Janelle Luk, MD - From Diagnosis to Hope: Navigating Endometriosis and Diminished Ovarian Reserve

Then I finally came back to USA and went on to college. But during the years, because I was an athlete, and this is very consistent with my patients, when you're skipping cycles during your teenage years or when you are having, because I was vacillating between two countries, I didn't really have stable medical care. I still remember when I first immigrated those days, was health insurance. And I remember my uncle scared us, "Well, ambulance roy is going to bankrupt your whole family. It's $3,000 because you don't have insurance, you're an immigrant." And I'm like, "Oh my God, my mind would be so scared." But I'll be struggling with pain when I'll have my period. And it was very hard because now your family is trying to adjust to a new world and we didn't have resources at that moment to find out, to study. And quite honestly, even I brought to a pediatrician or OB- GYN, they may not have told me, "Oh, just take some birth control pills." I know.

That's usually the first sentence, take some birth control trophies. And so they shut down the cycle, but not really anyone understand those diseases. And we're talking about in the 1990s now. So yeah, a little bit old. So 1990s when I was teenage years. It's very different now. And yeah, there was no math quest. Even coming to here, I mean, I was remembering all those years going to Jersey 280. I have to print out maps and my mom is next driving the little car. I'm like, "Mom, turn right. The paper said turn right." But there's a roadblock. There's no adjustment on a piece of paper. But today, when I look at MapQuest, I blocked, MYPD blocked this one. Whatever I'm trying to say is information was not as clean, direct. There was no opportunity to be here to share those information. So it was very hard.

There was no internet. As a young teenage girl, it's really, really hard to understand there's something called endometriosis or what you're struggling. But then I also had missing periods because I was an athlete. So when I do struggle with starting around 16 and 17, 18, where the pain become more severe, but then it becomes a nuisance because I have to get into college and medical school. So who cares about the period and pain? So then you're just stuck with it. In Chinese, there's like a saying in similars like eat it, tolerate it and you just go through the days like that. And then finally, what makes me diagnose endometriosis when I was at residency in Boston at Brigham and they found a dermoid cyst on my ovary. A dermosis for some of you to know, it's like a complex cyst that is a benign, not cancer.

But yes, I know when you're a medical student or resident, you don't know it's, "Oh my God, I have cancer. After all this year of studying, after went through all this school, I'm going to have cancer and die. I don't know why. It's very morbid the thought. I'm going to die. That's it. I'm going to die." And those times at Brigham, which is one of the very top hospital in the nation, we do see lots of rare cancer come to our way. So I see lots of 25, 26. Don't be scared audience. It's not that common, but it's like one of a 10,000 patients. I'm like, "Oh God, I'm that patient. That's it. I'm the case report. They're going to worry about me. " But then obviously I was worried. So this led into everyone telling me, Dr. Janelle is benign. But then I was so scared and they would do a ... So then I said, "Let's move this.

Let's remove this. I don't want to have cancer. I don't know what this is. I've seen all these rare cases." And then the doctor said, "Fine, Janelle, we're going to bring you for laparoscopy. We'll remove the cyst." And because of that fear of the cyst, that's how the endometriosis was diagnosed. So I wasn't even attending my pain. I didn't care. Pain is normal. I'm supposed to suffer two days a month, 24 days a year. Some people may have to pay time off, but I didn't know. Yeah. And some of my staff would tell you, "Dr. Luke doesn't know what's visual holiday." Well, we didn't have holidays, so I don't even know what's vaginal holidays. Yeah, don't worry, staff. We know. Don't worry. So we work through the year. Who cares? I don't take those times off. I suck it up. So at that moment, they found a stage two endometrial diagnosis.

I mean, at that point, once you have a complexist on your ovary, that will be ... And also I have an endometrioma in addition to that. And so the diagnosis was really something that make me face because now when I woke up, my doctor, I chose the doctor because I think I want children. I don't know if I want children or not at that moment. And I was in my 20s. And there's very vulnerability. There's no egg freezing. I know. I'm still very, a little bit long time ago. This is before 2012. So egg freezing technology, if you freeze 10 eggs, you lose five eggs at that moment. So I don't forget it. I don't have money. If you watch Grace Anatomy and all those, it's true. I didn't eat the patient's food though, but I'm kidding guys. But I'm just saying is that there's no resources for egg freezing at that moment and there's no technology for that.

So at that moment, I basically was just treating this disease, but my doctor talked to me and said, Janelle, you have to get pregnant. I said, why? Because you have moderate to severe endometriosis and it was my 20s. And it was a very vulnerable time because obviously we have medical school loans.

You just have your first job and residency does not pay that well. It's our minimal wage. But it planted in my head. I have to plan ahead. That means I have ... And luckily I met my husband at Cornell. So in college, we've been going through residency together and able to have my first child, this is my second child, and during my fellowship. So I did plan able to plan ahead, but not everyone is as lucky as me or have a ... If I didn't have that complex cyst, I may not have ever even attend to my pain. And that is very interesting for women to shout out to endophamine to all the education and empowerment material there is that when you have pain, you should not tolerate it. You should finally empower yourself and understand where we are and where you are and what you want in life and plan things out.

And now we have egg freezing, obviously, and many other resources that can really help a woman. For my first child, I didn't have any issues. And I don't think age, and I say that to all my patients. I don't think it's one thing, a causation and you not get pregnant. I think it's age and endometriosis together can have a synergy effect to a woman's fertility. So I tell all my patients, I mean, some of them really don't want surgery. They think they have endometriosis because they read a lot of internet and resources, ChatGPT, anything they can read, they're kind of aware of this disease. So sometimes I'm like, "It's not a black and white disease." And which is we're getting to our next couple of slides to talk about what is endometriosis and some of you already understand the disease is that how do you look at this from a different perspective as in if you do have pain and you don't want a surgery, how do you balance that?

Or when you have pain, is it necessary for you to have surgery? So I'm going to kind of, using this talk today to summarize some of the thinking and idea when surgery is needed. And everyone is a very personal answer. I've been educating hundreds and thousands of women every day about endometriosis and they will come up with same history, same personality, maybe different story in terms of family or life. They will come in different conclusions. So I don't think one treatment is for all. I think at the end is how much information us doctors would give to the patient. At the end, the patient will be empowered to make that decision, I think. So let me go on to the next slide.

Good. Okay. So this are just subcover of the introduction slides, like 25 to 50% of women with infertility does have endometriosis, and 20 to 60% of women with endometriosis experience infertility. And now this is already not black and white. It's not 100%. So it means you have endometriosis does not mean you have infertility. So there are patients, I know I see endometriosis on the ovary. I say, "Hey, you have a two to four centimeter complex cyst." And I would tell them that, "Hey, you need to remove it before possible for your first embryo transfer." "No, Dr. Luke, I haven't even tried a transfer. I don't want you to remove this cyst. I don't want to do surgery. I'm not in pain. You came on scanning in my ovary because we are doing IVF, but just transfer. "And they got pregnant. And then when they went for a second child, I tell them again," Hey, you may have endometriosis like, Dr. Luke, I'm fine.

I don't feel pain. Can you do the second embryo transfer for my second baby? "And obviously when you have complexes, the first thing we tell patient is to you have to do an MRI to further evaluate, make sure it's not malignant. Once they'd say an MRI technology is pretty good nowadays, so they will tell you, oh, it likely is a complexist or a endometrioma. And if you do have an endometrioma, there's a very low likelihood that the endometrima will become bad in the next year or next two months or next two years. So I usually will tell patient to follow up on the endometrioma. There's a number. Some days it's like five centimeter or four centimeter, which is a complex cyst on the ovary may indicate that you may have trouble or ... What I'm trying to say is very low chance of doing something because of incidental finding, except the cyst is growing bigger or causing symptoms.

So if any cyst is not yet causing symptoms, some of my patients do reluctant to remove the complex cyst. And if it is less than four and there's number out there that doctors start to say," Hey, you need to remove it. It's like four to five centimeter every year. I don't think it changes plus minus one centimeter from journal articles and reviews. That's not a must. But if you do keep it in, like my patient, I told her, fine, please follow up in your years because after she have a second child, she may never even come back to see me. "I said," In your 40s, and that's why we all do mammogram, pap smear. "I said," You can change, but please follow up with the size as you grow older. "And yes, as you go through possible menstrual cycle and biological clock, some cysts do dissipate.

They do get strange, they strung up together because the feed that the enemy of endometriosis is estrogen. So the more estrogen and you keep on cycling, the cyst can grow bigger. But if you go through menopause as you go through the biological clock, the cyst sometimes will shrink and decrease in sizes. So why I'm trying to bring the point is that endometriosis is definitely not a black and white disease. It's a very gray area.

And then there's just some statistics about chances of pregnancy when you're doing natural cycles, as in having sex, so forth. It's about two to 10% with endometriosis when you're getting pregnant and 15 without endometriosis just per month. So it drops by half the chance once you have endometriosis. But then again, it's not black and white. People can get pregnant with having sex. So endometriosis, endometrioma, these are all different types of kind of a very schematic view about endometriosis. My research at Yale was on endometriosis and basically I used to work on collecting pelvic fluid on women's belly where after the surgeon do it, we collect the fluid from the operating room and we look at something called interleukins, which is our inflammation marker. I don't know, do you guys understand what's interleukins? Interleukins or cytokines are components of your immune system. So when we have rash on our face or any, let's say you have an allergic reaction after you take a medication, you start coughing.

So there's all cytokines increase in your body. Endometriosis, one of the theory is that women's have inflammation in their belly.

Some women, the inflammation is settled. They have a good immune system that will deregulate. So you can think of some people have rashes and allergic eczema. So one of the theory is endometriosis is like a dysregulated immune system that somehow the body doesn't know what's going on, just attacking itself and very inflamed. And then when your pure comes to estrogen flare, I mean like, oh, I'm in pain. That's one theory. Second three is the Samsons three back in 1928 where he believed the period has a backflow to the pelvis. So all of us have retrograde bleeding. I know you're like, hmm, how does that work? So blood is flowing from the us down to the vagina, but there are two holes, right? I used to have my dolly if someone followed good luck look, I have a little doll. And so one of the patients, one of the colleagues was like, "Dr.

Janelle, where's your uterus?" And I'm like, "Where's my uterus? It's right here." But I usually have a doll, but there's two holes to the tube. So what I'm trying to say, when the blood is coming down, they can retrogate backwards, which is 10 to 20% is supposed to be normal. So don't be scared, guys. It's okay. But they're supposed to clear out the 10 to 20% for a normal women. Then they're not supposed to stay in here. So there's an immune system to take the blood away. That's how, because life, I know gravity, it should come down, but our uterus is tilted. You guys all know that it's not like a bottle, it comes straight in our body, it's crooked. So actually, if some of us are retroverted, introverted, why would not blood go through the tubes? So blood will go through the tubes. And the idea is that the immune system inside the abdomen will clear those blood.

So the theory, and this is where when I was in medical school and residency, they would say, "Janelle, don't be too stressed." Women who are stressed and type A personality will have endometriosis. And this is well studied that people who are very stressed out, wherever trauma, anything, just stressed, so stressed that they usually have more painful periods, which I thought, wow, that is so Eastern and Western because I was from Hong Kong. I love Eastern. I talk about chi and yang. And I'm like, wow, that is fascinating. And so I do believe when you're stressed, there is a dysregulation of the immune system for certain individuals.This is not true for everyone because I was listening to the lecture right before because I was also at Brigham, which is a place where they do lots of knockout. What does knockout means is a mice? How do we know bronchigene causes breast cancer?

Sorry, I'm weaving back to that point, but I'm coming back.

So there was one knockout paper because everyone, scientists in the world want to discover the next bronchi gene means I have this gene, you're going to have breast cancer. That is a big 190 people would cut their breast, take out ovary for genetic testing. So it's a big deal. It's not like, "Oh, it's great. You have antivirus. You may get pregnant, not pregnant." It's not like that. It's like you have the gene, you will have breast cancer, ovarian cancer, you need to cut your breath, you need to do your mastectomy, you need to viphrectomy. So every scientist want and a human being in the world want to discover something with that high correlation. So everyone's trying to discover an endometriosis gene, which I was here the audience was asking. So then there was one gene. So it can also from genetic. It's called a KRAS, K-R-A-S, the KRAS gene.

And they knock out that gene and the mice did not have endometriosis. But obviously no one in the audience, I didn't hear the recent literature about this. Well, because they haven't really identified, which is what the previous speaker was saying, that's more than one gene turns out. That was on that mice when we're not mice. We don't have a tail, we don't eat in the cage. So there's lots of multifactorial things that's affecting. So that's why genetic, that is a component of cause of endometriosis, but it's not the only answer. BRCI is the only answer. Cystic fibrosis, having mutual carriers, there's certain things that's an answer, but that's not yet for endometriosis, which makes this a little bit more frustrating disease to take care of. And then that's where the diet comes in, the inflammatory diet versus antioxidant diet also is also very part of, as we are talking about the disease and the causes, and I will offer some therapy also as we go over this.

So adhesions, and some of you may know, it's a scar tissue ovaries and tubes that ... Some of you may have endometriosis and you do something called a hysterocell pangiogram, especially if you're struggling with infertility. And when the tubes are unblocked, you're like, "Oh, great. The tubes are great." But the tube actually, if you watch movies on the fallopian tube, I know YouTube sometimes have some movies, is that the fallopian tube is a very flexible organ.

There are patients with a left ovary taken out with a left tube intact, right ovary intact, but no right tube, and get pregnant. So what I'm trying to say, the tube is expected to be very elastic and flexible. Even if it is unblocked, does not mean the endometriosis did not affect the patient because the adhesions, because you cannot see the movement is very ... I don't know if you see bowel moving, it's like water waves. This is nature. So if there's adhesions, even the tubes unblocked, it may still can affect the endometriosis, the fallopian tube mobility. And because of that, it does can affect fertility, even though the tubes is unblocked. Because tubes unblocked is a very interesting thing. It's like you expect the tube to stay there and grab the egg. But the ovary is a orbit. I don't know if you've seen it's a little organ that's like a ball.

So it's not just getting the ... The egg can come on the bottom of the ovary. The tube has to adjust to grab that egg. I don't know, you guys watch alien. Again, you guys are so young, but I hope alien, old time alien movie you now have to grab the eggs with the arm. So you think about that. It's very flexible organ. So again, adhesion is one of the possible causes of infertility with endometriosis. Inflammation, so fertilization sometimes inflammation around the interleukin. So one of my study was into leukine. There's over, I think, 25 into the leukines inside our belly. And when there is a upsurge of endometriosis, it can cause us the inflammation of the egg having trouble with the sperm to fertilized. And then yes, this is a new thing, which is when people are having endometriosis, sometimes they have failed with embryo implantation.

So now we are seeing patient with normal embryos. In the past, we cannot blame the embryo and the egg, especially the egg. And so now we're seeing that inflammation on the outside may affect the implantation from the egg to the uterus. And finally, it's the ovarian cyst. We talk about the ... So endometrioma sometimes is an issue, especially they're on the side of the ovary that having trouble for retrieval. So sometimes endometrial has to be removed before egg freezing. But if the endometrioma is far away, we usually want to get the eggs first before you do the surgery. Because once you do the surgery, I sometimes don't see the ovary. They do such a great surgery. The ovary is gone after the dissection. So that discussion has to be discussed with the physician, what's the risk and benefit doing the endometrial removal first or after the egg freezing.

And adhesion we found ... Yeah, so this is just of the general statistics we've seen in patients. Adhesions were found 65 to 88% of endometriosis patients with pelvic pain and implantation rates were 50% lower endometriosis patients undergoing IVF and 17 to 44% of endometriosis patients develop ovarian endometrioma. And for patients with develop endometriosis, sometimes they have 36% of AMH levels, but that AMH level is based on quantity of the eggs. So AMH is produced by granulosis cells around the oversight. And so the more endometrial you have, you may have a inflammation to the ovary itself. But the removal of the endometriomas may also reduce AMH levels by up to 44%, which I was talking about where you can remove that and that will happen with diminished ovarian reserve.

So I know we have about, I think one minute ... No, two minutes. Okay. So I'm going to just kind of summarize how patient comes to me and for infertility and what the things I guide them with. Number one, patients may or may not have symptoms. So they may say, "Dr. Luke, I don't have pain during a period." And so with that, I don't assume they don't have endometriosis. You can still have endometriosis. So this is just something how confusing endometriosis is. So when I was doing a residency for you to understand there will be a patient with so much pain, we thought we're going to pelvis, there'll be adhesions everywhere, but then we only found one dot of implantation on the belly. That was it. It was like, "What?" So now we don't know, is it really endometriosis or is irritable bowel syndrome? I can keep on going, maybe pelvic floor disorder, like there are many things because you have to really take a really good history.

Sometimes not just endometriosis, they may have pain during sex. They just didn't tell you or maybe just one day of cramping. So we have to dissect those things and also shows you endometriosis can show in different colors, means they can be one dot and have lots of pain or a patient with no disease and they went in for appendix move removal and I found stage four endometriosis. So you can see the wide spectrum. So it's very simple. We don't take care of every patient with infertility all the time going to surgery. This is the talk I would give to them. And then they would say, "Doctor, look, I'm in lots of pain. I don't want IVF." I said, "That's great. How many years you have tried getting pregnant, then I think time to once don't hit two birds, go and remove your endometriosis and have more sex.

Hopefully you don't need IVF and that removal of endometriosis does improve fertility." IVF in itself supposedly is the therapy of endometriosis for fertility means if you're in pain or not in pain and you just want to get pregnant, you're not here for pain control, usually endometriosis, excuse me, insulin IVF is much better than endometrial surgery because no one want to go through the surgery for IVF. Then we'll go for first embryo transfer. If the transfer doesn't work, then this topic will keep on coming again. Patients, some of the patients just really didn't come to me for endometriosis therapy. They're only here really for the fertility. So then with that said, then I would just educate the patient. Again, I would say, "Doc, I would not want you to go through surgery." So we're now treating patient with Olisa or Lupron shot to suppress them to improve the implantation rate.

So those are the things that we are kind of offer patient because what is your goal? If your goal is here for pain control, well, this is where ... And pain control, there's only suppression with medication versus surgery. If you're trying to get pregnant, there's only surgery. Every medication is a birth control method, so you can't use birth control or Lupron or birth control pills or any other therapy because it's just not compatible with pregnancy. So I think those are the things that we usually. And finally, for patients who do IVM coming to our office or to me, I usually do Letrozole. I just don't want the flare of the estrogen. So we usually do Letrosol to suppress the levels of the estrogen level, which is very classic. I do that for patients who have active breast cancer who come here for freezing before they get their chemo, but that is also, that help our patients a lot and give them birth control pills right after the retrieval to suppress the ovaries.

Okay. I am sorry. I know I see the sign, QNA. I got you. Thank you so much. You're

Really fine. We actually have about a little 10 minutes.

Oh, great. So

If any ... I mean, I don't know if you want to continue.

Oh, thank you. We also do have extension.

We also do have a little bit of online questions as well.

Oh, great. Great. So I'm going to just do two more minutes and I will open the audience for answering. So the fertility ... Yeah, so we talk about ovarian reserve. So one of the thing that I want to emphasize is dementia of reserve. So after you remove, I see patients is after endometrial surgery. They have done twice already. And I've seen the ovary does not have that many eggs. AMH is low. So one more time, guys, let me be very clear. It's very important. A quantity does not equal to a quality. So if you are a young woman who had two surgery and now you're 32, 33, coming to me and you couldn't get pregnant, do not cry about your AMH. It's okay. We'll figure it out because the fact that you are young, I know it goes by with the age again, your diminished ovarian reserves does not define you.

You will get pregnant. One of my lowest AMH that get pregnant with twins. I know it's a little bit dramatic. It's 0.08 AMH, okay? IUI.

And it was funny because it's a single mom by choice. I know it was traumatic and exciting, but she came in IUI. She's crying because obviously has chance of her foreign partner. She's like, "Dr. Lu, what should I do? I did two surgery for endometriosis. My AMH is 0.0 menopause by tomorrow." It's okay, we'll be fine. We'll do some latrasol and she knows the choice, "Well, I need to get pregnant now." I said, "Okay." And then she got the IUI. She got twins, AMH 0.08. So I just want to know, the ministry reserve is not a definition. And yes, that's why I'm passionate about this because when I first enter the fertility world, AMH is being like anytime AMH is a way to diagnose a woman and it has got so much tears and still happening. I have lots of mommies come with the daughter with AMH.

They both look so sad. I'm like, "No, you guys are great. Do you have a husband?" Yes, some of them don't have husband and boyfriend. So the mom of the patient is like yelling, "Just get married tomorrow." Things like that. But usually then I would talk about egg freezing out the channel, but I said, "Just get pregnant. Why wait so long?" Especially some of them are married, I don't wait too long. I know it's a little bit insensitive for ... I totally understand. My mom did that to me too. Just have the child now in medical school. I'm like, "I'm not ready. It's medical school." But it is very important to understand that dementia varian reserve does not define you, does not equal to your equality. And equality usually defined by two factors, only two numbers. How long have you tried and how old you are?

So there's not yet. I know the Nobel Prize winner will come. Once they find out how to discover equality and each month, because different companies like a casino here. So if each month you have different draw, you don't know which egg. And if I can predict a woman, isn't everyone come to me on day three? I will predict you, Mary. You will get that this is the month, have sex. Not April, May, you can take a break. That will be amazing, but not yet. There's no egg quality test. There's no egg quality prediction. And so we use a very mild stimulation for those patients, one egg to baby. That's it. We don't need to define that. And also the same thing for IVF success rate. I usually do not use AMH to define it. It's by only age, not AMH. Okay. I'm sorry. That was my really tidbits.

And let me see if I have any more slides that the audience like. Yeah, this is what I was talking about and some people do surgery. Yes, it's different. Yes. It is different. Endometriosis and fertility is different for everyone that makes this testing is ... Yep. So that was my slides. I'm open to Q&A if there's anyone. Oh, thank you. Oh, yes.

Not work. Oh, you mean testing for the ovary reserve or? Yeah.

And for a quality or fertility testing?

Yes. You come to me, OBGYN. I mean, I do a little bit more discussion. It is true. I love all the OBGYN. They're all my girlfriends and I am an OB- GYN myself. I Just think the community of OBGYN may not be as conscientious about endometriosis because it seems to me 90% of the patients that have cramping and pain. But I am an OB- GYN, we take anyone most REI also. We would love to see. I've got patients coming for just fertility evaluation, knowing all her options. Yes, we do do that. Thank you. Yes.

Hi, I have a question about AMH and how early women, young women should be getting it tested. When I first started learning that I thought that I had endometriosis and was learning about AMH, I was like, let me at least get this tested and see where I'm at. And they didn't want to do it. And I was already 26 at that point. And I was like, it's a blood, just give me the test. Multiple doctors refused or didn't want to do it. So I'm confused as to when young women should be asking for that and who to go to.

I think in your 20s after, I mean, it can be during college or after college, after you just want to learn about fertility, I think everyone can get it. AMH also has to correspond with antral follicle count. But because of that complaint, I have been giving free AMH per, is it every other month? And yes, we work for the community. We don't even care. You don't have to do any services at the center. It's just a way to give back. So what you just said, because the whole point of me doing this was doing this, this is my joy on a Saturday, Sunday, coming here to talk about things I love and passionate about, which is empowering women with resources that they don't have and telling them and then give them a new opportunity to write their own story. Because you're exactly right. Lots of patients did not understand it.

So there's two types of anxiety here. One is getting a very low MH doesn't know what's going on. Some patients don't even access to get an AMH or know that they should ask because decreasing a quantity until you're menopause, you're asymptomatic. So both of them are, you don't feel, "Oh, I'm decreasing my eggs today." There's no decreasing eggs feeling. So how would you know what is going on? What's your baseline of your ovaries? And so knowing AMH is one of the factor. But again, if you're young, you got low MH, don't start like, "I will never be pregnant again," and things like, because it's not true. So there's something that's very important. Yes. Oh. Okay.

I'm asked, in your opinion, what is the ideal amount of eggs needed to do IVF?

Actually, I am a big component. There's no number of eggs cannot do IVF. So there's very common in when I was taught, I think someone see already wears myeloma and all that. So anytime more than less than three follicles, they don't retrieved. Okay. That's classic. I don't know. Some places five. I think it's because of the extronomical cost of IVF. So if you only get one egg and they worry, the embryologist cannot viralize. So unlucky to my staff at my office, we have lots of one egg to baby cases. The reason is because these are the patients that no one even wants to try. And it's so funny, last two days I interview is still happening. I'm like, "Why are you calling me from Washington? It's so far, Seattle, Oregon." And just know they said, "Don't come here. We don't want to take you. " Because the one egg to them has ... That may be true by pure mathematics.

And it's also true. I don't think I'll get in trouble. Let's talk about this. There are agency governing IVS centers means they're using success rate. And some of you would love, what's your success rate? Because maybe ChatGPT said, "How do I know I want this IVF center? Well, I want the success rate." But I never, for me as a doctor, I'm not treating the national statistics. I'm treating you. So there were lots of patients that was actually, that's how I was born. I mean, as in my center, me. Because the issue here is we do not want to make patient feel because if less six, no one will take care of you. And it's true. Then possibility you have a less chance because you only have one egg or two egg. But then that's exactly what happened to them. They will keep on canceling one egg.

Until six months later, I retrieved that one egg, that was the baby because that is how the world works because AMH low does not define that you will not get pregnant. You may be five or 10% just because of the AMH a little bit lower, a little bit lower than patient who's 50%, but you still have 40%. Why make it zero? That certainly sex didn't work. We still have to be there, but if the adhesions on the tube, it didn't work even though your tubes are unblocked. So I think that theory of one hominy eggs in the world in the coming years, hopefully the organizations and the people up there who are controlling success rate and so forth will understand that we're not here to treat success rate, but we're treating patients themselves.

We have time for one more question. I wasn't sure who was first or not.

No, I'm sorry, but I will be around if anyone have questions. I apologize. Yeah, go ahead.

So if someone comes to you and they've never had excision before, do you recommend that they try that before trying any IUI or IVF?

It depend on pain. So our patient literally, they can even walk from ... Because as you know, IVF centers, we need them to come on day three for blood work. I didn't know how traumatic her pain is, but one day someone from front desk go, "Dr. Luke, patient's in pain." I said, "What happened with shake retrieval?" No, she's on day two of a period. But she'd been struggling like this for her lifetime, that she'd be in pain at the elevator. So for those patients, I said, "Don't do IVF, please. Can you please treat yourself?" But if your pain is not there and you just cannot get pregnant, your tubes and everything, everything is check off, majority of the patient will then go through the letrosol, the IUI. I know the sex, as you know, there are only three ways to get pregnant, sex, IUI, IVF.

So after they go through the letter of it, depending on how short, how long patients and me drive the bus together, we decide together, and then we will then go on to IVF. Majority, I would not say majority, but 60% to 70% patient would not want surgery right away, especially they're not on the elevator, but that patient, definitely I persuade her, "Please get a surgery first. You should not be living like this. " Yes.

Well, I was curious because sometimes people will have insurance that will cover their excision surgery, but not insurance that will cover fertility services. And so just for cost savings, would you recommend to them?

I don't think the effectiveness IVF is still winning depending on age. And that also depends, that is a multifactorial variables to decide that decision because if you are 30, let's say you're a little bit younger and you are not in pain and you don't have coverage, I usually would give the ... But not in pain is the key. So if you're in pain, surgery is kind of a good option. But if you have not in pain, you're just here, you cannot get pregnant, we usually do not recommend surgery because it is the risk and benefit of surgery. What do you discover? What if there's nothing in there after laparoscopy? It can be endometriosis, but if there's a pain, then usually we suggest that as the first line. Okay. Thank

You so much, Dr. Lu.

No, thank you so much.

Obviously, as she mentioned, you would be around, so please feel free to-

Yeah, that would be with

Conversation and it's now time for lunch, so we can go ahead and-

Okay, great guys. Thank you. Thank

You so much. Lunch will be-