It was kind of odd and I had never been asked this before, but a patient asked me “why do you do what you do?” It was like she was Barbara Walters and it was 1994. I squirmed in my seat. I know why I do what I do in my heart but it’s pretty hard to articulate. It’s like when someone asks you why you love your partner. You can come up with a laundry list of the attributes you like about them but it’s hard to put “love” into words.

There was a long awkward pause after she asked me this while I decided whether to give her a thoughtful answer or the kind of answer that moves the conversation along. I like her as a person and I had lots of time so I thought I’d just try and put why I do what I do into words.

In retrospect, I didn’t really answer the question but I did give an answer that I think reveals my motivation for why I do what I do. I said that when people come to see me as their doctor I want them to get an honest, thoughtful, thorough opinion on their fertility and to get the best possible care. I said I wanted to look people in the eye and know I am giving them the best possible chance… like they couldn’t go to some other doctor anywhere else and get a better standard of care or a better chance of conceiving.

I suspect most fertility doctors want this very same thing for their patients and their practice.

There are a lot of parts to doing this. One part is keeping up with the science. What’s the latest thing we should be trying, doing, thinking about for patients? One example is what’s happening with BCL6 and endometriosis.

BCL6 in the endometrium is one of the latest “things” in fertility care. A doctor named Bruce Lessey has been researching this marker in the uterus for a while but only recently has testing become available to patients. There is very little research on BCL6 testing for infertile patients but more research is being done and we want to be part of that knowledge acquisition. The group of doctors here at Olive have been talking about the test called Receptiva which tests the BCL6 levels in the uterine lining (aka endometrium)

Let me explain. About 1 in 6 couples who come to see us have unexplained infertility. We know some of those women will actually have endometriosis as the cause of their infertility but we cannot diagnose endometriosis unless we have them do a surgery called laparoscopy.

Laparoscopy is a minor surgery during which a woman is put to sleep (at a hospital) and a camera is inserted through her belly button to look inside at the uterus, tubes, ovaries, bowel, and bladder. Scar tissue, unusual anatomy, and endometriosis can all be diagnosed, and potentially treated, by laparoscopy. In Canada, laparoscopy is funded by the health system. The wait is typically 4-8 months to get this surgery.

We can diagnose severe cases of endometriosis by ultrasound. Laparoscopy is needed when you cannot see endometriosis on ultrasound - usually when it is milder.

It would be really great if we could diagnose milder endometriosis without putting women through the wait for and risk of laparoscopy. We do know that the endometrium in women with endometriosis is different from those who don’t have endometriosis. Exactly how it differs has been defined, and one main difference is in levels of BCL6. Women with endometriosis have abnormally high levels of BCL6 in their endometrium.

This test, called Receptiva, involves taking a sample of the endometrium and sending it to a lab in the USA. That lab then reports back the BCL6 levels.

• If you have unexplained infertility and the level is normal - you likely do not have endometriosis (< 10% chance).
• If you have unexplained infertility and the level is high - you likely do have endometriosis.

Those people who do IVF with endometriosis benefit from suppressing their endometriosis prior to an embryo transfer. This suppression typically takes 2 months. So, for example, if you have unexplained infertility, you do IVF and get embryos. Then you do Receptiva (and often an ERA test which is explained in a different blog). If the Receptiva shows high BCL6 you would be suppressed with medication for 2 months prior to a frozen embryo transfer into your uterus. If your BCL6 levels are normal then you would not be suppressed for two months and just go right into a frozen embryo transfer.

Lots of questions still remain about optimal suppression medication protocols, whether those with unexplained implantation failure (multiple failed IVF embryo transfer, even if their infertility wasn’t “unexplained”) would benefit, etc.

It is a lot to put women through these biopsies - they hurt, they take time and they cost money - so we need to really think hard about who would benefit and research this as we go along.