions. Now let's talk about that rash I can't get rid of... ha! (joke.)

  2. Dr. Bates, I have to confess that I only briefly skimmed this post because science is my least favorite subject... please forgive me.

  3. I agree that this is interesting. But did you tell us which version of surgery he's going to do on you?

    Also, did I tell you that I recently learned that psyc majors at UGA now have to take 2 semesters of biology for SCIENCE MAJORS?! Like, mixed in with the real science students. I'm not sure I could have completed my degree if we had to do that.

  4. Very nice explanation (both scientific and artistic). My doctor never went into that much detail but she always said that they would approach my surgery to "preserve fertility" and would drain the cysts to keep as much of my ovaries in tact as possible. Not sure if they even measured my ovarian reserve, though. She also told us that we'd have a 6-9 month window of heightened fertility after the surgery because no matter if they removed all of the endo or just most of it, the stupid endo will always start to grow back due to the hormones in my body (hence all of the food, vitamin, and body product changes I've made to try and limit the amount all of those things were making my endo worse). Sounds like your doctor really knows his stuff...makes me want to come to Georgia for my surgery, too!

  5. So I'm not a scientist, nor do I have any inclination to be a scientist, (I'm one of those artist types you mentioned!), but this was really interesting. And it made me curious about my own ovarian reserves. It is pretty cool to think about how intricate our bodies are.

    Thanks for a very clear, informative, and interesting lecture Dr Bates. I'll definitely be dropping by your class, I mean blog, again!

  6. That's pretty awesome news. I wonder how long it will take them to get the results of your blood test so you'll know what situation you're dealing with. Prayers for you that it's a GREAT AMH level and he can take the whole dang thing!

  7. Super interesting... and I had no idea.

  8. I like this Dr. S. He seems like good people.


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