[00:00:00] Dr Renee White: Knowledge is power, and we are all about empowering the mamas of the world. In each episode, we will unravel and interpret the latest research and evidence-based practices for pregnancy, postpartum, and motherhood. As mums and researchers ourselves, we have experienced firsthand the overwhelming complexity of information myths and those classic old wives tales.

[00:00:27] I'm Dr. Renee White, and this is The Science of Motherhood. Hello and welcome to The Science of Motherhood I'm your host, Dr. Renee White thank you so much for joining me today. This episode is proudly supported by Our Cow, which is, I don't know about you people out there, but I am very, very particular about my meat, where it comes from, what the quality is. I think we've all heard, you know, some pretty dire stories around all of those things, quality and sourcing. And I have been on the hunt ever since I moved from, uh, Melbourne, where I had my, my ultimate butcher there. And I've been on the hunt for an amazing butcher, which we have many, many here in Tasmania, and I have got some favorites.

[00:01:20] Big, big shout out to, um, Vermey's and Wursthaus they are great in Tassie, but when we are doularing, I need, I needed to find someone who was able to. People to ship across Australia without losing quality I also was trying to find someone who really supported local farmers, rural communities you know I wanted to know where the meat was coming from and it needed to come from a consistent source, 'cause that's what we're all about here at Fill Your Cup. When, when I'm not in front of the microphone, I'm leading the charge at Fill Your Cup, which is Australia's first doula village and I stumbled upon Our Cow and Our Cow is absolutely amazing because they do all of those things. They support local farmers.

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[00:04:25] Alright, let's dive into today's episode. On today's episode, we have got Dr Kokum Jayasinghe, who is a fertility specialist at Melbourne IVF. She has never been on the podcast before, but I'm gonna say I don't think it's gonna be the last time that she's on this podcast.

[00:04:44] Amazing personality first and foremost, I love it when I have guests on this podcast and they just are so full of energy and knowledge. This woman taught me so much in the hour that we spoke, and you'll definitely hear that in today's discussion. She's a highly awarded fertility specialist with extensive training and experience. She's completed a specialist training in obstetrics and gynecology at the Mercy Hospital and has subspecialty training in infertility and IVF at the Royal Women's Hospital and Melbourne IVF. But it was kind of like her own personal story, which was the driving force for her to enter into this field.

[00:05:30] It was her own fertility challenges, and that is where she really understood the journey, her patients face and her role in helping them achieve success and we talk about that in the discussion today. Obviously you'll know from today's title that we are talking all things endometriosis. We talk about how common it is, why there's an increase, um, in more women being diagnosed.

[00:05:57] What is endometriosis actually like if we're looking at the nitty gritty, what the symptoms are, how does it impact your fertility? And then we kind of deep dive into what are the treatments, um, in today's day and age 'cause it's obviously very different to, you know, what it was five, 10 years ago. And then we talk about the new research that is available to tap into.

[00:06:25] I absolutely loved this discussion and you'll hear from myself in the pod. You know, I've got a family history of this and so I was so, so curious. This is what I do I kind of self indulge in, in having these guests on, and I kind of ask a few like little tidbits for myself along the way. But I hope you enjoy this.

[00:06:46] I know you're gonna find this really valuable. If you would like to reach out to Dr. Jayasinghe, just head over to the Melbourne IVF page and you can access all her details there and they'll also be in our show notes. Alright, let's uh, hear from Dr Kokum Jayasinghe. Hello and welcome to the podcast Dr Kokum Jayasinghe how are you today?

[00:07:14] Dr Kokum Jayasinghe: Good. Very well, uh, thank you Renee, and thank you for having me on your podcast.

[00:07:18] Dr Renee White: Oh, my pleasure. Thank you for coming on and we would've heard from the introduction that you are a fantastic fertility specialist at Melbourne IVF and today's episode we are gonna be talking about endometriosis and fertility, and I know it's March, it is endometriosis awareness month. And so I think, you know, it's very timely to have these conversations about it, and it's something that actually hits home for me because I grew up with my older sister who had endometriosis and funnily enough, I just found out the other day that my mum had endometriosis.

[00:08:01] We just didn't, I don't know why we didn't talk about that in the household. Maybe she was kind of like, you know, it's just, you know, that generation where they just kind of get on with things and what have you. But I distinctly remember seeing how difficult it was for my sister to have endometriosis and it wasn't that classic, oh, I've got my period this month, and we kind of can continue on with our life. Like she had days of school all the time. How common is endometriosis?

[00:08:37] Dr Kokum Jayasinghe: Very good question, Renee. So we believe endometriosis is very common and one in seven women can have endometriosis. So to your point that if someone is having extreme pain, rather than normalising it as, uh, what do you expect? This is your period pain. Mm-hmm. Um, it is worthwhile, um, seeking help and trying to figure out or work out what is going on. So have a suspicion, a healthy suspicion about the condition and see what's going on. So all this March and endometriosis awareness month is to raise the awareness so people don't put this, uh, under the carpet and not talk about it and normalise things are pathological.

[00:09:20] Mm. So one of the biggest issues with endometriosis is it is taking a very long time to diagnose. So because people are reluctant to seek help, you know, seek help and go to a doctor. And even if you go to a doctor to initiate investigations and to make a formal diagnosis can take years. So that's why this whole concept of endometriosis awareness, so we are talking about it openly. Patients are aware of it, GPs are in a better position to investigate that. So sooner we understand and work out what's happening with the patient the better she, she is informed and make some informed decision about your, about her, um, medications, her treatment options and her life pretty much.

[00:10:07] Dr Renee White: Yeah, absolutely. And I think that was the thing with my sister, like in the beginning, like it was just kind of like dismissed and it was like, oh, you've just got really bad period pain. And like, come on, like just get on with it. Or like, this is a fact of life. Um, maybe, you know, you've got a a decreased pain tolerance or, or something like that. Mm-hmm. There's obviously a lot of awareness and growing awareness, I think from the media and we've luckily got some amazing new funding that's coming from government. Do you think that from this there is an increase in more women being diagnosed?

[00:10:49] Dr Kokum Jayasinghe: I think there is both. There's two factors there. It is, uh, probably the incidence was similar, but now we are getting more women to come forward and talking about it and asking for help. Mm-hmm. So the, um, diagnosing them much sooner so that would be a bigger factor in us now saying it is one in seven. So I remember when I was a much younger doctor, or in my medical students days, I would say, we were saying the statistics, one in 12 or one in 10 women had endometriosis. So it is becoming more and more frequent.

[00:11:22] I don't think it is a true incidence of disease getting more, uh, common. Mm-hmm. It's a fact of, uh, raising awareness and we are diagnosing women quicker, timely. Mm-hmm. And, and it's a common condition.

[00:11:36] Dr Renee White: Yeah.

[00:11:36] Dr Kokum Jayasinghe: And as you mentioned, the days are gone that we normalise pathological pain and, and, uh, put the blame on the patient to say, oh, well, can't you deal with the period pain, this is normal part of life. It's actually not a normal part. It's a pathological condition. It is a medical condition and there's treatment available.

[00:11:55] Dr Renee White: Why is it that it takes so long to diagnose? Like, what, what. You know, back, back in the day and it did. It took a long time for my sister to get diagnosed. What do you think it is about that?

[00:12:07] Dr Kokum Jayasinghe: So I can think two reasons why it was the case. So one is women are not openly talking about their periods. It is not necessarily, back in those days, it is not necessarily a coffee conversation or the dinner conversation, um, you would have with a friend. You don't, you may compare the dresses or the jewelry or the nail color you are wearing, but you don't always compare your period with someone else's.

[00:12:32] Dr Renee White: Yeah,

[00:12:32] Dr Kokum Jayasinghe: You, you should. So if you think your period is abnormal, I think it is definitely time that we ask, Hey, do how many days you bleed, how often your period come? Is it painful? Do you need to take painkillers? So we are making it a normal conversation. Now, we are encouraging women to talk about their gynecological health. Mm-hmm. And that's a good thing to ask others. Right. But back in those days, it was not the case. So maybe patients like your sister, just bear with it rather than making complaint because you are seen as a whinger. Yeah. If you just keep whinging about a lot of health issues right. That's one thing. And the second thing is the GPs and the, the initial care practitioners would have the similar attitude saying, well, what you gonna do it is the period pain and, and, um, period pain are supposed to be uncomfortable mm-hmm and, uh, unpleasant. So there was a reluctance, investigating and what the first line investigation would be, an ultrasound. And if you do an abdominal ultrasound, a non-specific, with not the right people, without, uh, specialised skills, the ultrasound not, may not find anything. So, and that doesn't mean the patient doesn't have endometriosis, so it would be multifactorial in those days why it took such a long time or delay in diagnosing endometriosis.

[00:13:53] And that's the very thing we are trying to change by raising awareness and making patients comfortable talking about it. Talking about endometriosis on a daily conversation mm-hmm without any hesitation, Hey, why do you ask about my periods? You would say, okay, what do you wanna know about my periods? And, and, and if a colleague or a friend ask, uh, to say, this doesn't sound normal, you should go see someone mm kind of, uh, advice and GPs are now encouraged to in fact, ask the patients about your, uh, about their periods and if they find something unusual or some not fitting in with normal descriptions to start investigation sooner. And also the awareness that ultrasound not, may not be the gold standard test for endometriosis mm-hmm and having a normal ultrasound doesn't completely rule that out.

[00:14:47] Dr Renee White: Yeah right. Uh, when you like the, I think you, you've hit the nail on the head in terms of like having those conversations with, you know, your, your best friends over a coffee about what your period is and I also think, 'cause I have seen it, my, I mean, my daughter's seven now, but I'm already thinking about, you know, normalising having a period like just full stop normalising having a period. I think, you know, back in the day it was kind of like, oh, okay, you've got your period all right. Okay, well here are a few things that you can do and like, you know, hush hush, and we're just gonna like.

[00:15:22] Put that to the side, and yes, it's something you're gonna have to deal with every month, but it wasn't, as you say, it wasn't a dinner table conversation. Whereas I think now, perhaps my generation is like, okay, let's celebrate this. Like this is an amazing event to have and let's normalise it both with girls and boys. Like I just saw the other day, one of my friends had posted that she, every time she gets a period she puts a little red bracelet on and her two boys know that mummy's got her period, and therefore she might be a little bit more irritable and she might be a bit sore and she's tired and she needs a bit more nurturing and patience and things like that. I think, you know, and I'd love your opinion, those are the types of conversations and norms we should be investing in for our society.

[00:16:14] Dr Kokum Jayasinghe: Absolutely, could not agree with you more and talking about that. Renee, I have two boys and, um, they talk about, um, these kind of things openly with me. In fact, they come to me and ask about the reproductive anatomy and biology and whatnot, which I'm very proud about rather than googling. I have keep the communication channels open and say any question you have, come and talk to me. Mm-hmm. I don't want you Googling and trying to find out these through Google. So that's, I'm very proud about that and also, we have a little girl puppy, so they are actually, I have told them what to do if a if she start having her first period while I'm away. Mm-hmm. So they're sort of in tune, they're sort of in tune with what to do until I come home with the dog so

[00:17:00] Dr Renee White: well equipped.

[00:17:00] Dr Kokum Jayasinghe: So, yes. Yes, definitely. So it's not only the girls, we have to make the boys also aware of this medical conditions. Mm-hmm. So they would, um, look after their future partners and female family members.

[00:17:12] Dr Renee White: Yeah, absolutely um I'm just gonna shift gear 'cause I guess we, we dive into this kind of, you know, topic and you and I both know it quite intimately about what endometriosis is. But if there's someone out there, you know, perhaps they're, they're quite young and you know, they're like, okay, well what the hell is it Endo? Or they think a family and friend have it, or they think they have it. What is endometriosis and what I guess are the red flags where you start to think, oh, hold on a minute, on a bit of self-reflection. Maybe that's something I'm experiencing, it's not just period pain.

[00:17:46] Dr Kokum Jayasinghe: Yeah, so endometriosis is the condition we find similar tissue that is lining the endometrium outside the uterus. So if you think about the female anatomy, you have the uterus, you have the tubes and the uterus and the tubes and the ovaries sit in the pelvis. So the, the particular tissue that lining the uterus is called endometrium, and that's quite unique and specific, and you are not supposed to find it elsewhere in the body. But when you find similar tissue to that is lining, the uterus is outside, uh, the uterus and in the pelvic tissue we call it endometriosis. Mm. And there are many theories as to how this happens. There's no hundred percent agreed theory, or in other words, we don't exactly know but the most commonly believed theory is it is by back bleeding.

[00:18:39] What I mean by back bleeding is if you understand the uterus and the anatomy, when you have your period, you are shredding the endometrial lining, and that is what you notice on your pad. Mm-hmm. That blood can flow backwards through your tubes into the pelvis. So back into the abdominal or the tummy, the blood can backflow through the tubes if your tubes are open. And most of us have open tubes. Mm-hmm. And that is how endometriosis happens. So every woman will have this, every woman will have some blood flowing backwards into the abdomen and you have a cleaning mechanism, I simply call it, it is the mopping up. So you mop up the blood that, uh, goes backwards every month.

[00:19:22] And in some women this mopping up or cleaning is not hundred percent. Mm-hmm. So there's going to be some residue or collection of blood every month. So the more opportunities the body has to keep collecting this blood, the, the more severe the endometriosis can be. Right, so it, it doesn't happen overnight. It doesn't happen in a month or week. This happens over time when you have many months of menstruation and blood collecting in your pelvis.

[00:19:52] Dr Renee White: Mm mm Uh, is there some genetic elements as well? Do we know that?

[00:19:58] Dr Kokum Jayasinghe: Definitely. Definitely there is not that exactly we know the gene Renee, but we certainly believe there is a genetic, a strong genetic component because we see this running in families. Mothers with severe endometriosis can have their daughters affected with the condition and the siblings, like if your sister has endometriosis, you are likely to have endometriosis. So these tend to run in the family and the commonest symptom we see with endometriosis is pain. Mm-hmm. So pain can be with the periods, pain can be with sexual intercourse.

[00:20:31] Overall pelvic pain that is out of proportionate to that crampy and mild pain that anyone would get with your periods mm-hmm is the typical presentation. So I'm gonna keep going, um, elaborating this a little bit more. Yes. So pain is very subjective. So how one would experience pain is different and some women actually will, uh, experience the pain, but think, well, this is normal. Right. And then, so she may not necessarily go and see, um, medical advice or seek help because she call it normal. Everyone's pain threshold and experience is different at the same time the disease itself, it is not black and white. You won't call yes or no for endometriosis. It is not black and white.

[00:21:15] Mm-hmm. So there's going to be a spectrum of the disease. It can start from very mild deposits of endometriosis to very severe end of endometriosis and during laparoscopy, when we go and operate on these women, we also see the appearance of endometriosis, again, is not universal there can be different appearances. It can have brown color, white color, black color. The appearance itself can be different. The pain itself, sometimes we can see women with mild, very mild disease, having extreme pain and very severe disease having no pain whatsoever and it can be incidental finding. You go into a pelvis to operate for something else and you incidentally find out, oh, she has, um, severe endometriosis.

[00:22:01] Wow. So it's not a correlation to say, well, severe disease equivalent to severe pain minor diseases, no pain, no less pain. There's no correlation between disease severity and the experience of pain for the patient.

[00:22:14] Dr Renee White: That's so interesting because I was talking to my mum the other day about it, and when I could finally kind of, you know, worked out that she had endo, she said, oh, do you have it? And I said, I don't think so because I, I mean, I've never had that kind of extreme pain that I saw my sister go through, but you know, now that what you've just said, like that could be something, it could be something that I've had. My question is, actually, I have a, do have a question. I had an elective cesarean for my daughter, so when they, you know, operated on me, do you think that they would've seen if I had endo.

[00:22:51] Dr Kokum Jayasinghe: No, no. So at the elective cesarean section Renee, the uterus is, um, quite enlarged and uterus is, uh, it, it, it is, it is the elephant in the room. It is taking the whole, whole space in the pelvis, and we make a tiny incision to get the babies head out. Mm-hmm and we deliver the baby. Yes. And then we quickly, because it is bleeding, the uterus has very high blood supply in pregnancy, it is start to bleed.

[00:23:16] So we wanna just quickly suture it, uh, back up. Yeah. Back in and put the uterus and close the abdomen. So no one is gonna go

[00:23:23] Dr Renee White: no one's poking around

[00:23:24] Dr Kokum Jayasinghe: Endometriosis at the time. Yeah. And with the amount of bleeding that happens, um, around the uterus and the pelvis, no one is gonna notice it. Yeah. So if, if your obstetrician has not noticed endometriosis at the time of the C-section, but later you find out, oh, I do have, how come he or she hasn't noticed it? I'm not surprised at all.

[00:23:42] Dr Renee White: Ah, okay. That's fascinating. 'cause yeah, when my mum asked, I thought, I don't, I I don't know, like, I dunno, you dunno what you dunno, right?

[00:23:53] Dr Kokum Jayasinghe: Yeah. Yeah. And, and again, it's like, it's not a condition that you would go asking for and say, can you do a laparoscopy and see if I have endometriosis? If you don't have significant symptoms? Yeah. Because it is not necessarily like a cancer that ignored, that's gonna get you and kill you. Yes, yes. So the, your symptoms, your, uh, whatever the problem would be, the trigger to look for and ask ourselves the question, does she have endometriosis? So we don't have to scope every single woman.

[00:24:24] We don't have to put a camera into every single woman's pelvis thinking, oh, what if she has endometriosis? Yeah. Right. So there will be women who has endometriosis and they are totally unaware of it, and that's okay. Yeah. It's not going to, um, catch them or make any, do any harm if it is undiagnosed and untreated. Mm-hmm. So what we don't want is people who are symptomatic is getting ignored mm-hmm and calling normal when there is a pathological condition and there are treatment available so we can make their lives better or we can improve their quality of life. If the patient quality of life is already good and she's happy, she's smiling, she's enjoying life, we don't wanna give her a label unnecessarily and saying, Hey, by the way, did you know that you have endometriosis? What difference does it make?

[00:25:12] Dr Renee White: Yeah, absolutely. Agreed. Okay, that's interesting. Um, so on the topic of like, you know, the impact of having Endo, and I know my sister, you know, went down this journey, the impact on fertility. How does that work? Is it, is it kind of similar to pain where it's like the more kind of scar tissue you have, the bigger impact it has on fertility? Is there any correlation with that?

[00:25:41] Dr Kokum Jayasinghe: So this is where my interest lies, Renee with fertility and endometriosis because I'm a fertility specialist. So again, the key point is not everyone who has endometriosis end up with, uh, trouble falling pregnant. So the most important, um, point there I wanna highlight is in fact two third of women or majority of women with endometriosis may not have any trouble falling pregnant whatsoever.

[00:26:07] Dr Renee White: Really? Because I feel like this is a huge myth out there. I feel like, I feel like people, like I've got endo, it's the end of the world. Like my fertility journey is just gonna be so challenging. But you're saying this is not true.

[00:26:23] Dr Kokum Jayasinghe: And this is the, the, the facts there are vast majority of people with endometriosis may get away without having any trouble falling pregnant. So when we look at the statistics and studies, two thirds of women who have endometriosis have no infertility. And it is about one third of women with endometriosis have trouble falling pregnant. Mm-hmm. However, Renee, as I keep telling you, I'm a fertility specialist. When you look at my waiting room with women who come in with infertility to see me, up to 50% of women in my waiting room has endometriosis because I am seeing a selected population.

[00:27:03] Dr Renee White: Yeah.

[00:27:04] Dr Kokum Jayasinghe: Okay. Just a few points there. So if we find, let's say we have a 21-year-old presenting with period pain and pain with sex and she has significant symptoms and we took a good history and we invest, uh, investigated and we did a pelvic ultrasound and pelvic ultrasound is showing some endometriosis. So how are we going to educate her and how is she going to make an informed decision about her future? So 21, she's coming in with pain is this a time to do an operation thinking unless we do any operation, she's gonna develop infertility for future. So that is not the thinking. So what we wanna do at the age of 21 when she came with um, symptoms, is to do something to improve her quality of life and manage what she came in with.

[00:27:58] So we don't have the suggestion of prophylactic surgery, that means going in, jumping in and removing the endometriosis, thinking she may develop infidelity later. Right. So it is more to say, Hey, yes, you do have endometriosis. Now what is your symptom? What is your problem? The problem is pain. So surgery is not the only way to help pain, and we can start with much less invasive options. So for treatment of endometriosis, there are variety of options. Right, including starting from lifestyle changes, dietary changes, exercise, like, you know, alternative medicines like, uh, acupuncture. So these simple things or trying to stop the periods we can, one of the very common methods we use for symptom control is contraceptive pill.

[00:28:47] Yeah, so contraceptive pill, other than contraception has huge other benefits. So endometriosis management is one of them. So if the patient tolerate the pill, we can skip the periods, totally avoid the period, um, and go for months without any bleeding. So her problem is solved there in multiple ways. She's not getting any pain and also she's not getting any back bleeding to cause the disease to progress.

[00:29:13] Dr Renee White: Yeah.

[00:29:13] Dr Kokum Jayasinghe: And there's nothing wrong with being on the pill for months, years, as long as she wants to. Mm-hmm. So that might be all she needs. She doesn't need anything else. Yeah. Right. And if the pain is not controlled with simple things, we may consider surgery because surgery is definitely a proven method of helping with pain as well as helping with fertility. Mm. So it could be a different situation. If I have, let's say I have a 35 year old coming in with uh, period pains and symptoms, and we take a good history and we do an ultrasound and we find endometriosis right. So now I am asking her, now you are 35 because it is a well known fact now with age, your fertility declines.

[00:30:01] Mm-hmm. And I would be asking her on top of controlling her symptoms, now do you have a partner? What are your thoughts about, uh, family planning? Are you ready to start a family? How many kids would you like to have? So these kind of things, I'll be poking her, making her think and ask have you thought about your reproductive plans? Right. Because she's 35, she's not 21. Like my first patient I mentioned. Mm-hmm. So if she has a partner, she's in a stable relationship, I would say, I would want you to consider, um, starting a family soon, because the truth of the matter is the, the real test of fertility is trying to get pregnant, so I can't give her a diagnosis and say you will have trouble.

[00:30:41] Mm-hmm. I'm saying this is a good age. You are 35 now start trying and endometriosis is linked with subfertility, so you may have trouble and you are in now a good age to start trying. And if she told me, look, I really, really would like to have kids in future, but I don't have a partner. Mm-hmm. And that is an opportunity I would take and say, how do you feel about egg freezing? Because there is a link and a connection and we know women with endometriosis can have, um, reduced fertility. You're 35, this is a good discussion point to say how do you feel about egg freezing? Because the last thing I want is your endometriosis as well as age acting synergistically to reduce your fertility in future, when I know about these things, when you are 35, and we had some opportunity for some preventative medicine and to preserve your fertility.

[00:31:35] Dr Renee White: Yeah, absolutely. Yeah, that, that term makes sense having kind of very different conversations depending on where you're at in your kind of chapter of life.

[00:31:45] Dr Kokum Jayasinghe: Absolutely yeah.

[00:31:47] Dr Renee White: So you've mentioned surgery, acupuncture, contraceptive pill, are there any other, you know, methods of managing endo at all?

[00:31:57] Dr Kokum Jayasinghe: There are lots of, um, options Renee, there are lots of options. So I think we need the most important point is we need to look at the patient holistically mm-hmm not just jump into surgery. So look into things holistically uh, work as a multidisciplinary team and also individualised, all those are the key words. Holistic approach, multidisciplinary and, and individualised treatment. So it's not one treatment fit everyone. Mm. So with the younger women who's, uh, presenting with their symptoms, we just need to just work out is there any room for improvement with their exercise, with their diet um, and there are studies showing anti-inflammatory type of diet may help with their symptoms.

[00:32:39] Dr Renee White: I was gonna ask you about that.

[00:32:41] Dr Kokum Jayasinghe: Yeah, yeah. Acupuncture, yoga, and, uh, and, and, and some would need some. Some kind of psychological support, right? Mm-hmm. And especially with younger girls, because this is going to be a chronic condition. Mm-hmm. It is not something we can wave a magic wand and clear it. It is going to be a chronic condition, so it's gonna affect the patient. It is going to affect her partner, it is going to affect her family, it is going to affect her workplace because she may have some sick days. So it is, if, if we can work in a team and a group and, um, get some psychological support as well for her mental health wellbeing, her understanding, how the partner can cope when she has her periods, how the family can cope when she has her periods, how she can cope with the workplace when she has her periods.

[00:33:29] So making some thoughts and ideas and plans in place so she doesn't need to go through this herself and she has some empathy, some understanding, kindness, and love from everyone.

[00:33:41] Dr Renee White: I think that's a really, really good point that you raise because I think there is this whole focus on, as you say, the pathology of the disease, the pain side of it, but the ripple effect into the community and how that person functions as a human being with their workplace, with their relationships.

[00:34:03] Dr Kokum Jayasinghe: Absolutely. Yeah.

[00:34:04] Dr Renee White: It, it, it, it is, it everyone is affected around you, um, through this chronic disease. Fantastic points. 'cause Yeah, I just, I keep, I. Coming back to the way that my sister like had to endure all this stuff and it was unknown then and as I said, probably, you know, swept under the carpet a little bit. Obviously this is the science of motherhood. We are all about the science. So I'd love to talk to you about. Any latest research, um, that we have around, um, assisting women with endo, because I, I do hear a lot, this is kind of the running theme I get from, um, messages and emails from people, like, why aren't we doing more in women's health research?

[00:34:45] And I'm like, well, we're kind of really expensive to like, you know, research on, 'cause we're so complex as, as humans, we're not, I call them flatliners for the males. Um, in terms of hormones and things like that, we're complex things like, what do you wanna do? So, do you know any research that's that's come out quite recently?

[00:35:05] Dr Kokum Jayasinghe: Yes. Um, so I will answer that question and go back to, there's few more things I wanna talk about the fertility side and the treatment side.

[00:35:12] Dr Renee White: Oh yeah, absolutely.

[00:35:13] Dr Kokum Jayasinghe: So in terms of the research, there is a blood test that we are working on that would make things much easier in terms of diagnosing if we are not there yet as to clinically be available. But, uh, it, we are close, we are getting close. There's a blood test being developed to do on these patients who presenting with symptoms to do and work out whether they have the condition or not, right? So that will be much easier than the imaging and, and a laparoscopy. So we are getting there. And if I can take you back to infertility and how we believe it, um, the endometriosis effect and some of the treatment options.

[00:35:51] So we believe with the endometriosis, the how it is linked to infertility is multifactorial. It can certainly affect the egg quality, it can reduce the egg quality, and it causes inflammation in the pelvis. Mm-hmm. So it causes not the, the healthiest environment for the embryo to grow. So, and that can also, um, reduces the patency, um, in the tube. So the tubes may have some inflammation and blockage with severe endometriosis.

[00:36:21] Dr Renee White: Mm-hmm.

[00:36:22] Dr Kokum Jayasinghe: With severe disease, the organs can get stuck to each other. So there can be adhesions and, um, what we call the, it, it looks like, we call it the obliterated pouch of douglas. So that means the uterus is stuck to the bowel and there's no space between the bowel and the uterus. So it is bit like, um, glue or concrete. Yeah. So endometrial tissue can make organ stick to each other. Okay. So that itself can cause the, the ovaries and tubes to get stuck and the tubes to be blocked. So tubes are important in transporting the egg against sperm to meet the egg against sperm, fertilize, and bring it to the uterus.

[00:37:01] Mm-hmm. So that's one way it can reduce inflammation, it can reduce egg quality, and then overall inflammation in the uterus and the uterine environment make it unhealthy for an embryo to grow. Mm-hmm. So multifactorial. Mm. And treatment. When we are talking about treatment with infertility, the real treatment that may improve pregnancy rates is going to be surgery.

[00:37:24] Dr Renee White: Right.

[00:37:25] Dr Kokum Jayasinghe: So with surgery, we can remove endometriosis and the removal of it will give you a window of high pregnancy rates with less inflammation and a clear pelvis and unfortunately, even though we re uh, remove the endometriosis 50% of the time, disease disease is gonna come back at a variable timeframe though.

[00:37:46] Dr Renee White: Okay?

[00:37:46] Dr Kokum Jayasinghe: Right. It can be months to years, but disease is gonna come back. So after we do surgery on a patient who's trying to get pregnant, keeping in mind what her age is, I would suggest. If the tubes are open, you have a trial of natural pregnancy for certain time. It could be four to six months, depending on the patient's age. Mm-hmm. And if it has not worked, then suggest considering IVF sooner than later because it's not just the age. She has other pathology linked to her infertility.

[00:38:17] Dr Renee White: Right, right.

[00:38:19] Dr Kokum Jayasinghe: Okay. And again, let's take an example here. So it's not that every single patient who comes with endometriosis need to go through surgery or IVF, so these are really need to be individualised and even the people who only do this, nothing else, still can't give you a yes or no, and like a recipe, this is what you're gonna do. Mm-hmm. So when the patient comes, you need to talk to the patient, and it is really individualised case by case. And also discussing these things with the patient and certainly get her involved in the decision making.

[00:38:51] So someone might come with severe endometriosis, but she has no symptoms. Mm-hmm. And her, we find out through imaging that good ultrasound scan that she has endometriosis, but she's totally unaware of it and her main thing is getting pregnant. She wanna be pregnant, so then she might as well go for IVF straight away rather than surgery, because surgery can be associated with its own risks right? Yeah. Another patient might come with pain and infertility, and she is gonna benefit from surgery to improve her pain, and certainly surgery will improve her pregnancy potential as well. Mm-hmm. And at the time, we would check her tubes, and if we find at the time of the surgery her tubes are blocked by endometriosis, then there's no point waiting for natural pregnancies.

[00:39:40] Unlikely to happen you would take her to IVF sooner.

[00:39:44] Dr Renee White: Yeah. Yeah.

[00:39:45] Dr Kokum Jayasinghe: So it is at the end of the day, we can keep going around these points in details, but the key take home point is it has to be individualised depending on the patient yeah and we also wanna take into consideration how old she is mm-hmm. How long she has been trying and what her overall family goals are. Yeah. Is she planning to have more than one child? Right, and surgery certainly can affect your erv, especially if she has endometriomas, which means blood filled cyst sitting on the ovaries. The more we operate on that, her egg reserve is going to go down.

[00:40:21] Dr Renee White: Ah, okay.

[00:40:21] Dr Kokum Jayasinghe: So, so all these things we need to think about and on the same, the other side, if she has a blood field sing on her ovary and we are planning an IVF cycle and during an IVF cycle, we are gonna put a needle in to collect these eggs and that can be a risk factor for infection, right? So all these things you need to just have a very good, thorough assessment of your patient and individualise the treatment.

[00:40:46] Dr Renee White: Yeah wow okay yeah, that's, that's a lot. I, I wonder

[00:40:50] Dr Kokum Jayasinghe: That is a lot yes.

[00:40:51] Dr Renee White: Yeah no, but it's, it's all really valuable information because I think, you know, it's, it's something where a lot of people, as I said, go in going, I've got endo, like, um, it's doom and gloom, but there are absolutely options. My follow up question to all of that is if you, and whether, I don't know if it's different in either regard, but if you have endometriosis and you either fall pregnant naturally or through the IVF route, does the endo have any impact on your pregnancy journey at all?

[00:41:28] Dr Kokum Jayasinghe: Good question, Renee. We believe not, we believe not. Okay. If anything, there might be slight increase in miscarriage rates. Is that because of the inflammation? But overall the, what we believe is the endo is linked with infertility or falling pregnant. Mm-hmm. But once it has happened, it's unlikely to cause problems later.

[00:41:46] Dr Renee White: Okay. Okay, that's good. Yeah, that's good to know.

[00:41:49] Dr Kokum Jayasinghe: And going back to treatment options. Mm-hmm. So we touch base on the, the multidisciplinary approach and whatnot, and there are now lot more medical options available before considering surgery. Okay. So in the past probably pretty much one, the only option we had was the contraceptive pill, which is still a very good option and a good starting point and if the patient tolerates the contraceptive pill, the best way to do that is to avoid the periods altogether. Mm-hmm. So she doesn't get the pain and she, we can have the disease control. Now there are certainly more developments in the, the medicine and in more, more options available in the market. So I wanna mention about those ones.

[00:42:29] There are progesterone only options so Mirena, I'm sure you are aware of that, Renee. Yeah. Mirena again is a contraceptive option, an IUD. Mm-hmm. And Mirena has progesterone in it and um, that's a good option for women with endometriosis symptoms and even, um symptoms with, uh, period pain and, uh, pain with sexual intercourse and active disease. So what it does is it keeps the endometrial lining thin and it reduces the bleeding. It reduces the bleeding, so, and also it reduces the pain. So, controls the pain as well as, which means it is going to reduce the disease progression for future.

[00:43:08] Dr Renee White: Right.

[00:43:09] Dr Kokum Jayasinghe: Other than the Mirena, there are oral forms of progesterone, Visanne is one of them, and Visanne recently got on PBS for endometriosis and the new preparations are available, are is Ryeqo, Ryeqo it is a old concept, but a new preparation. Mm-hmm. So what's involved in Ryeqo is GnRH agonist with estrogen and progesterone. So what that means is GnRH agonist is gonna shut down the ovaries, it stops the ovulation. And in a young woman in the reproductive age, we don't wanna do that more than six months because if she's not ovulating and if she's not getting estrogen, she's at risk of things like osteoporosis and thin bones.

[00:43:51] Hmm. So what this does is, uh, bringing back or giving back a small dose of estrogen and progesterone so you can continue this if the patient is tolerating and it is working for her as long as you want. Okay, so there are more medical options for endometriosis, pain management in the market than we used to. Mm-hmm. So these things are new developments and Visanne has come on PBS and can have access, um, for much lower price. So key, key point there is none of the medical options will actually help with fertility because all of these options is going to one way or the other, stop you from getting pregnant.

[00:44:31] Dr Renee White: Yes.

[00:44:31] Dr Kokum Jayasinghe: So surgery. Yeah. So surgery is the, the way removing, physi, literally removing the endometriosis and plaques are going to help with fertility and that helps with pain. Medical options will help with pain and no immediate benefit of fertility because these, these options will stop you from getting pregnant.

[00:44:52] Dr Renee White: Mm. Yeah. Okay. So it's kind of a double-edged sword.

[00:44:56] Dr Kokum Jayasinghe: It's definitely, and when we diagnose endometriosis in young girls or in, in our reproductive age, um, girls, what we wanna, the key points to talk about is quality of life, how to improve their quality of life mm-hmm and educate them, this can be linked with infertility, so we'll start thinking about family sooner than later. Mm-hmm. And if they are not in a place to do that. Have the discussion of egg freezing.

[00:45:23] Dr Renee White: Yeah. Yeah, absolutely. Yeah. Oh wow. Okay. That's, that's amazing. That's a great synopsis of it all. Obviously we touched on new research, but was there anything that else you wanted to add for that new research kind of piece or anything?

[00:45:39] Dr Kokum Jayasinghe: So I think it is the blood test. That is the, that is the, the excite, exciting new thing. Watch this space. It is coming and it is happening in the laboratory level. Mm-hmm. But it has not come to the clinical, um, use yet. Yeah. But it will be a matter of time and that certainly will help us reducing that diagnostic time. Presenting to the GP versus diagnosing with the condition we believe that will help because education and knowledge is the key. So if we can get women to talk about it, raise awareness, and make the diagnosis within a shorter time, then the patient is empowered with options. Yeah. So she can make the the choices and options suitable for her.

[00:46:21] Dr Renee White: Absolutely. Is that re do you know, is the research coming out of Australia or the US or European?

[00:46:26] Dr Kokum Jayasinghe: Oh no, it is, uh, coming out of this probably in multiple countries. Yeah, certainly it's happening in Australia. It is happening in Melbourne. It is happening in the Royal Women's Hospital.

[00:46:34] Dr Renee White: Oh, wow.

[00:46:35] Dr Kokum Jayasinghe: Yes.

[00:46:36] Dr Renee White: Ladida, look at us go!

[00:46:37] Dr Kokum Jayasinghe: It goes through. Yes.

[00:46:40] Dr Renee White: I might have to, uh, yeah, I might have to work out where that's happening and, uh, get them, get them on the podcast. That's, that's very exciting. We we're almost out of time, so I'm, I'm mindful of that 'cause I wanna get our rapid fire in as well. Last kind of question, what are the other kind of support services you've talked about, and I think this is great, like the multifactorial approach to all of it.

[00:47:03] Do you work closely with other teams in Melbourne in, you know, specifically, like how is it all being organised? I guess that that's the other thing. Like logistically, is it kind of like, is there a hub like. You know what I mean? Like is it like a logistical nightmare for patients to work this out? Or have we worked something?

[00:47:23] Dr Kokum Jayasinghe: I think Renee. Yeah, I think Renee, it is in the private and the public sector things work slightly differently. Mm-hmm. So if you come to a place like the Royal Women's Hospital, which is at, uh, tertiary hospital, all these things will be within the hospital and each unit will be working in conjunction to look after their patient and giving them the best quality of best possible care coordinated. Yeah, so the GP would send them to a gyne clinic that is equipped with the laparoscopic surgery. So those gynecologists will be then, um, depending on the need, can get some counselors and some psychological support. Mm-hmm. As well as in extreme cases, if necessary can get the chronic pain team involved with managing pain.

[00:48:06] Right? Yeah. And um, so in the private sector, and of course even in the public sector, if the patient then has any, any fertility issues, then the IVF unit or the fertility um, unit can be joined in with the patient management. Mm-hmm. Either egg freezing or IVF and getting pregnant. In the private sector, it is a similar thing so when the GP send you to the specialist with either fertility or with pain, you will be linked with, depending on your skills and your expertise, you would be linked with an IVF doctor or laparoscopic surgeon. Mm-hmm. Um, or your colleagues that are experts in the pain management. So either setting, there will be a multidisciplinary setting that you are working in because these conditions are complex and patients' needs are complex and to give them the best possible care, you need a whole team mm-hmm to using their expertise and their experience.

[00:49:01] Dr Renee White: Yeah. Fantastic. That's great to hear. Alright, we are gonna jump into our rapid fire was, but bef was there anything else that you wanted to touch on before we jumped into that?

[00:49:10] Dr Kokum Jayasinghe: Don't think so really I think we covered a huge range of um Yeah, this is problems on that yeah.

[00:49:15] Dr Renee White: One of the most thorough conversations I've had and I've very much enjoyed it 'cause I'm just like. So many myth busting. I think that, I think a lot of the listeners will absolutely appreciate. Alright, here is our first question. It's a bit of a broad one, but what is your top tip for maybe mums or to be mums, if they are thinking about starting a family and they've, they've got endo or they think they might have endo, what would be your top tip to them?

[00:49:45] Dr Kokum Jayasinghe: Seeking help early. The top tip would be seeking help early if you think there is some concern. So rather than thinking mm-hmm um, it would be good to go have a chat to someone.

[00:49:55] Dr Renee White: Mm-hmm. Mm-hmm.

[00:49:57] Dr Kokum Jayasinghe: And, and that is also when you ask me about what are the new developments and what are the things in the horizon that is happening to help these patients. There's gonna be long conversations, well build long conversations that the GPs are going to do from July this year to talk about these kind of things. So if the patient is thinking something not quite right, I may have endo and whatnot and they are going to be starting trying for a family soon.

[00:50:23] Go talk to your gp. Mm-hmm. In the meantime, try and be your in, be in your best health possible. Because endometriosis is one condition, age is one thing, certain things we cannot reverse, we can't do so much about it, especially the age. So if you try to be in the best health possible, eating the right food, avoiding the toxins, um, and looking after your health, that invariably goes to your eggs, your building blocks. Mm-hmm. And you will be in the best shape possible for pregnancy to happen within the shortest time period.

[00:50:56] Dr Renee White: Amazing. Did you have a go-to resource? I I kind of, this could be like a book or a poem or something for mums to be, was there something in your motherhood journey that like you kind of leaned on, you thought, oh gosh, that was an amazing resource, I love that.

[00:51:16] Dr Kokum Jayasinghe: I think my experience was very different, Renee. So how I am today, the reason I am, um, where I'm today is my own experience with fertility. So when I was in my O&G training in late twenties, actually, I wanted to start a family and I realised, look, it is not happening. Mm-hmm. So I was in the O&G training or trying to be an obstetrician gynecologist, and then I was in, faced with infertility myself and ended up needing IVF and that was the spark of interest to be in the field I am in now, so I can't say that kind of thing. Uh, actually, um, caused the interest or the enthusiasm in me. It was my own experience. Mm. But it will be good sources of when we are talking about good sources of information, it can't be just random Googling. It has to be some, some reputable, uh, source of information, evidence based, some reputable source of information.

[00:52:12] So I certainly think your podcasts sound like a great place to start and these are, you are talking to experts and asking day to day, um, common questions that every woman, even though they're not speaking out loud mm-hmm. Is going through their mind and thinking, what if, um, what is the answer? So rather than random Googling, you are talking to the experts in the field and, uh, giving them the right answers. So podcasts like yours will be a very good source of information to get. And other reputable places like, like our O&G college and, and, and, and, uh, the Royal Women's Hospital. Mm-hmm. So these places, when you go, there is a patient information section with frequently asked questions, things that people are actually asking and thinking there are information given by medical staff, reliable, simple, patient level information. So those would be good sources to look at.

[00:53:03] Dr Renee White: Yeah, I think that's a great answer. I think one of my, uh, most common phrases that when I talk to mums is, please don't get your advice on a Facebook forum from like Jane, from Austin, Texas. Like, that's not the place to go.

[00:53:18] Dr Kokum Jayasinghe: And also, this is a conversation I have with my patients frequently, is not to compare yourself to others right. And then so she, the patients may come and say, blah, blah, blah, if this, and this is her outcome, and we are saying, well, we, we, it's okay to talk to other people, but please don't compare yourself and this is a simple answer we tell our kids every day. Mm-hmm. Right? It is, um, it is, everyone is different. Everyone, everybody's. Medical conditions are unique and different. You have your team of expertise, your team that is looking after you, and try not to compare yourself on these Facebook groups and forums and whatnot that you communicate. And also keeping in mind, especially when patients go through IVF and things.

[00:54:03] People who are unsuccessful and going through difficult journeys are the ones who go on these forums and groups and binge and talk. I mean, I feel for them. Mm-hmm. So they want some support and they, they, they talk about their expertise and things, and IVF sometimes, or most of the time, actually work straight away right. Yeah. And these journeys are quite short. And these mums are busy looking after their babies, their kids, and they're having a busy life enjoying, they don't have time to go on and give their opinion on this forum. So you are not getting a balanced weave on things. Mm. So it is okay to talk about, um, your experience and if you think you are helping someone, don't judge, um, your journey and how your situation is gonna be, just because someone else had a difficult time.

[00:54:48] Dr Renee White: Yeah, absolutely. I think that's good advice. Last question, which we borrow this one off Brene Brown, what is on your bedside table?

[00:54:58] Dr Kokum Jayasinghe: On my bedside table, certainly not my phone. I try not to keep, um, I try not to keep my, uh, phone on the bedside table. There are some books, actually, there are some books on the bedside table that I can't say, I frequently look at them every now and then. There's some quotes, some inspirational quotes, a little book I found when I was traveling in England, and that is on my bedside and every now and then I flip through that and I look at these, uh, quotes written by all different people. And that gives you a little bit of tickle inside um,

[00:55:33] Dr Renee White: Yeah little oxytocin booster.

[00:55:35] Dr Kokum Jayasinghe: Absolutely. Yeah little bit of an oxytocin booster. Like a little hug. Yeah. And make you more motivated.

[00:55:41] Dr Renee White: Oh, I love that. That's so sweet. It actually reminds me, because when we work with families in our doula care, we always gift our mums these beautiful cards, which is from a, a company, uh, called Seasons of Mama, and they're little cards and they've got little quotes on them and essentially it's a little like, woohoo, like you're doing an amazing job. Like, you know, I feel like if the card was like a real human, it would have like, you know, pompoms and like whistles and whatever.

[00:56:10] Dr Kokum Jayasinghe: I can tell you what is on my, um, table, the work, work table. Oh, yeah. Yes, you can. These, these are certainly cards. Oh, this is one of my rooms. Renee, this is not my main room. I mean, yeah, this is my second room, the East Melbourne room. It is a, a partner desk. It is a massive desk. The whole desk is full of these Thank you cards. Right, and it looks a bit messy, but I have to say, it just gives you that inspiration. There are so many patients that are happy and I have helped them to have their families or start their families or grow their families.

[00:56:43] Yeah. So sometimes not every day is uh, good news so happy news. And some patients I unfortunately have to deliver bad news. Mm-hmm. And my heart sink as well when I deliver these things. But then is this looking around to see, well, it's part of the job. Sometimes it is good news and sometimes it is, um, not so good news. And then looking at these happy notes and cards and pictures and things, give you a bit of, uh, oxytocin boost to say, well, it's okay. Just keep, keep trying, persist, and we can help these people.

[00:57:14] Dr Renee White: Amazing. Well, it has been so lovely to have you on the podcast. I have learned a lot and I'm so, I know a hundred percent that the listeners will have learned so much from you. Thank you so much for coming. If there are listeners out there who are in Melbourne who would love to connect with you through a referral or something like that, where, where do you practice? I think you just said East Melbourne.

[00:57:39] Dr Kokum Jayasinghe: East Melbourne is the home, so it is Epworth Freemasons, Suite 4, 320 Victoria Parade Epworth Freemasons and the number is 9 4 1 7 3 7 5 5. And I'm sure you can find me if you just Google my name. Yeah. Um, and that is the, uh, the phone number.

[00:57:55] Dr Renee White: Okay, fantastic. We're gonna put all of that in our show notes on the podcast. But again, thank you so much for your time, appreciate it.

[00:58:01] Dr Kokum Jayasinghe: Thank you for having me, Renee. It was lovely chatting with you.

[00:58:04] Dr Renee White: Lovely to chat with you too. Alright everyone, until next week, we'll see you. Bye

[00:58:10] Dr Kokum Jayasinghe: bye-Bye.

[00:58:12] Dr Renee White: You loved this episode. Please hit the subscribe button and leave a review. If you know someone out there who would also love to listen to this episode, please hit the share button so they can benefit from it as well.

[00:58:27] You've just listened to another episode of The Science of Motherhood proudly presented by Fill Your Cup, Australia's first doula village head to our website ifillyourcup.com to learn more about our birth and postpartum doula offerings where every mother we pledge to be the steady hand that guides you back to yourself. Ensuring you feel nurtured, informed, and empowered so you can fully embrace the joy of motherhood with confidence. Until next time, bye.