Posted on April 22nd, 2021by RMANY

Ep 59: Everything about Endometriosis with Dr. Kimberley Thornton

Fertility Forward Episode 59:

About 30% of women with unexplained infertility are found to have endometriosis. While this condition is usually associated with severe pain during menstruation, it often goes undiagnosed, and about six to 10% of women are likely to suffer from it. Today on the Fertility Forward Podcast, we talk to Dr. Kimberley Thornton, a Reproductive Endocrinologist, Infertility Specialist, Obstetrician, and Gynecologist about everything ‘endometriosis’. She explains in detail what endometriosis is and how it affects the body. She describes what symptoms you may experience if you have it and how to get diagnosed. Later, she talks about how birth control and surgery can help, and whether or not surgery may be the best option for you. Even though 30 to 50% of women with endometriosis struggle with fertility, she explains that there is hope! Hear some helpful advice for women who have endometriosis or suspect they may have it, and discover some available treatment options for those who want to fall pregnant and those who just want to treat the symptoms.

Transcript of Episode 59

Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
Dara: We are thrilled to have back on our podcast today, Dr. Kimberly Thornton, one of our favorite doctors at RMA. And today's topic is something that I find super interesting and I'm sure you all will as well. We are here to discuss everything about endometriosis. So thank you so much Dr. Thornton for being here.
Dr. Kimberley Thornton: Well, thank you so much for having me back. It's always a pleasure to be on the podcast. So I figured, you know, we should just start out with the basics, you know, what is endometriosis? So a lot of women may have been diagnosed. They may know what it is, and a lot of women walk through my door and actually I end up diagnosing them and they never even knew they had it or, or what it was. So it is essentially the way I kind of describe it to patients is it's a GYN disorder where the kind of the tissue or endometrium is the tissue that lines our uterus. So when we get our period, that's what we shed every month. And it's so when that tissue implants on other places besides the uterus. So it can implant on the ovary. It can implant on the fallopian tubes. It can implant in the bowel, the bladder. And so women who have this disorder, the classic symptom is really severe pain or what we call dysmenorrhea with their menses. And I always like to think of, or explain it as well, it's kind of like you're having a menstrual cycle all throughout your abdomen or belly. And so clearly that's going to be really painful. And women sometimes have pain with intercourse or sometimes have pain with bowel movements. And a lot of like classic patients with endometriosis will say, well, you know, when I was growing up, my periods were so painful, I couldn't go to school. I have to stay home. Or some days I can't go to work or this pain is so severe, it wakes me up from my sleep. And sadly, some women don't know that that's not normal because that's what they've lived with their entire life. And I have to say, well, this is not a normal thing to have to be living with. bBt it's also hard because it's a really difficult disorder to diagnose. And the main reason is really the only definitive way to diagnose endometriosis is through surgery, meaning you have to do like they're most commonly, what's called a laparoscopy where they look through a camera on the belly button and we see these endometriosis lesions in the abdomen or pelvis. And then they often biopsy them and we get a pathology report. We actually have no serum markers in the blood, no biopsies or any other way that we can diagnose this disease. And so a lot of women have it or have symptoms very suspicious of it and don't actually know and have never had a diagnosis. And the only other really exception to this I said is, well, it's a surgical diagnosis, which is true. Some women can have what's called endometriomas or large cysts of endometriosis on their ovary. And those sometimes we can see on ultrasound and those we can say pretty certainly sometimes they'll say it looks like you have an endometrioma, it looks like you have endometriosis and we can pretty, fairly accurately diagnose it in that manner without surgery. But a large portion of women with this disease don't actually have these endometriomas or cysts or sometimes we call them chocolate cysts because they look like old dried blood when we open them. And so, you know, I guess let's start with your guys's questions and we can go off on different topics and kind of go from there.
Dara: Well, I'm thinking about in terms of the pain is the pain something that's recurrent, every single time someone menstruates? And then also the second question I have is, you know, sometimes I believe with fibroids that also can be painful in terms of intercourse. That must be a hard thing to distinguish whether it's fibroids or cysts or something that has to do with endometriosis.
Dr. Kimberley Thornton: Yeah. So you're correct. So especially large fibroids can cause pain with intercourse as well. But fibroids are pretty easily diagnosed on imaging. So usually a pelvic ultrasound almost always can pick that up. If there's really concern, an MRI, but that's almost never needed to diagnose fibroids. While if you do a pelvic ultrasound and somebody you're not seeing any fibroids or pathology even if you don't see an endometrioma or a cyst of endometriosis, it's more suspicious for endometriosis. Classically endometriosis, the pain typically really comes around your period or your menses. Now of course, there can be always exceptions. Over time, somebody with really severe endometriosis, it's a very inflammatory disorder. It can cause a lot of scarring in the abdomen and belly. Other things it could cause chronic pain. So some people with this have chronic pain at some point where it's not just on their menstrual cycles. And so fibroids, if they cause pain or discomfort, especially with your, with intercourse, that's not usually going to be around your necessarily your menstrual cycle, but you know, you can pretty much pick that up on imaging.
Rena: And what about fertility and endometriosis? Is there,if you are diagnosed with endometriosis, does that mean that you'll need fertility treatment or is there a scale or what does that mean?
Dr. Kimberley Thornton: So, there is a strong association with endometriosis and infertility. So for, in general, women who are diagnosed and are known to have endometriosis about 30 to 50% of them will end up suffering from infertility. So it doesn't mean someone definitely will, but they are definitely going to be at high risk for having issues. In the general population, it's only about six to 10% of women have endometriosis, although that's a pretty good portion, it's almost one in 10 women may suffer from this disease. We do know a large portion of infertility patients are what we have, what we call unexplained infertility. Meaning when we do a fertility evaluation, we're going to look at, you know, the sperm, we're going to look and see if the fallopian tubes are open. We're going to look at other factors. And sometimes we don't see anything abnormal on testing. And that's when we say it's unexplained. Well actually it's about 30% of women with unexplained infertility, even without pelvic pain, actually, if they ever ended up needing surgery, ended up being found to have endometriosis. So it does have quite significant impacts on the fertility world. Hardest part of this disorder is unfortunately there's no cure. So we actually don't know what causes it. So we don't know why some women get endometriosis and some women don't. There are all sorts of theories. One of the leading theories is that we believe that there's what we call retrograde menses so that when you normally get your menstrual cycle, lead comes out in the reverse way in your fallopian tubes into the abdomen. Now we know that happens to all women, even women without endometriosis, for women who've had to have surgery for other purposes on their time of their menses sometimes we see menstrual blood. But something about the disease with endometriosis causes these implants to stay or stick onto other body parts and causes this inflammatory reaction, which causes the disease. Endometriosis has even been reported in other areas outside the abdomen in rare cases things like the lung. And so there is also certain theories that it can maybe spread through lymphatic or blood vessels or that there can be what we call metaplasia where some cells that are not endometriosis cells can convert and become those, those lesions over time. And so we really need more research because we're not quite sure what causes it. We know it's more common if a family member has it. You’re at greater risk for developing it. And there is no medicine or no definitive cure. So even if somebody has surgery for endometriosis and has the lesions removed, or sometimes they have to be burned off, they almost always, certainly almost always grow back. And so it's definitely a conversation to have if somebody has endometriosis to start planning for fertility because they're at high risk because we have no way to permanently make this go away. We need to think of what are the goals. Are there are your goals to have a family? How many children do you think you're going to want to have? When do you think, realistically, you're going to start planning your family? And if those things are lining up when it may be further in life, are we worrying about just regular age related changes? And then we're worried about endometriosis on top of it. Do we need to be thinking about freezing eggs? Do we need to think about planning pregnancy sooner or later, freezing embryos for multiple children or families? So all important conversations to have with patients with endometriosis.
Dara: Wow. It's interesting to hear that. Unfortunately it sounds like a lot of people don't find out right away that they have it or often it's something that kind of can not be diagnosed until perhaps either when people are starting to try to get pregnant. And if, you know, since there isn't necessarily treatment, that could be long lasting. This is my other thing is what about in terms of, so you said you can do surgery, but almost always things can still come back and it could still progress. Would that mean that if it wasn't treated that it can continue to worsen and worsen as time goes on?
Dr. Kimberley Thornton: Yeah. So definitely. So that means for, let's say that's why a lot of women will say, well, I had really bad periods when I was a teenager and then they put me on birth control and I never really realized there was a problem. Well, it wasn't wrong that that person was put on birth control. The birth control actually helps prevent the progression of endometriosis. So it usually controls the pain because you don't, you can control your menses, you can even take the pills continuously so you don't get a menses and endometriosis is really sensitive to estrogen. And when you're not on birth control pills and you're ovulating each month, when you make an egg, that egg is growing and producing estrogen. So you're getting that exposure. Now, most birth control pills do have estrogen in it, but it's a much lower dose and they have progesterone in them. So it doesn't, I guess, aggravate or often times it helps quiet endometriosis. Now let's say you're off the, you know, you can't get pregnant on birth control pills so that becomes a little bit harder situation. When you're older or you come off and then maybe the pain is starting to return. Let's say somebody does have surgery and they have the endometriosis removed. Usually the goal is either get pregnant as soon as possible after removal or if the plan is not pregnancy anytime near future, that person really was not served any like, you know, help from that surgery if they're not put on some sort of hormonal therapy to help suppress the endometriosis long-term. Besides birth control pills, we also sometimes use medicine called Lupron to help quiet or shrink endometriosis. It almost essentially puts women almost in a menopausal state so it's usually not good long-term medication because we worry about bone density for really, really long time periods. Although we can use other what we call add back therapies or pull medicines, if we need to really keep somebody on it for a long time. And they're, you know, more and more nowadays. I think that they're starting to use that like a lot of GYNs or endometriosis specialists for not fertility purposes often use like IUDs. That Marina IUD seems to help or improve endometriosis, but you're exactly correct. You need something else when you're not trying to get pregnant, or even if you get pregnant and deliver you in your thinking, you'd want to still, you know, have fertility for later on, it's better to go on something or also even just for the pelvic pain aspect. It's good to be on something. Also, I think since we're talking a lot about surgery, I think it's important to know that, you know, for the fertility field or world, we used to be very heavy surgery if we suspected endometriosis. And I think the field in general is shifting away from that because unfortunately surgery isn't always without any risks or complications and it's not always necessarily a fix for the disorder. So if somebody is having really extensive pain from endometriosis, most of the studies, most of the literature and data really support that surgery does help improve pain. Now, there can always be exceptions. So you can always have, let's say an endometrioma removed or lesions and scarring from the surgery itself happens. It causes you more pain later. So it's not a hundred percent, but for most people it will help. But for fertility, the data is not as strong. So especially for like stage, we usually stage endometriosis stage one through four. They stage it during surgery depending on how deep the lesions are, how large they are, but for stage one or stage two, which is usually gonna be the more mild stages, you know, typically you're not going to see an endometrioma that usually upstages somebody right away. So those are the people who you're suspecting based on their history, but you may not see something on ultrasound. Well, if with known endometriosis, it has to be, 12 women have to undergo surgery before we'll see one extra pregnancy. And that's also why when we say unexplained, well, this, when I said that there's this percentage of people who are asymptomatic, you don't know what's going on. Well, if you put those in the mix, meaning they end up not, because every person that you do surgery looking for endometriosis is actually going to have it. It actually is only one in 40 women are actually going to have an additional pregnancy by having surgery. So the, for, you know, doing something that's time off of work, money, recovery, you know, it's not always as black and white on it doesn't mean surgery is wrong for every patient. There are definitely reasons that some people should have it, but it's also a reason why a lot of women don't have surgery or a lot of physicians may not recommend having surgery. Larger stage, you know, stage three, stage four endometriosis, you know, there may be more benefit from undergoing surgery, but there are also risks of surgery, especially in those scenarios, because those are a lot of the women with those endometriomas and removing an endometrioma from the ovary almost certainly will cause reduced what we call ovarian reserve, meaning it doesn't just shell out nicely and we just can take it off. Almost always the surrounding tissue of the ovary may be damaged in the process. For even smaller lesions, if they're on the ovary, it's not a full endometrioma. one of the ways we remove them is usually we have to burn them. And so if you burn your ovary, you are going to be killing potential eggs. And as women we're born with every egg we have, we can't generate, um, we can't make new ones. So when they're lost, they're lost. And so you have to weigh that with the possibility that you may have less eggs quantitatively from having the surgery. There's, always surgical complications where your ovary may need to be removed completely. And so it's a, it's a fine line of determining when the risks outweigh the benefits and vice versa and who, who should have surgery and who shouldn't.
Dara: It sounds like a long discussion because of the potential risks for surgery. And it sounds like if someone does go through surgery, perhaps there's a, a smaller window, right after that surgery, that can be more beneficial in terms of getting pregnant or going through IVF. And then if someone ops out of surgery and goes straight to IVF and is able to get pregnant, are there usually issues during your pregnancy? Is there often more pain seen in patients with endometriosis who get pregnant during a pregnancy?
Dr. Kimberley Thornton: So that good news is pregnancy usually quiets down endometriosis. So you're when you're pregnant, you have a high progesterone state from the pregnancy itself. So it usually, it's almost kind of like in a way of being on super birth control pills. So you also don't get your period when you're pregnant. So that pain from your menses is going to be improved and actually the disorder usually doesn't worsen or progress during actual pregnancy. But more of the concern is when somebody delivers. Part of it is making a long-term plan.
Rena: I was gonna ask about that with, cause I had heard that, you know, pregnancy quiets endometriosis. Is that also long-term? So if you do carry, you have a child, does that mean sort of long term your endometriosis is quieted or that's really only during pregnancy, but not after?
Dr. Kimberley Thornton: For somebody who already has endometriosis, it's really just during the actual pregnancy. For somebody who doesn't have endometriosis, pregnancies are protective, meaning it's more pregnancy, somebody has, they're less likely to develop endometriosis. And that's probably because they're going that nine months of, you know, just similar to like, the birth control pill aspect of things. But unfortunately it's not a permanent fix. Breastfeeding as well, postpartum, also is a, reduces risks for women developing endometriosis, which is probably because people don't ovulate most of the time when they are breastfeeding.
Rena: And can you differentiate too between the different stages? So kind of stage one through there's four stages?
Dr. Kimberley Thornton: Yeah. So there's stage one through four. There's a whole classification system. And so what it looks at is, it really has to be diagnosed interoperative. So it looks at how many pelvic adhesions there are, how large the lesions are, like in, in size, location of where there are. So you can't really tell somebody without having surgery, Oh, your stage, this or that. The one thing is endometriosis. What happens is you get points. So it's actually a grading system for each one of these you have, and then your total points puts you stage one, stage two, stage three, stage four. Endometriomas already give just one alone has a pretty high point system that for most women that's going to upstage them until at least three or four without having surgery or knowing. So that's why I kind of use that as an example, but it's, it's very much needed, surgery is very much needed to actually stage somebody. If that makes sense. Like, I can't say, Oh, this is, you know, stage one being minimal, stage four being severe, but it's like minimal is you have one to five points, you know? And so it depends on what you see during surgery. So I guess it's hard to tell somebody without having an operation. And so for those like stage three, stage four women with endometriosis, there is seen a slight benefit for fertility wise for, for natural conception, at least in that short term timeframe after, but it isn't a promise or guarantee. Some women will have this invasive surgery. They may reduce their ovarian reserve. They may still not get pregnant and be back and needing fertility treatment. And so it's not a wrong pathway to go, but usually if someone goes that pathway, you want to give a timeline, okay. If you know, six months post surgery, no pregnancy, well, we need to start back to, to intervening. Sometimes though there's reasons like if something, especially if they have an endometrioma depending on the location or the size of it, sometimes if someone is going to need IVF or fertility aspects, it can be blocking where we can't get the eggs extracted. Now other women it's depending on size and location is, is not a factor. So those things are also weighed and whether it needs to be removed before undergoing fertility treatment
Rena: And what, who else would be able to diagnose endometriosis. So say you're not trying to conceive, but maybe a really painful period, you know, do you go to your OB? Who else could give you this diagnosis besides a reproductive endocrinologist?
Dr. Kimberley Thornton: So most regular OBGYNs can diagnose somebody in the sense of based on symptoms. Like I said, surgery is the gold standard, but usually I can be pretty certain for a good portion of women based on just what they're telling me. How they cycle, so there are a lot of women that I'll say we’ve done everything, a full fertility workup everything's normal, but they're telling me that they're in so much pain. They can't get out of bed. They're up all night with their periods. Well, you probably have endometriosis without having surgery. So I'm going to treat you like you have endometriosis. And we usually talk through, well, we could do surgery or we could just, you know, try to do fertility treatment and see what's best for them. So a regular OBGYN, they are well-trained about endometriosis even for not fertility reasons. Sometimes somebody may have this pain and not be wanting pregnancy. So they may not necessarily walk through my door or office. There are what we call minimally invasive GYN surgeons and they are like regular gynecologists who've done extra training in, like robotic and laparoscopic surgery. It's another, like I do infertility most, they do surgery. Most of those are actually endometriosis specialists as well because endometriosis tends to be very complex surgery. It's not easy GYN surgery. So a lot of these minimally invasive GYN surgeons specialize in pelvic pain and endometriosis surgery as well, if someone needs, you know, further assessment.
Dara: So I know somewhat controversial also, but you know, the people who have endometriosis, you know, whether their lifestyle changes, that can be helpful. And I get asked quite often, you know, the patients that I get with endometriosis, is there anything diet related? And it's interesting because, you know, with the research that I found, it's somewhat mixed and it's not quite definitive, but because I know you mentioned this in the beginning, and this is what I kind speak to my patients about is that it's related to inflammation. So when I hear inflammation, what are foods that could be pro-inflammatory that can create more inflammation in your body? Sugar or refined processed foods and carbohydrates. So that's typically what I like to, and this is what I talked to all patients about, but, but it's something that I often like to stress that not cutting out, but minimizing your intake of added sugars and added white flours. And on the flip side, what are things that can help lower inflammation and maybe create more antioxidants in your system is fruits and vegetables and whole foods. But it's interesting cause I know in terms of lifestyle changes, there's a little bit more research on endocrine disruptors and maybe environmental toxins that potentially can be attributed to endometriosis. I'm not sure if it could be the cause of it, but is it something that you've seen at all?
Dr. Kimberley Thornton: So, I mean, it's definitely something that people ask about all the time. So, you know, it's hard. We don't really have good evidence or data on either one yet. To be honest, we just need better studies. And so it is a very inflammatory disease and disorder. And so I can see the logic behind trying to reduce inflammation through lifestyle, maybe help with the disorder. We don't have the medical science backing that up saying if you do that, it will improve your endometriosis. At this point, it's very mixed. Some studies say, yes, others say, no, we just don't have really good trials. I don't think it's ever a negative or bad thing to be cutting those things out. You know, I usually tell people it doesn't need to be that extreme in the sense, you know, people are like, I can never have this or that. A lot of things are common sense, you know? And, and everything in moderation. Yes, you could slip up and maybe have something with carbohydrates, but every, you know, don't have cake five times a day, every day, things like that. But you know, I think it will be exciting in the future when we kind of figure these things out a little bit more because right now it's a big question mark.
Dara: There was research that just came out a couple of days ago. I want to look into it more because I can't speak too much about it, but there was this research that showed a connection between frequent cosmetic use to an increased risk of endometriosis. And they even said in the, you know, the brief article, it was an article. So I didn't, I wasn't even able to see the study yet, but they had mentioned that there's still a lot more research to back it up and that it wasn't quite definitive, but it was an interesting link and they kind of pointed it out to the connection between parabens and benzophenones and a lot of the cosmetics, hopefully I'm saying that correctly, in a lot of the cosmetic products that people use. So it's interesting that it could also be environmental, not just what you eat, but also what you're putting on your skin.
Dr. Kimberley Thornton: Yeah. You know, and I guess it kind of, you just kind of prompted me to think what we really hadn't talked too much about. I talked about what endometriosis is, is like how it affects fertility. And I think that links a lot with this inflammation and we're not a hundred percent sure how this disease even causes infertility. So, you know, some people it's clear cut. So sometimes these lesions implant on the Fallopian tubes, they scar down, okay, your tubes are, well, it doesn't matter how perfect your eggs and sperm are. They're not going to get together and fertilize, but outside of that window, open fallopian tubeswhy it is so many women suffer from infertility with this diagnosis. And we know that there is more inflammatory cytokines and overall it's just a more toxic environment, more scarring even outside the fallopian tubes. And so that is probably the role that it impacts with fertility more than anything. There's all theories is this inflammation make the sperm not function as well? Does this cause you know, negative impacts on the egg so they are in the ongoing embryo that it grows those first for early development days and inside the body. All possibilities. Controversial whether it actually impacts implantation or the uterus. Interesting, they've done studies with donor eggs to try to weed that out. Meaning they've taken donor eggs from the same donor and split them and given them to women receiving with endometriosis and women without endometriosis. So they're getting eggs from the same donor. And we actually don't see differences in pregnancy rates between the women with endometriosis and the woman without in the egg donor population. But if it's reversed, meaning the donor had endometriosis and not the recipient, we actually see worse pregnancy outcomes. So it may be more that it affects at the embryo stage, although we can't rule out completely that it it's not impacting the uterus. And so, you know, I guess it's all just linked with all these, you know, we may find out more later on with the diet and, you know, environmental toxins, although I'd have to argue a lot of people wear makeup and don't get endometriosis. So it can't be the only cause or explanation there has to be some or it's multifactorial of things.
Dara: Yeah. I wonder if there's some sort of genetic component as well. And as I know you mentioned that there may be something genetically linked, so it sounds like there's many potentials that all need to be lined up for it to perhaps manifest.
Dr. Kimberley Thornton: Yeah. If somebody has one first degree relative with endometriosis, their risk is increased of developing it by seven to 10. So there is some sort of genetic aspect.
Rena: And I feel more and more, you know, sort of high profile people, celebrities or whatever speaking out about it. And so I think the dialogue at least is, you know, getting larger and people, people are talking about how debilitating this can be. So, you know, hopefully the dialogue will increase and people understand more and more that this is, you know, it can be really difficult to live with.
Dr. Kimberley Thornton: Yes, it's probably one of the worst chronic disorders because especially the pain factor outside of the fertility world, you know, it's very hard to have to live with chronic debilitating pain.
Rena: Is it considered autoimmune?
Dr. Kimberley Thornton: it's interesting. There are some thoughts that it could be almost like that because it in a sense it's like, well, these implants implant other places and you know, your body has a reaction, which is kind of similar to autoimmune disorders because we know women and this happens, all women have this endometrial tissue that comes throughout. Why is it, you know, having that almost inflammatory reaction process, which is kind of like what we see with autoimmune disorder where your body attacks the thyroid gland or other things. So it, it could be along the lines of that. But we just don't really, we just don't know.
Dara: So definitely more research is needed in this area. Just hopefully to get more answers, more clarity, but I guess, is there anything that you want to leave with in terms of any advice that you would give to those people who have endometriosis or those people who may think that they have it?
Dr. Kimberley Thornton: I think a big thing for women with endometriosis is to be an advocate for your health. I think I've seen so many women who have gone years and years, especially women with pain, who've been told nothing was wrong and their pain hasn't been validated and made to feel like it's something that they made up in their brain or made to think that this is normal and it's not normal to be having that significant symptoms on your period. And so, you know, even if someone tells you nothing wrong, then you know, seek a second opinion, you know, if you're really having this pain. So that's like my biggest advice for the not trying to conceive. I see a little bit more of, of the, you know, fertility aspect of things, obviously just being in this field. And so I see a lot of people that don't necessarily have the really, really chronic pain. They may have mild or undiagnosed because a lot of the times the severe pain is they've already been diagnosed before coming through my door. Although I do certainly see those as well. And so the good news is though a lot of our fertility treatments are very effective with endometriosis, and so, especially IVF of course, you know, success can be improved with lesser invasive methods, but IVF really does seem to significantly improve odds and success with endometriosis more so than any other treatment. And so that there is, you know, hope, you know, don't, nobody wants to come in through here thinking that they need to do IVF, no one ever wants to sign up for that, but there are things, you know, those things can help and be game changers. And so, you know, it's best not to think I have this disease, there's no chance of me getting pregnant. And then for the women, for the fertility aspect who aren't ready to get pregnant now, if you know you have endometriosis, I don't think it's ever a bad idea from an early age, just to meet with a specialist, just so you understand your natural fertility, what happens with age and time that happens to everybody and then how endometriosis may impact things on top of that, so that you make smart decisions to help you reach your goals.
Dara: That's great. I'm thrilled to that, that we had you on today because I feel like I learned a lot. And I think that our listeners will have a better understanding of this and become their own advocate if they feel like something isn't right and to seek a second opinion, which I think is always great, if something, if they don't hear the answer that they feel like they have. So thanks for being on. And, and I'm sure, you know, by now how we end our podcasts with some gratitude. So what are you grateful for today, Dr. Thornton?
Dr. Kimberley Thornton: I think the last couple of times I always kept saying health cause we were, well, we're still in the pandemic, but you know, I feel like we're starting to see the light at the end of the tunnel. And so I'm really grateful. I got to go for the first time in a long time with my daughter to see my parents a week ago. And so, because we were all finally vaccinated in my family and I think I'm just grateful that things are starting to normalize a little bit and, you know, feeling like old life again,
Rena: So nice. Dara, what about you?
Dara: As I took a walk out today, this is, I just realized it's one of my favorite times of the year because the blossoms, the blossoms on the trees are starting. And there's just something about coming out of hibernation in more ways than one this year. And, you know, with the weather warming up and with the leaves blooming, there's just something in the air that naturally makes me feel grateful. So something very simple, but I love it. What about you Rena?
Rena: I guess sort of the combination of you guys. You know, in line with sort of normalcy, I'm finally starting to run again and was just having a lot of fatigue for a long time so I love running in Central Park and it's so beautiful this time of year, the flowers, and I love doing the paths on the dirt and just sort of being in nature. So really grateful that I feel good to go ahead and do it and live somewhere that's close to somewhere that’s so beautiful. That's my gratitude.
Dara: Amazing. I love this chat. Thank you so much. I'm sure Dr. Thornton we’ll have you on again soon and appreciate you taking your time out of your busy day.
Dr. Kimberley Thornton: Thanks for having me.
Rena: Thanks so much.
Dara: Thank you so much for listening today and always remember practice gratitude: give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram @fertility_forward. And if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.

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