Send us a text with a question or thought on this episode ( We cannot replay from this link)
Professor Horace Ramon, a world-renowned endometriosis surgeon and researcher, reveals how excision surgery can significantly improve fertility outcomes for women with endometriosis. His groundbreaking studies show that nearly half of women with colorectal endometriosis can conceive naturally after surgery, while those with multiple failed IVF attempts saw remarkable improvement in pregnancy rates following proper excision.
• Fertility rates after colorectal endometriosis surgery can reach 80%, with most pregnancies occurring naturally
• For women with failed IVF attempts, excision surgery resulted in a 45% pregnancy rate compared to an expected 5% with additional IVF
• Surgical expertise matters significantly – endometriosis surgery should be performed by specialists with high case volumes
• When preserving fertility, sometimes draining endometriomas rather than excising them may better protect ovarian reserve
• The prevalence of endometriosis is increasing partly because modern women have 450-500 menstrual cycles in a lifetime compared to less than 150 in the 19th century
• Expert centers should offer long-term management strategies that consider a patient’s fertility goals and extend to menopause
• Multidisciplinary teams are essential for optimal endometriosis care, including fertility specialists, colorectal surgeons, pain specialists, and others
Continue advocating for yourself and seek care from true endometriosis specialists with proven surgical volume and experience, not just social media presence. A proper excision surgery can transform both your quality of life and fertility outcomes.
Website endobattery.com
Introduction to Fertility After Endo Surgery
Speaker 1
0:00
What
if
surgery
,
not
just
IVF
,
could
make
the
difference
in
your
fertility
journey
with
endometriosis
?
In
this
episode
of
EndoBattery
,
I
sit
down
with
Professor
Horace
Ramon
,
a
world-renowned
surgeon
and
researcher
,
to
talk
about
his
groundbreaking
studies
on
fertility
after
endometriosis
surgery
.
His
research
showed
that
nearly
half
of
women
with
colorectal
endometriosis
were
able
to
conceive
naturally
after
surgery
and
,
for
women
who
had
gone
through
multiple
rounds
of
IVF
,
excision
surgery
gave
many
of
them
their
first
chance
at
pregnancy
.
This
conversation
is
about
more
than
numbers
.
It's
about
hope
,
options
and
the
power
of
treating
endometriosis
at
its
root
.
Tune
in
as
I
sit
down
with
Professor
Horace
Ramon
to
go
over
all
his
work
and
so
much
more
.
Stick
around
.
Speaker 1
0:52
Welcome
to
EndoBattery
,
where
I
share
my
journey
with
endometriosis
and
chronic
illness
,
while
learning
and
growing
along
the
way
.
This
podcast
is
not
a
substitute
for
medical
advice
,
but
a
supportive
space
to
provide
community
and
valuable
information
,
so
you
never
have
to
face
this
journey
alone
.
We
embrace
a
range
of
perspectives
that
may
not
always
align
with
our
own
,
believing
that
open
dialogue
helps
us
grow
and
gain
new
tools
.
Join
me
as
I
share
stories
of
strength
,
resilience
and
hope
,
from
personal
experiences
to
expert
insights
.
I'm
your
host
,
alana
,
and
this
is
Endobattery
charging
our
lives
when
endometriosis
drains
us
.
Welcome
to
Endobattery
.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
at
the
table
Today
.
Speaker 1
1:37
I
am
so
honored
to
welcome
Professor
Horace
Ramon
,
a
world-renowned
surgeon
and
researcher
in
the
field
of
endometriosis
.
Professor
Ramon
has
published
some
of
the
most
impactful
studies
we
have
on
fertility
outcomes
after
surgery
for
deep
colorectal
endometriosis
.
His
work
has
changed
how
we
think
about
the
relationship
between
endometriosis
,
excision
surgery
and
pregnancy
rates
,
especially
for
patients
who
have
struggled
with
multiple
failed
IVF
attempts
.
We're
going
to
explore
that
today
in
a
way
that
gives
hope
,
clarity
and
practical
insights
to
those
navigating
this
journey
.
Please
help
me
in
welcoming
Professor
Horace
Ramon
to
the
table
.
Thank
you
,
professor
Ramon
,
so
much
for
sitting
down
with
me
and
taking
the
time
to
help
us
understand
some
great
work
that
you're
doing
in
the
endometriosis
space
,
as
well
as
understanding
excision
and
endometriosis
as
it
stands
.
It
is
a
complete
honor
for
me
to
be
able
to
sit
down
with
you
and
take
this
time
and
learn
from
you
,
so
thank
you
so
much
.
Speaker 2
2:39
Thank
you
very
much
for
inviting
me
.
Speaker 1
2:41
Anytime
.
It's
an
honor
for
anyone
to
be
able
to
sit
in
this
space
and
learn
from
one
of
the
best
in
the
world
in
endometriosis
excision
and
you
also
teach
endometriosis
excision
.
Can
you
start
by
telling
us
what
inspired
your
focus
on
endometriosis
and
fertility
,
and
particularly
in
complex
cases
like
colorectal
and
deep
infiltrating
endometriosis
and
fertility
,
and
particularly
in
complex
cases
like
colorectal
and
deep
infiltrating
endometriosis
?
Speaker 2
3:07
Yes
,
so
my
story
started
in
2003
when
I
discovered
endometriosis
,
and
at
that
moment
I
was
in
the
fifth
year
of
residency
.
So
I
discovered
this
disease
very
,
very
late
because
it
was
unknown
.
Very
,
very
few
gynecologists
were
aware
about
endometriosis
at
that
time
and
I
had
the
chance
to
work
with
Professor
Michel
Canis
,
the
past
president
of
the
AAGL
,
and
I
saw
him
performing
this
surgery
and
I
fell
in
love
with
the
surgery
of
endometriosis
.
Before
being
gynecologist
,
I
had
the
training
in
colorectal
surgery
and
in
neurosurgery
.
So
I
was
four
years
,
I
had
been
a
resident
in
neurosurgery
.
Speaker 2
3:56
So
I
was
looking
for
an
interesting
and
exciting
and
complex
surgery
in
gynecology
and
also
I
was
looking
for
a
field
where
the
research
is
not
as
developed
and
where
I
can
bring
my
contribution
to
the
development
of
the
knowledge
.
And
the
endometriosis
meets
all
these
criteria
.
I
stated
that
I
will
be
an
endometriosis
surgeon
in
2005
.
And
at
that
moment
most
of
my
colleagues
were
surprised
because
they
did
not
understand
what
actually
I
want
to
do
,
because
for
them
endometriosis
was
PO
and
generate
analogs
,
and
me
I
said
no
,
no
,
no
,
endometriosis
is
surgery
,
and
I
started
doing
surgery
in
2005
.
Speaker 1
4:41
Wow
,
it's
shifted
and
changed
so
much
.
But
one
of
the
things
that
I
really
feel
like
is
progressing
and
is
amazing
is
the
work
that
you're
doing
to
help
many
people
understand
endometriosis
much
better
.
One
of
the
articles
that
you
published
the
high
postoperative
fertility
rate
following
surgical
management
of
colorectal
endometriosis
patients
.
This
study
,
when
I
initially
looked
at
it
,
kind
of
threw
me
for
a
little
bit
because
I
would
have
never
in
a
million
years
correlated
what
your
findings
were
,
which
is
fertility
rates
and
colorectal
endometriosis
.
Can
you
go
over
this
study
just
a
little
bit
and
break
this
down
for
people
to
understand
kind
of
what
this
study
entailed
,
as
well
as
what
some
of
these
findings
were
?
Speaker 2
5:31
Yes
,
now
I
will
start
with
the
onset
.
So
you
have
to
know
that
in
2008
,
I
became
a
PhD
in
epidemiology
and
clinical
studies
.
So
I
accomplished
this
PhD
in
order
to
have
the
tools
to
perform
good
level
clinical
studies
and
in
2009
,
I
could
have
a
grant
to
open
a
large
database
and
to
enroll
prospectively
all
my
patients
.
So
since
2009
,
I
have
had
with
me
a
clinical
researcher
,
which
is
not
involved
in
care
but
only
in
the
management
of
the
database
.
So
this
clinical
researcher
now
I
have
two
clinical
researchers
because
the
database
is
larger
,
but
I
always
have
had
someone
taking
care
,
giving
preoperative
questionnaires
to
patients
taking
care
.
That
may
,
I
feel
a
surgical
questionnaire
and
then
calling
the
patients
one
year
,
three
years
,
five
years
,
10
years
after
the
surgery
to
see
what's
happened
during
this
interval
.
It
means
that
I
have
a
database
with
now
I
think
we
have
5,000
,
6,000
women
who
had
surgery
well-done
surgery
,
excisional
surgery
with
a
follow-up
which
now
is
15
years
the
oldest
patients
have
15
years
of
follow-up
and
we
have
just
today
submitted
an
article
about
15
years
follow-up
after
colorectal
endometriosis
surgery
years
follow-up
after
colorectal
endometriosis
surgery
.
So
this
database
allows
me
to
study
everything
post-operatively
,
what's
happened
after
the
surgery
,
and
it
also
allows
me
to
see
the
real
number
,
the
real
percentage
who
is
pregnant
and
who
is
not
,
how
the
pregnancy
is
achieved
,
how
long
time
after
the
surgery
.
Speaker 2
7:26
And
I
could
,
in
this
case
I
could
,
publish
studies
which
show
that
after
the
surgery
of
most
advanced
,
most
complex
endometriosis
,
the
pregnancy
rate
is
very
high
.
And
this
happened
at
a
moment
where
a
lot
of
colleagues
,
a
lot
of
gynecologists
,
were
telling
to
patients
don't
have
surgery
because
you
will
be
infertile
.
And
my
answer
was
no
.
Conversely
,
if
you
want
to
be
pregnant
,
please
consider
the
surgery
as
a
treatment
of
your
infertility
.
And
of
course
,
all
my
studies
try
to
put
in
the
mirror
pregnancy
rate
in
women
who
have
no
surgery
and
have
only
IVF
with
women
who
have
surgery
.
And
I
could
demonstrate
that
women
with
surgical
management
of
endometriosis
have
at
least
the
same
pregnancy
rate
that
women
who
have
up
to
four
IVF
successive
IVF
.
And
right
now
in
the
world
there
are
two
randomized
trials
comparing
in
a
random
manner
,
comparing
IVF
to
the
surgery
.
One
of
them
is
in
France
,
endofert
,
and
the
other
one
is
Bordeaux
and
Denmark
it
calls
F4
.
So
I
am
involved
in
both
studies
,
I
recruit
for
both
studies
because
both
studies
the
hypothesis
is
based
on
my
data
and
both
studies
try
to
show
that
the
Professor Ramon's Journey into Endometriosis
Speaker 2
8:52
pregnancy
rate
after
the
surgery
with
natural
conception
or
post-operative
IVF
,
this
pregnancy
rate
is
better
than
in
women
who
have
no
surgery
and
are
sent
directly
to
IVF
.
Speaker 2
9:04
Wow
,
but
the
surgery
is
like
the
Soxer
,
like
everything
else
.
Better
than
in
women
who
have
no
surgery
and
are
sent
directly
to
IVF
.
Wow
,
but
the
surgery
is
like
the
sockser
,
like
everything
else
.
So
surgery
is
not
.
We
cannot
speak
about
surgery
.
We
speak
about
surgeons
who
perform
surgery
.
So
some
surgical
procedures
may
render
the
patients
infertile
if
the
surgeon
does
not
take
care
at
ovaries
.
So
we
have
a
myriad
of
patients
who
had
cystectomy
,
bilateral
cystectomy
,
and
their
ovarian
reserve
went
down
at
the
point
that
no
IVF
,
nothing
is
feasible
.
So
the
surgery
is
a
very
good
tool
to
improve
fertility
when
the
surgeon
takes
care
of
what
he
level
,
whereas
not
everyone
is
.
Speaker 1
10:07
Does
that
change
the
fertility
rate
for
those
patients
depending
on
their
surgeon's
skill
level
?
Speaker 2
10:14
Now
the
surgery
is
a
manual
craft
and
I
compare
the
surgery
to
the
Soxer
.
So
everybody
knows
that
football
players
do
not
play
alike
.
So
you
have
Messi
,
ronaldo
and
Pelé
they
are
stars
and
then
there
are
other
guys
who
play
the
Soxer
less
and
have
less
results
.
But
the
surgery
is
alike
.
So
you
cannot
,
in
some
cases
you
cannot
compare
the
results
between
several
surgeons
.
That's
why
all
the
studies
reporting
results
of
the
surgery
should
be
read
from
the
first
row
to
the
last
one
,
and
to
see
who
performed
the
surgery
,
who
are
the
surgeons
,
where
is
the
center
.
For
example
,
the
results
in
terms
of
fertility
after
a
surgery
done
by
the
team
of
Marcello
Ceccaroni
in
the
Negrar
Hospital
in
Italy
,
which
is
the
biggest
endometriosis
center
in
the
world
,
cannot
be
the
same
with
the
results
performed
in
the
hospital
in
a
small
town
,
even
though
in
theory
there
is
the
same
surgery
.
So
it
is
politically
correct
to
say
,
yes
,
we
are
all
at
the
same
level
,
but
in
theory
there
is
not
.
That
is
not
true
.
So
a
good
surgery
for
me
in
endometriosis
takes
care
to
the
excision
which
is
done
depending
on
several
factors
on
patient's
age
,
intention
to
get
pregnant
,
features
of
the
lesion
,
but
also
,
or
more
than
the
features
,
the
symptoms
which
are
related
to
each
lesions
.
I
think
that
a
good
surgery
should
completely
excise
all
the
lesions
which
are
symptomatic
,
while
lesions
who
are
not
symptomatic
should
be
discused
case
by
case
.
Some
of
them
can
be
removed
and
some
of
them
cannot
be
removed
or
can
be
left
behind
if
the
price
to
pay
for
this
excision
is
high
.
In
other
terms
,
if
one
patient
comes
with
me
,
I
receive
a
lot
of
emails
from
patients
where
they
sent
me
a
picture
with
a
big
nodule
of
the
rectum
and
they
said
what
I
have
to
do
.
And
my
answer
is
I
don't
know
,
because
with
this
nodule
you
can
have
the
surgery
or
you
cannot
having
the
surgery
.
It
depends
what
do
you
feel
?
Because
if
you
have
a
big
nodule
of
the
rectum
and
the
patient
is
completely
asymptomatic
by
chance
,
it
is
for
sure
that
performing
the
surgery
increased
the
risk
that
patient
became
symptomatic
after
the
surgery
.
Speaker 2
12:50
So
there
are
some
I
think
I
have
at
least
10
or
15
patients
with
very
severe
endometriosis
and
I
see
them
every
year
.
I
tell
them
the
surgery
is
justified
if
you
have
just
one
symptom
.
And
I
ask
them
every
year
do
you
have
a
symptom
or
you're
still
asymptomatic
?
They
say
I'm
still
asymptomatic
.
Okay
,
see
you
next
year
.
So
this
is
the
philosophy
of
endometriosis
.
So
the
endometriosis
is
not
a
cancer
and
should
not
be
treated
like
a
cancer
If
the
patient
should
have
a
better
quality
of
life
.
It
means
that
you
have
carefully
to
treat
all
the
lesions
with
or
symptomatic
,
and
you
have
to
take
care
at
the
resection
excision
of
lesions
which
are
not
symptomatic
in
order
to
avoid
new
symptoms
which
are
sequelae
of
your
surgery
.
And
this
is
the
same
on
fallopian
tubes
and
on
ovaries
.
Speaker 1
13:40
It's
kind
of
like
essentially
saying
you're
going
to
eradicate
lesions
that
are
creating
the
symptoms
,
but
if
something's
not
affecting
you
,
you
don't
want
to
disturb
that
tissue
creating
more
issues
.
Is
that
kind
of
what
you're
pointing
to
being
valuable
in
surgery
?
Speaker 2
13:59
Exactly
so
.
A
very
interesting
information
about
the
postoperative
pregnancy
rate
after
complex
surgery
for
deep
endometriosis
was
provided
by
a
randomized
trial
.
I
carried
conservative
to
radical
surgery
for
colorectal
endometriosis
and
the
goal
,
the
main
endpoint
,
was
the
bowel
function
after
the
surgery
.
So
the
goal
of
the
trial
was
to
prove
that
if
we
perform
disc
excision
Groundbreaking Fertility Research Findings
Speaker 2
14:40
or
shaving
,
you
have
the
same
results
than
those
after
colorectal
resection
,
maybe
with
less
complications
and
with
the
same
rate
of
recurrences
.
So
I
enrolled
60
patients
and
these
60
patients
I
carefully
followed
them
up
at
six
months
,
one
year
,
up
to
10
years
.
So
this
woman
,
this
60
woman
,
I
know
them
as
they
were
from
my
family
Because
I
met
them
so
frequently
.
And
10
years
after
the
surgery
,
the
rate
of
loss
of
follow-up
is
9%
,
meaning
that
more
than
90%
of
patients
came
up
to
10
years
to
tell
me
how
they
feel
.
And
I
observed
that
among
this
woman
who
all
had
a
very
advanced
surgery
with
colorectal
resection
,
parametrium
reimplantation
of
the
ureter
,
very
,
very
severe
surgery
After
the
surgery
,
among
the
patients
who
intended
to
get
pregnant
,
80%
could
be
pregnant
,
and
most
of
them
naturally
.
And
then
I
looked
at
inside
the
woman
who
were
pregnant
,
I
looked
at
who
was
infertile
before
my
surgery
,
who
came
to
the
surgery
with
the
sticker
of
infertile
need
IVF
,
and
in
this
subgroup
of
women
infertile
women
who
had
complex
surgery
for
correct
endometriosis
the
pregnancy
rate
was
75%
.
Wow
,
and
even
in
this
group
most
pregnancies
were
natural
.
And
for
me
,
this
study
,
with
actually
no
loss
of
follow-up
,
with
very
accurate
long-term
follow-up
,
this
study
provided
me
that
proved
me
that
the
surgery
for
complex
endometriosis
improves
the
fertility
rate
.
And
I
put
these
results
in
the
mirror
with
studies
done
by
two
friends
of
me
,
two
French
friends
from
other
hospitals
,
who
reported
the
pregnancy
rate
in
women
with
severe
corrector
endometriosis
who
had
no
surgery
but
only
IVF
,
and
both
of
them
estimated
that
if
women
with
colorectal
surgery
have
1
,
2
,
3
,
or
4
IVF
,
they
can
be
pregnant
in
60-65%
of
cases
,
all
pregnancies
or
IVF
.
Speaker 2
17:02
Now
,
it
is
difficult
to
compare
80%
to
65%
in
two
different
populations
.
Right
,
I
cannot
state
that
my
pregnancy
rate
is
higher
than
the
pregnancy
rate
of
the
IVF
,
but
I
can
state
that
if
you
perform
a
complete
surgery
of
endometriosis
,
the
patients
will
feel
better
in
the
long
run
because
10
years
after
the
surgery
they
are
still
in
good
shape
.
The
complaints
are
improved
in
the
long
run
.
Currency's
rate
on
the
rectum
10
years
after
the
surgery
is
5%
and
they
were
pregnant
in
80%
of
cases
.
So
at
least
the
same
rate
you
may
have
in
the
same
patients
without
surgery
,
with
symptoms
,
with
big
lesions
,
bigger
and
bigger
,
once
one
,
two
,
three
or
four
IVFs
are
done
.
So
this
allows
me
to
state
that
if
you
do
a
correct
surgery
,
there's
no
reason
to
be
frightened
by
the
risk
of
infertility
because
you
have
.
Conversely
,
you
have
the
opposite
result
you
improve
the
fertility
.
This
may
happen
even
in
women
with
low
ovarian
reserve
.
Speaker 1
18:14
Wow
,
why
do
you
think
doing
surgery
in
those
patients
who
had
bowel
or
colorectal
surgery
for
endometriosis
had
such
a
significant
improvement
in
fertility
?
What
would
cause
that
?
Speaker 2
18:26
Well
,
we
do
not
know
exactly
If
the
patient
has
a
bowel
endometriosis
together
with
ovarian
fallopian
tube
endometriosis
.
It
is
obvious
that
removing
the
bowel
endometriosis
,
together
with
restoring
the
fallopian
tube
patency
and
removing
the
ovarian
cyst
,
of
course
,
it
improves
the
fertility
Right
.
You
may
have
infertile
women
with
bowel
endometriosis
and
the
fallopian
tubes
are
almost
normal
and
the
ovaries
are
involved
by
only
superficial
lesions
.
In
this
case
,
after
the
surgery
,
I
am
almost
sure
that
they
will
be
pregnant
naturally
and
I
think
that
in
this
case
the
endometriosis
impaired
the
pregnancy
in
an
indirect
manner
,
because
it
had
been
demonstrated
that
endometriosis
,
like
the
smoke
,
may
affect
the
fertility
at
every
level
,
beginning
with
the
quality
of
the
oocyte
,
with
the
mobility
of
the
sperm
,
with
the
inflammatory
ambience
of
the
pelvis
where
the
meeting
between
the
spermatozoa
and
ovocytes
occurs
.
So
at
every
level
endometriosis
may
reduce
the
probability
of
pregnancy
and
I
think
that
cleaning
the
pelvis
we
give
a
supplementary
chance
for
natural
pregnancy
.
Speaker 1
19:48
It's
a
remarkable
finding
.
I
feel
like
a
lot
of
us
wouldn't
have
put
those
two
together
,
Although
I
think
in
a
lot
of
ways
it
makes
sense
,
because
the
more
your
body
is
fighting
against
itself
and
has
a
diseased
state
,
it
would
make
sense
that
it's
harder
to
become
pregnant
.
It's
not
your
body's
not
at
its
optimal
.
Speaker 2
20:08
Then
there
is
another
factor
of
infertility
,
of
natural
conception
,
which
is
the
deep
dyspareunia
we
do
not
speak
about
.
We
do
not
speak
enough
about
deep
dyspareunia
.
But
women
with
big
rectovaginal
nodules
have
less
sex
than
women
who
are
not
painful
of
a
genital
nodule
,
have
less
sex
than
women
who
are
not
painful
,
and
they
may
be
painful
,
more
painful
,
during
exactly
the
three
days
of
ovulation
.
At
that
time
they
reduce
the
frequency
of
sexual
intercourse
.
They
may
be
involved
too
in
a
better
,
in
an
improvement
of
natural
conception
rate
.
Speaker 1
20:39
Yeah
,
well
,
and
it
makes
sense
,
with
the
inflammation
that
we
experience
oftentimes
during
our
cycle
and
when
we're
in
a
flare
,
why
that
would
be
so
much
harder
.
Speaker 1
20:49
And
eradicating
that
disease
is
so
important
for
that
conception
,
so
your
body
can
function
normally
and
not
have
the
inflammation
.
It
makes
a
lot
of
sense
from
that
perspective
.
There
was
another
study
that
you
did
which
I
think
is
interesting
because
you
touched
on
the
IVF
and
you
know
women
who
had
IVF
previously
maybe
had
failed
IVF
.
You
did
another
study
of
pregnancy
rates
after
surgical
treatment
of
deep
infiltrating
endometriosis
in
infertile
patients
with
at
least
two
previous
IVF
ICSI
failures
.
Can
you
touch
on
that
?
Because
I
think
a
lot
of
people
don't
really
know
do
they
want
to
try
IVF
first
?
Do
they
want
to
potentially
look
at
excision
for
endometriosis
first
,
and
what
are
the
pros
and
cons
of
that
?
But
this
study
kind
of
looked
at
that
and
highlighted
that
a
little
bit
more
.
Can
you
speak
to
that
?
Speaker 2
21:41
Yes
,
in
some
cases
the
patient
have
an
endometriosis
,
a
deep
endometriosis
,
and
someone
else
decided
to
refer
them
to
IVF
.
What's
happened
in
France
?
Four
IVF
or
reimbursed
,
so
for
free
,
wow
.
So
,
as
women
know
that
they
have
four
IVF
for
free
,
when
they
have
the
second
and
the
third
IVF
failure
,
they
think
about
let's
do
something
different
for
the
last
one
,
because
after
that
it
is
not
longer
for
free
.
So
I
have
a
lot
of
patients
coming
to
seek
care
and
to
ask
about
their
endometriosis
management
.
Once
they
had
two
or
three
IVF
and
I
asked
I
was
a
professor
in
Rouen
at
that
time
.
Speaker 2
22:22
It
was
in
2016
,
I
think
10
years
ago
and
I
asked
one
of
my
residents
which
was
very
interested
in
fertility
.
I
said
let's
look
at
all
our
patients
who
come
with
at
least
two
IVF
.
Let's
see
if
we
do
the
surgery
,
what's
happened
after
?
Anyway
,
as
the
patients
are
recorded
in
our
database
,
we
can
very
easily
see
what's
happened
after
our
surgery
.
Right
,
and
actually
we
put
the
threshold
to
two
IVF
,
but
the
mean
number
of
IVF
in
our
Syria
was
three
,
because
the
patients
go
up
to
the
four
IVF
and
they
come
to
do
something
before
the
fourth
IVF
,
which
is
the
last
one
,
which
is
reimbursed
come
to
do
something
before
the
fourth
IVF
,
which
is
the
last
one
which
is
reimbursed
.
So
after
three
IVF
failures
,
performing
the
surgery
was
followed
by
a
pregnancy
rate
of
45%
.
Now
,
45%
of
course
is
very
far
from
80%
,
but
let's
put
in
the
mirror
the
results
which
can
be
expected
if
the
patients
with
three
failure
do
the
fourth
IVF
.
And
we
have
this
information
in
the
studies
I
talk
to
you
where
the
patients
did
not
have
,
in
other
facilities
,
in
Cochin
and
Tenron
Hospital
in
Paris
,
where
the
patients
went
up
to
four
IVF
without
having
surgeries
.
Speaker 2
23:42
In
this
study
you
see
very
,
very
clearly
that
women
who
still
have
colorectal
endometriosis
and
go
to
IVF
have
a
pregnancy
rate
of
about
35%
after
the
first
IVF
.
Then
if
they
go
to
the
second
IVF
they
have
maybe
20%
.
So
the
step
is
lower
.
A
third
IVF
will
bring
10%
more
,
while
the
fourth
IVF
almost
nothing
.
Wow
,
because
if
you
fail
free
IVF
,
it
means
that
something
happens
,
something
does
not
work
Right
.
We
should
compare
our
40%
,
45%
pregnancy
rate
,
not
to
80%
but
to
5%
,
which
would
have
been
expected
if
the
patient
had
had
the
fourth
IVF
after
three
failures
.
So
even
in
this
patient
,
in
this
patient
,
I
think
we
can
improve
something
.
That's
why
,
in
our
daily
practice
patients
who
had
two
IVF
failures
.
We
discuss
them
in
our
multidisciplinary
meeting
and
in
a
majority
of
cases
we
propose
the
surgery
before
the
last
two
IVFs
.
Speaker 1
24:54
For
the
IVF
piece
of
it
.
I
think
a
lot
of
people
feel
like
that
is
their
first
line
of
defense
for
infertility
.
And
you're
saying
that
when
you
go
and
have
endometriosis
excision
surgery
by
an
expert
,
your
chances
even
of
naturally
conceiving
are
much
,
much
higher
.
And
then
if
you
do
IVF
,
your
chances
of
conception
are
even
higher
than
if
you
would
have
just
done
IVF
naturally
.
I
think
yes
.
Speaker 2
25:21
If
you
have
the
surgery
and
then
you
go
to
natural
conception
or
to
IVF
?
Naturally
,
I
think
yes
.
If
you
have
the
surgery
and
then
you
go
to
natural
conception
or
to
IVF
.
If
the
fallopian
tubes
are
destroyed
or
if
you
do
not
achieve
natural
conception
after
one
year
,
you
go
to
IVF
.
So
all
these
solutions
taken
together
80%
of
pregnancy
rate
in
my
series
of
patients
,
with
actually
no
loss
of
follow-up
.
Speaker 1
25:47
Wow
.
Speaker 2
25:48
That's
a
huge
.
But
now
the
situation
is
more
difficult
and
this
is
just
a
samurai
.
We
samurais
,
but
we
use
every
case
in
our
multidisciplinary
meeting
.
Because
if
a
woman
has
come
with
an
ovarian
reserve
which
is
very
,
very
,
very
,
very
low
,
almost
zero
,
of
course
you
can
do
whatever
you
wish
.
The
results
will
not
be
satisfactory
.
They
can
be
pregnant
,
but
the
pregnancy
rate
is
much
lower
.
If
the
husband
has
a
sperm
which
is
completely
abnormal
,
naturally
or
IVF
by
IVF
,
it
will
be
difficult
.
So
but
if
you
put
everybody
,
all
the
patients
,
together
,
we
expect
to
have
higher
pregnancy
rate
.
Speaker 2
26:33
And
the
two
randomized
trials
which
are
ongoing
right
now
have
the
same
hypothesis
that
in
the
group
of
surgery
you
expect
a
higher
pregnancy
rate
than
in
the
group
of
only
IVF
.
Speaker 2
26:47
So
we
speak
about
pregnancy
rate
,
but
then
we
have
to
speak
also
about
the
complaints
the
risk
of
growth
of
endometriosis
during
the
time
necessary
for
IVF
,
risk
of
complication
you
may
expect
after
a
big
nodule
when
compared
to
a
smaller
nodule
you
could
have
removed
three
years
earlier
.
Speaker 2
27:14
So
all
these
factors
taken
together
,
that
in
my
daily
practice
,
if
I
see
a
patient
with
infertility
and
severe
endometriosis
,
in
theory
80%
of
patients
receive
a
surgery
and
20%
are
referred
for
the
IVF
.
So
I
can
refer
for
the
IVF
a
patient
who
has
a
deep
endometriosis
but
she's
not
symptomatic
Two
ovarian
endometriomas
,
fallopian
tubes
which
are
not
in
good
shape
,
so
the
natural
pregnancy
is
very
unlikely
,
and
a
husband
with
abnormal
sperm
.
So
here
,
when
I
expect
that
this
patient
needs
an
IVF
,
I
give
her
the
choice
for
IVF
and
if
she's
not
very
symptomatic
,
it
is
logically
not
to
perform
a
surgery
with
risk
of
functional
sequeira
and
to
propose
her
to
start
by
IVF
sequeira
and
to
propose
her
to
start
by
IVF
.
And
then
for
patients
who
tell
me
immediately
my
first
goal
is
the
pregnancy
and
I
want
to
go
to
the
IVF
,
I
just
want
to
tell
,
I
just
want
to
hear
from
you
if
it
is
risky
to
do
this
.
Speaker 1
28:20
So
there's
like
there's
this
balance
between
starting
IVF
first
and
then
or
doing
surgical
management
first
,
yes
,
and
the
surgical
management
piece
of
it
you're
saying
if
you're
symptomatic
,
surgery
might
make
sense
prior
to
starting
IVF
.
Speaker 2
28:35
Of
course
,
and
then
,
yeah
,
if
I
have
a
patient
with
a
very
severe
endometriosis
suboclusive
endometriosis
,
very
severe
endometriosis
,
suboclusive
endometriosis
.
If
I
have
a
patient
with
a
big
rectovaginal
nodule
which
is
still
feasible
,
where
the
disc
excision
is
still
feasible
but
where
the
growth
of
the
nodule
would
require
a
low
rectal
resection
,
in
these
patients
I
advise
the
surgery
because
I
said
,
look
,
if
you
do
one
or
three
IVF
and
you
come
back
within
two
years
and
this
nodule
is
bigger
,
we're
not
longer
able
to
do
this
conservative
surgery
.
I
am
able
to
do
this
today
and
maybe
we
will
go
to
the
more
aggressive
surgery
and
the
price
to
pay
may
be
a
lower
acceleratory
action
syndrome
with
bowel
sequeira
,
which
are
related
to
the
surgery
,
because
the
surgery
should
be
done
.
So
I
think
it's
in
your
interest
to
go
to
the
surgery
right
now
because
anyway
I
will
take
care
of
your
ovaries
.
So
it's
happened
,
for
example
,
that
in
this
woman
,
if
they
have
bilateral
endometriomas
,
the
fallopian
tubes
are
not
in
good
shape
and
during
the
surgery
I
know
that
they
need
an
IVF
.
Speaker 2
29:45
After
my
surgery
I
may
simply
drain
the
ovaries
not
to
excise
.
So
I
can
excise
everything
everywhere
,
diaphragm
everything
except
the
ovaries
.
So
Surgery vs. IVF: Comparing Success Rates
Speaker 2
29:55
for
the
ovaries
I
may
put
in
the
front
the
pregnancy
intention
and
the
preservation
of
the
ovarian
reserve
.
It
seems
for
me
more
important
than
the
complete
excision
of
endometriomas
Interesting
.
We
may
combine
this
.
Speaker 1
30:10
Interesting
.
You
know
,
I've
always
heard
that
you
want
to
take
everything
out
regardless
.
Speaker 2
30:15
Yes
,
in
theory
.
In
theory
,
very
specific
cases
.
For
example
,
if
you
have
a
patient
,
painful
patient
,
right
,
let's
say
,
25-year
year
old
,
very
painful
,
you
see
her
,
she
has
an
eight
centimeter
endometrioma
on
the
right
side
,
a
four
centimeter
endometrioma
on
the
left
side
.
She's
single
.
So
you
cannot
refer
her
for
IVF
.
She's
painful
,
you
have
to
do
the
surgery
.
The
best
attitude
is
not
to
remove
the
endometrioma
,
is
not
to
remove
the
endometrioma
.
So
in
this
patient
,
if
someone
goes
to
remove
,
to
excise
the
endometriomas
,
the
ovarian
reserve
will
go
down
.
So
I
think
the
excision
should
be
forbidden
under
the
jail
.
You
do
this
under
the
jail
,
I'm
joking
.
It
should
be
forbidden
by
the
law
.
In
this
patient
you
can
do
the
surgery
to
relieve
the
symptoms
.
You
can
do
a
sclerotherapy
or
a
drainage
on
both
ovaries
.
You
reduce
,
evacuate
the
cyst
.
You
refer
immediately
the
patient
to
ovocet
freezing
.
You
introduce
a
pill
in
order
to
avoid
that
at
the
first
period
the
cyst
come
back
Right
.
So
you
freeze
15
or
20
OOCs
and
then
you
come
back
and
you
treat
the
endometriosis
.
Speaker 1
31:32
Interesting
.
Speaker 2
31:33
So
the
patient
is
painful
,
you
have
to
do
something
Right
,
but
you
choose
your
weapon
.
Speaker 1
31:39
Right
and
getting
the
patient
understanding
what
the
overall
goal
is
for
the
patient
,
whether
they
want
to
have
children
or
not
.
But
in
this
instance
,
when
you
have
patients
coming
in
saying
I
want
children
,
I'm
not
there
yet
,
but
my
endometriosis
is
bad
enough
,
I
just
need
symptom
relief
.
This
is
an
avenue
in
which
they
could
go
.
In
these
circumstances
,
do
you
have
them
freeze
their
ovocytes
and
then
do
you
have
hormonal
suppression
at
that
point
,
or
is
that
you
don't
even
touch
?
Speaker 2
32:09
yes
,
for
example
me
.
I
have
a
lot
of
patients
who
had
,
who
have
have
already
frozen
.
They
all
there
,
right
woman
.
Most
of
them
will
never
need
their
OC
because
then
the
surgery
I
did
preserved
ovarian
reserve
so
they
will
be
pregnant
naturally
.
But
the
ovarian
ovocet
freezing
is
necessary
when
you
have
a
single
woman
,
young
,
with
good
ovarian
reserve
and
bilateral
big
endometriomas
.
Ovarian
situation
.
Second
situation
you
have
a
patient
with
subocclusion
because
of
the
big
nodule
of
the
rectum
.
She
wants
to
get
pregnant
.
She
is
at
the
limit
of
the
occlusion
.
So
you
have
to
do
the
surgery
because
stimulating
,
doing
an
IVF
on
a
subocclusive
lesion
may
push
definitively
the
patient
into
occlusion
.
It
has
been
demonstrated
.
Speaker 2
32:59
I
had
patients
like
this
.
So
after
the
surgery
,
but
she
has
two
big
endometriomas
on
each
ovary
.
In
this
case
if
you
do
a
complete
excision
move
the
ovarian
bowel
endometriosis
,
deep
endometriosis
and
ovarian
endometriomas
the
ovarian
reserve
will
go
down
and
this
is
definitively
lost
.
So
in
this
case
I
start
by
looking
at
the
fallopian
tube
.
If
the
fallopian
tube
,
if
the
fallopian
tube
are
in
good
shape
and
if
I
estimated
at
the
end
of
the
surgery
I
could
clean
everything
,
she
can
go
to
the
natural
conception
.
The
natural
conception
is
likely
In
this
case
.
Speaker 2
33:40
I
do
a
very
careful
cystectomy
on
each
side
.
Her
reserve
is
good
before
the
surgery
.
If
the
reserve
is
low
or
if
the
fallopian
tubes
are
not
in
good
shape
shape
and
I'm
sure
that
she
needs
an
IVF
I
certainly
won't
remove
the
endometriomas
by
excision
because
the
ovarian
reserve
will
go
down
and
the
IVF
will
fail
.
It
is
important
to
understand
that
a
patient
who
needs
an
IVF
needs
a
good
ovarian
reserve
.
Right
,
it
requires
a
good
ovarian
reserve
.
The
stimulation
requires
a
good
ovarian
reserve
.
The
same
patient
if
she
goes
to
the
natural
conception
,
the
ovarian
reserve
may
be
lower
.
There
is
no
problem
.
Speaker 1
34:23
Right
.
Speaker 2
34:23
So
she
needs
one
OOC
every
month
.
So
women
with
low
ovarian
reserve
after
the
surgery
may
be
pregnant
naturally
in
the
same
manner
as
women
with
normal
ovarian
reserve
.
But
if
the
IVF
is
most
likely
it
is
better
not
to
excise
,
and
this
is
the
experience
.
Speaker 1
34:42
Right
,
yeah
,
and
that's
what
I
was
going
to
say
.
Speaker 2
34:43
This
is
the
experience
of
the
surgeon
and
the
culture
of
the
experience
.
Right
,
yeah
,
and
that's
what
I
was
going
to
say
the
experience
of
the
surgeon
and
the
culture
of
the
surgeon
.
That's
why
it's
very
difficult
to
standardize
everything
in
endometriosis
and
that's
why
it's
very
difficult
to
create
,
I
think
,
software
of
artificial
intelligency
to
give
the
good
management
in
each
case
.
Speaker 1
35:04
Yeah
,
well
,
that's
what
I
was
going
to
say
.
I
think
this
is
something
that
not
every
surgeon
would
even
consider
or
even
know
about
,
because
it
takes
years
of
really
integrating
yourself
,
not
only
on
the
surgical
side
of
things
but
also
the
academic
and
research
side
of
things
,
to
really
,
I
think
,
understand
probably
some
of
the
nuances
of
fertility
and
endometriosis
.
So
I
think
that's
probably
one
of
the
things
that
I
hear
a
lot
of
people
talk
about
is
,
you
know
,
I
went
in
for
this
surgery
and
I
still
can't
get
pregnant
,
but
they
just
the
provider
just
kind
of
left
it
at
that
.
There
was
no
workup
as
to
why
,
or
their
approach
was
a
standardized
approach
,
because
this
is
what
we
do
.
This
is
all
I
know
.
You
know
,
you
hear
about
providers
doing
excision
,
but
they
have
a
routine
of
excision
.
They
aren
the
guidelines
,
yes
,
of
course
,
but
the
guidelines
?
Speaker 2
35:55
are
not
the
Bible
or
not
the
Torah
or
not
the
Koran
,
or
based
on
the
data
we
have
,
if
we
have
data
Right
.
So
in
this
case
,
unfortunately
,
the
patient
falls
between
two
studies
,
two
results
,
and
you
have
to
do
with
what
you
feel
,
with
what
you
smell
,
and
this
becomes
difficult
and
that's
why
I
think
there
are
15
years
I
have
stated
that
the
endometriosis
surgery
should
be
a
subspecialty
,
and
in
2011,
.
So
in
2005
,
I
decided
to
become
an
endometriosis
surgeon
,
but
until
2011
,
of
course
,
I
also
did
over
cancer
and
sacro-colpo-pexi
,
but
in
2011
,
I
could
afford
to
stop
all
over
surgeries
until
I
was
having
enough
endometriosis
patients
to
fill
in
all
my
program
and
not
to
take
care
about
other
specialties
.
And
I
think
that
at
that
moment
I
started
understanding
much
deeper
everything
.
Speaker 2
37:13
Well
,
for
example
,
in
France
but
worldwide
,
there
is
a
discussion
about
what
policy
we
have
to
adopt
.
Should
we
create
expert
centers
?
Should
we
?
And
if
we
create
expert
center
,
where
we
have
to
put
the
threshold
Volume
of
surgery
,
you
need
to
state
I
am
expert
,
and
when
this
discussion
is
done
with
colleagues
,
of
course
each
one
tried
to
push
the
threshold
down
below
his
level
and
they
say
no
,
it
is
not
demonstrated
that
doing
only
this
make
you
better
than
having
a
more
generalistic
practice
.
And
I
said
I
cannot
agree
with
this
Because
if
I
agree
,
if
I
say
you're
right
,
it
means
everything
I
have
done
during
the
last
15
years
is
for
nothing
,
because
I
decided
to
do
only
this
.
If
I
consider
that
I
could
be
good
enough
by
doing
only
one
corrective
endometriosis
a
month
once
now
I'm
doing
30
,
it
means
I
was
completely
wrong
in
everything
I
have
done
.
So
I
was
not
right
at
all
and
I
believe
I
was
right
.
Speaker 1
38:22
Yeah
,
you
know
I
equate
this
to
you
know
,
had
a
lot
of
dental
work
done
a
while
back
and
I
think
of
it
like
this
,
and
this
is
the
best
way
that
I've
been
able
to
explain
this
to
people
Dental
,
you
have
your
general
dentist
.
They
are
good
for
your
cleanings
,
they're
good
for
,
you
know
,
just
dental
maintenance
,
right
,
and
that's
your
general
GYN
or
family
practitioner
.
And
then
if
there's
something
more
that
needs
to
be
done
say
you
need
there's
an
infection
or
there's
something
crowding
of
your
teeth
,
then
you
go
see
the
orthodontist
for
the
braces
,
right
?
So
it's
a
different
specialty
,
although
maybe
the
orthodontist
could
clean
the
teeth
or
you
know
the
dentist
could
,
you
know
,
look
at
the
infection
,
who
knows
?
But
then
they
say
you
need
to
remove
your
teeth
,
a
tooth
,
well
,
you
have
to
go
to
the
surgeon
,
you
have
to
go
to
the
endodontist
and
you
have
to
.
So
there's
so
many
different
steps
depending
on
what
you
need
done
when
it
comes
to
dental
work
.
Yet
there
is
not
that
when
it
comes
to
endometriosis
.
Speaker 2
39:24
We
make
it
such
a
broad
specialty
if
you
will
Exactly
,
and
this
was
happening
30
years
ago
in
cancer
Right
.
20
years
ago
it
was
stated
only
those
who
have
a
volume
of
cancer
surgery
are
allowed
to
do
this
cancer
,
to
continue
to
do
cancer
surgery
.
Right
,
it
was
very
,
very
difficult
to
make
people
to
accept
they
could
not
be
good
enough
to
perform
cancer
surgery
but
in
two
or
three
years
the
low
was
should
be
agreed
by
everybody
,
but
it
was
very
difficult
.
Speaker 1
40:00
Yeah
.
Speaker 2
40:00
The
problem
is
in
cancer
.
If
you
have
worse
results
,
you
can
see
immediately
because
the
survival
rate
is
low
.
Endometriosis
is
much
more
difficult
because
the
patient
will
not
die
,
they
will
just
be
painful
.
So
it
is
very
,
very
difficult
in
endometriosis
to
assess
the
results
of
someone
.
Speaker 1
40:20
Right
yeah
.
Speaker 2
40:35
And
the
endometriosis
.
Right
now
it's
a
kind
of
no
man
land
,
Right
yeah
,
a
confusion
,
because
they
allowed
the
surgeon
to
say
I
can
do
this
.
I
can
do
this
Because
in
social
media
,
everybody
,
everybody
may
seem
more
beautiful
than
it
really
is
.
Speaker 1
40:53
Yeah
,
yeah
,
it
is
true
.
I
mean
,
I
think
there's
a
lot
of
times
if
the
words
look
fancy
and
the
picture
matches
the
word
of
fancy
,
then
they
must
be
qualified
and
that
is
just
simply
not
true
.
I
think
that's
where
a
lot
of
times
,
our
eyes
can
deceive
us
a
little
bit
on
who
we
think
is
an
actual
surgeon
and
expert
in
that
field
,
and
that's
where
I
think
due
diligence
is
essential
.
Understanding
how
long
someone
has
done
something
,
where
their
training
has
been
done
,
what
their
training
is
specifically
in
,
I
think
makes
a
huge
difference
.
And
it's
not
just
fellowship
trained
,
it's
actual
,
like
integrative
training
and
having
a
large
number
of
cases
in
your
repertoire
before
you
can
really
Exactly
A
large
number
of
cases
and
enough
number
of
procedures
,
of
complex
procedures
.
Speaker 1
41:46
Yes
.
Speaker 2
41:47
And
we
now
.
We
think
that
to
state
that
someone
is
has
a
high
level
in
endometriosis
,
it
needs
should
perform
at
least
one
,
at
least
20
complex
surgery
a
year
.
When
I
proposed
40
,
then
I
went
down
to
20
in
France
and
there
are
a
lot
of
colleagues
who
said
no
,
20
is
too
much
.
I
said
no
,
20
means
one
complex
surgery
every
two
weeks
.
Like
surgery
every
two
weeks
is
not
too
much
.
And
they
said
no
,
like
this
,
you
have
to
.
You
have
to
put
the
threshold
at
your
level
.
I
said
no
,
this
was
my
level
in
2007
,
not
now
.
Speaker 1
42:24
Wow
.
Speaker 2
42:25
So
so
the
converse
.
I
think
one
complex
surgery
every
two
weeks
is
the
minimal
.
Feel
yourself
comfortable
with
the
complex
surgery
.
Speaker 1
42:34
Yeah
,
what
qualifies
something
as
a
complex
surgery
?
I
think
that
might
be
something
that
could
be
a
differentiating
factor
,
because
some
might
think
,
you
know
,
having
a
bowel
lesion
is
a
complex
surgery
.
To
you
,
what
would
be
a
complex
surgery
?
Speaker 2
42:48
To
state
that
something
is
complex
surgery
,
you
need
some
criteria
which
cannot
be
Surgical Approaches to Preserve Fertility
Speaker 2
42:55
fancy
,
which
should
be
real
.
One
such
criteria
is
the
bowel
suture
.
You
need
to
perform
a
bowel
suture
.
Nobody
will
do
a
bowel
suture
just
for
the
fun
because
a
bowel
suture
.
Nobody
will
do
a
bowel
suture
just
for
the
fun
,
because
a
bowel
suture
is
a
risky
procedure
.
So
a
complex
surgery
for
me
and
in
what
I
propose
in
France
,
is
performing
either
a
suture
of
the
bowel
,
either
a
suture
of
the
ureter
,
either
a
suture
of
the
diaphragm
,
either
a
complete
releasing
,
a
complete
neuralysis
of
the
sci
suture
.
But
the
bladder
is
easier
.
So
you
should
not
be
very
,
very
expert
to
be
able
to
remove
a
bladder
nodule
.
But
these
procedures
have
a
very
specific
code
and
nobody
,
nobody
,
even
someone
which
is
not
honest
at
all
,
will
not
do
it
just
for
the
fun
and
just
to
reach
the
number
.
So
they
are
procedures
which
are
required
by
a
complex
situation
,
a
complex
endometriosis
.
Speaker 1
44:00
Yeah
,
and
you
definitely
want
someone
that
knows
what
they're
doing
when
they're
doing
that
,
because
it
could
really
damage
the
outcome
of
not
only
longevity
and
pain
relief
,
but
also
,
as
we
were
talking
about
,
fertility
,
and
that's
why
having
an
expert
who
understands
not
only
the
fertility
aspect
of
it
but
also
the
endometriosis
aspect
of
it
is
really
important
to
have
both
.
Speaker 2
44:23
And
to
state
that
your
center
is
a
multi-discipline
.
Now
it's
very
interesting
because
in
2019
,
we
have
the
visit
of
the
Surgical
Review
Corporation
,
because
we
asked
to
have
the
certification
of
Center
of
Excellence
in
minimally
gynecological
surgery
basic
gynecological
surgery
and
we
had
an
inspector
who
came
and
see
us
and
then
the
end
of
the
day
,
when
she
checked
everything
a
whole
day
of
visit
she
said
it's
very
funny
,
but
you
have
only
one
disease
,
you
take
care
only
about
one
disease
.
I
said
because
you
are
in
endometriosis
center
.
She
said
I
have
never
seen
this
,
but
do
you
think
we
can
create
a
certification
for
endometriosis
centers
?
We
said
,
of
course
,
yeah
,
we
are
thinking
about
this
and
we
propose
her
the
threshold
,
taking
care
not
to
put
them
very
,
very
high
because
the
interest
is
to
recruit
.
That's
why
and
honestly
,
now
the
Surgical
Review
Corporation
certification
for
complex
endometriosis
care
and
the
multisignal
endometriosis
care
is
based
on
our
center
.
Speaker 2
45:28
It's
the
middle
of
our
center
and
we
said
such
a
center
should
have
a
multi-specialty
team
.
So
you
need
,
of
course
,
gynecologists
who
have
at
least
70%
of
activity
in
endometriosis
,
you
need
fertility
specialists
,
you
need
colorectal
surgeon
,
neurologist
,
gastroenterologist
,
a
physician
specialized
in
pain
management
Very
,
very
important
the
pain
management
specialist
and
then
,
of
course
,
physiotherapist
and
a
very
good
radiologist
.
So
all
team
and
this
team
should
meet
together
at
least
once
a
month
to
discuss
maybe
not
all
the
folders
,
because
we
carry
out
100
endometriosis
surgeries
a
month
,
so
you
can
do
stuff
to
discuss
100
medical
charts
,
but
every
month
,
but
we
discuss
30
,
the
most
complex
.
So
we
have
one
meeting
every
,
which
takes
four
hours
five
hours
the
time
we
need
,
and
we
discuss
the
most
complex
cases
and
we
choose
this
we
spoke
about
should
the
patient
go
directly
to
IVF
?
Should
go
to
the
surgery
?
If
we
propose
the
surgery
,
what
kind
of
surgery
we
propose
?
What
we
remove
,
exactly
what
we
do
not
remove
,
what
we
drain
,
what
we
excise
,
so
we'll
do
a
robotic
surgery
.
Speaker 1
46:49
And
then
after
that
discussion
I'm
sure
the
patient
has
a
lot
of
say
in
this
as
well
and
then
after
that
discussion
I'm
sure
the
patient
has
a
lot
of
say
in
this
as
well
Then
you
go
back
and
present
to
the
patient
what
the
course
of
action
would
be
,
so
that
it's
that
informed
consent
piece
as
well
.
Speaker 2
47:02
Yes
,
exactly
my
goal
is
.
Then
,
once
a
patient
had
the
discussion
with
me
,
the
goal
is
that
she
says
oh
yes
,
now
this
guy
understood
what
I
have
.
I
questioned
and
I
knocked
at
the
right
door
For
this
.
A
meeting
with
a
patient
may
take
30
minutes
.
For
the
first
time
,
it
may
take
one
hour
.
So
we
should
not
be
into
the
rush
because
,
particularly
in
complex
endometriosis
surgeries
,
is
a
long
list
of
complications
,
benefits
to
discuss
,
and
everything
should
be
very
,
very
,
very
,
very
,
very
clear
.
Otherwise
there
is
a
risk
of
misunderstanding
,
lack
of
satisfaction
,
litigation
litigation
and
all
the
things
that
kind
of
come
along
with
.
Speaker 1
47:58
That
absolutely
do
you
find
,
since
you've
done
this
research
and
with
years
of
experience
under
your
belt
seeing
all
these
different
patients
,
I
think
what's
interesting
is
you
know
we're
talking
about
the
experience
aspect
of
it
and
to
get
to
that
point
you
have
to
do
all
these
cases
.
But
if
there
is
a
provider
out
there
who
is
walking
through
that
right
now
,
if
you
could
jump
back
into
time
and
tell
them
one
thing
,
one
of
the
most
important
things
that
you've
learned
in
this
process
to
getting
to
where
you're
at
,
what
would
you
say
?
That
is
what
has
changed
the
most
in
your
outcome
.
Speaker 2
48:30
I
think
everything
changed
.
Everything
changed
and
even
my
practice
.
My
surgical
procedures
have
changed
.
So
I
do
not
hesitate
to
change
one
of
my
approach
if
my
study
shows
that
something
else
works
better
.
What
it
changed
is
the
knowledge
,
the
general
knowledge
In
endometriosis
.
Now
it
is
maybe
fourfold
more
than
when
I
started
in
2003
.
The
number
of
publications
with
endometriosis
in
the
world
are
fourfold
more
numerous
now
than
in
2003
.
Speaker 2
49:08
It's
incredible
,
the
surgical
tools
in
2003
,
we
have
only
small
screens
,
no
HD
,
no
3D
.
Now
I
cannot
imagine
how
I
could
do
the
surgery
at
that
time
.
And
as
I
record
everything
.
I
had
recorded
all
my
procedures
since
2005,
.
So
I
have
everything
recorded
on
hard
disk
.
When
I
go
back
to
these
movies
,
I
said
,
oh
my
God
,
it's
incredible
.
I
was
a
beginner
experience
and
I
could
do
this
surgery
with
good
results
using
these
tools
.
This
looks
to
me
unbelievable
now
,
because
now
I
carried
out
all
the
robotic
surgery
,
big
screen
,
this
.
So
our
,
this
or
our
operative
theater
is
very
high
technique
.
Speaker 2
49:55
But
this
was
not
the
same
20
years
ago
.
Then
the
strategies
,
the
strategies
to
manage
,
or
much
more
clear
for
everybody
,
the
,
the
knowledge
,
the
,
the
willing
to
do
to
increase
the
quality
of
life
,
was
not
.
We
were
not
speaking
about
this
in
2003
.
2003
,
the
goal
was
to
remove
everything
,
whatever
the
price
to
pay
.
Then
the
patient
were
having
self-catheterization
low
anterior
sexual
syndrome
.
I
remember
the
people
were
saying
,
yes
,
this
shows
that
it's
a
complex
surgery
,
right
?
Speaker 2
50:41
I
remember
in
2010
,
I
published
a
paper
in
Human
Reproduction
,
which
is
one
of
the
top
three
journals
in
the
world
in
gynecology
and
obstetrics
,
with
a
series
of
only
50
cases
of
colorectal
endometriosis
.
Because
in
these
50
cases
,
I
asked
a
question
which
was
not
asked
before
how
are
the
bowel
movements
after
my
surgery
?
Because
until
2010
,
if
you
look
at
all
the
articles
presenting
the
bowel
endometriosis
surgery
,
the
results
were
assessed
on
the
basis
of
dysmenorrhea
,
dyspareunia
,
chronic
pain
Right
,
which
are
not
directly
related
to
resecting
the
bowel
.
So
you
do
not
resect
the
bowel
and
to
say
I
resected
the
bowel
because
the
dysmenorrhea
improved
or
the
dyspareunia
improved
.
So
it
is
shocking
now
to
think
that
we
were
resecting
the
bowel
without
assessing
the
bowel
function
,
the
bowel
without
assessing
the
bowel
function
.
I
think
that
before
2010
,
only
the
papers
of
the
team
of
Marcello
Ciccaroni
was
assessing
this
dysfunction
and
then
,
after
2010
,
quality
of
life
,
the
function
,
the
low
anterior
recession
syndrome
become
.
So
I
think
the
patients
who
had
the
surgery
in
2005,
.
25
are
more
fortunate
than
those
who
had
the
surgery
in
2000
.
Speaker 1
52:01
I
look
back
at
my
first
surgery
,
which
was
in
2010
.
And
I
think
about
what
I
?
There
was
not
a
lot
even
spoken
about
endometriosis
back
then
for
my
first
surgery
and
of
course
I
had
ablation
because
that's
all
they
really
knew
in
the
area
that
I
was
at
and
I
didn't
know
any
different
.
And
even
looking
online
,
there
wasn't
a
lot
of
information
on
endometriosis
.
Speaker 1
52:24
So
I
think
like
looking
back
at
that
and
seeing
how
far
we've
come
with
social
media
and
seeing
how
you
know
good
,
bad
or
indifferent
,
right
,
like
we've
talked
about
.
But
I
think
the
awareness
aspect
of
it
has
gotten
so
much
better
and
I
do
think
that
we
can
get
there
from
the
surgeon
side
of
it
as
well
.
But
it's
gonna
take
a
lot
of
work
and
bringing
awareness
to
the
fact
that
not
every
surgeon
is
created
equal
and
we
should
have
a
higher
standard
for
our
surgeons
.
Speaker 1
52:56
And
that's
what's
really
tricky
too
,
because
,
you
know
,
access
to
care
is
also
a
big
barrier
to
a
lot
of
people
.
But
the
outcomes
in
what
you're
saying
,
the
outcome
of
,
you
know
,
quality
of
life
,
bowel
movements
,
everything
in
between
is
significantly
better
when
you
have
a
true
expert
doing
it
with
a
truly
multidisciplinary
team
,
not
just
two
or
three
extra
people
on
your
team
,
but
truly
a
multidisciplinary
approach
.
Speaker 2
53:24
What
it
has
always
also
changed
is
the
teaching
.
We
have
continuously
fellows
from
everywhere
here
in
Bordeaux
because
we
have
received
more
than
400
surgeons
from
all
continents
during
the
last
six
years
for
training
and
I
always
tell
them
you
cannot
imagine
how
you're
lucky
to
start
the
endometriosis
surgery
now
in
2025
,
because
you
have
a
lot
of
movies
,
a
lot
of
Me
.
For
example
,
I
have
a
YouTube
channel
with
1,000
surgical
procedures
explained
for
free
.
Wow
,
when
I
started
me
learning
the
surgery
,
I
had
only
one
VHS
cassette
with
a
surgery
done
by
Michel
Canis
and
this
cassette
I
think
I
saw
it
10
times
in
order
to
understand
each
step
.
Now
,
on
my
YouTube
channel
,
there
are
1,000
movies
you
can
visit
and
see
and
I
received
messages
on
the
movies
and
one
of
them
a
surgeon
from
Asia
,
I
think
.
He
said
you
cannot
imagine
the
number
of
patients
who
were
lucky
to
be
managed
by
a
surgeon
who
saw
your
movies
,
because
this
is
training
.
Speaker 2
54:39
Not
everybody
can
go
take
a
flight
,
pay
a
flight
,
pay
a
training
somewhere
,
but
everybody
can
look
at
the
computer
.
A
wall
surgery
in
full
time
with
my
explanation
.
I
do
a
lot
of
live
surgeries
everywhere
in
the
world
and
I
record
them
.
I
put
them
on
YouTube
.
So
someone
who's
in
I
don't
know
in
a
less
wealthy
country
can
look
this
surgery
live
surgery
at
.
It
has
been
in
the
room
of
the
Congress
.
This
is
something
very
new
,
and
that's
why
I'm
sure
that
the
number
of
good
surgeons
now
in
the
world
is
much
,
much
higher
than
20
Evolution of Endometriosis Treatment
Speaker 2
55:23
years
ago
.
And
this
is
the
big
,
big
change
.
Unfortunately
,
because
on
the
other
side
,
on
the
other
hand
,
I
think
that
the
prevalence
of
endometriosis
is
increasing
,
so
more
and
more
surgeons
to
treat
more
and
more
patients
.
Speaker 1
55:38
Yeah
,
yeah
,
and
that's
a
whole
.
That's
probably
like
a
whole
.
Nother
discussion
at
some
point
on
the
prevalence
of
it
now
,
as
opposed
to
even
20
years
ago
,
is
it
?
Are
we
just
more
aware
of
it
,
or
are
we
seeing
more
severe
disease
?
Speaker 2
55:52
Both
,
both
.
I
like
very
much
an
Italian
professor
,
Paolo
Vercellini
.
He's
a
very
,
very
,
very
clever
scientist
and
I
like
one
of
the
last
talk
because
what
he
said
joined
what
I
was
thinking
.
So
the
endometriosis
is
a
disease
of
the
modern
woman
.
Why
?
Because
it
is
disease
which
depends
on
the
number
of
periods
.
Women
have
never
had
so
many
periods
,
ovarian
cycles
during
their
life
,
during
the
whole
history
of
human
being
.
Speaker 1
56:28
Interesting
.
Speaker 2
56:29
And
Vercellini
compared
women
at
the
end
of
the
19th
century
to
women
today
.
So
in
the
19th
century
the
women
,
of
course
,
were
living
less
than
now
,
but
they
were
having
the
first
periods
at
16
,
15
,
16
years
.
Right
Now
we
have
10-year
,
11-year-old
.
Speaker 1
56:51
Yeah
.
Speaker 2
56:52
They
were
pregnant
earlier
.
Now
the
age
of
the
first
pregnancy
is
30
years
.
Dental
countries
they
were
pregnant
more
frequently
,
so
they
were
more
frequently
in
amenorrhea
related
to
pregnancies
.
Now
Occidental
women
have
one
or
two
children
,
rarely
three
.
The
breastfeeding
was
responsible
for
amenorrhea
too
,
for
each
child
for
two
years
on
average
,
while
now
women
go
to
work
and
the
breastfeeding
is
very
short
.
So
it
was
estimated
that
in
the
19th
century
at
the
end
of
the
19th
century
so
it's
the
time
of
when
Thomas
Edison
and
the
Eiffel
Tower
was
built
At
that
time
the
women
were
having
less
than
150
ovarian
cycles
during
their
life
,
while
now
we
have
450
,
500
.
So
only
the
number
of
cycles
explain
why
we
have
more
endometriosis
.
Because
there
are
these
conditions
to
have
an
endometriosis
,
to
have
periods
and
periods
and
periods
.
Then
we
have
,
of
course
,
we
have
the
pollution
which
may
impact
on
our
hormonal
system
.
We
have
a
lot
of
stimulation
for
infertility
because
the
infertility
is
going
down
.
So
we
need
more
and
more
.
So
there
is
a
kind
of
cocktail
of
factors
which
favor
the
prevalence
of
endometriosis
.
Speaker 1
58:22
Yeah
,
and
also
,
I
would
imagine
,
because
we
are
having
more
cycles
,
the
ovarian
reserve
as
we
get
older
,
when
we're
having
kids
.
A
lot
of
people
are
having
kids
older
,
their
ovarian
reserve
is
not
nearly
as
high
either
,
because
they've
had
more
cycles
.
So
it's
kind
of
this
looping
factor
of
things
that
is
contributing
to
probably
the
infertility
rates
,
along
with
the
endometriosis
rates
,
along
with
all
these
other
,
you
know
,
morbidities
of
sorts
.
Speaker 2
58:50
That's
why
I
think
it's
an
emergency
to
find
a
treatment
,
a
medical
treatment
for
endometriosis
.
Speaker 1
58:56
Yes
.
Speaker 2
58:57
A
medical
treatment
which
is
not
hormonal
,
which
may
destroy
the
cells
,
not
just
block
their
growth
by
blocking
the
ovarian
cycle
,
A
medical
treatment
without
side
effects
and
which
is
compatible
to
the
intention
of
pregnancy
.
We
need
it
because
I
think
the
surgeon
will
not
be
able
to
eradicate
this
disease
,
and
I
think
my
opinion
is
now
.
The
prevalence
of
endometriosis
is
increasing
,
but
once
this
therapy
will
be
available
and
I'm
sure
it
will
be
available
the
prevalence
will
decrease
,
decrease
and
maybe
within
50
years
the
surgeries
I
do
now
every
day
will
almost
disappear
.
Speaker 1
59:41
That
would
be
amazing
.
Speaker 2
59:42
Now
we
are
a
lot
of
surgeons
doing
complex
surgeries
.
Now
I
think
that
within
30
or
40
years
or
50
years
,
there
will
be
less
surgeons
because
there
will
be
less
cases
to
manage
surgically
.
I
hope
.
Speaker 1
59:56
I
hope
.
I
hope
that
is
the
case
.
I
really
do
For
so
many
reasons
.
I
hope
that
is
the
case
For
you
.
What
is
next
for
you
on
the
research
end
of
it
,
because
you've
done
some
amazing
work
already
,
but
you
know
there's
more
to
be
done
.
What
are
you
working
on
next
that
excites
you
?
Speaker 2
1:00:13
So
me
.
I
am
an
epidemiologist
,
so
my
clinical
trials
compare
treatments
,
compare
surgical
strategies
,
compare
results
,
estimate
the
results
,
assess
the
results
of
our
medical
treatment
.
But
the
research
,
the
research
,
the
general
research
in
endometriosis
should
develop
the
basic
research
in
order
to
identify
on
the
cells
,
or
endometriosis
cells
,
a
receptor
which
may
be
a
target
of
a
new
therapy
.
This
should
be
the
future
.
Unfortunately
,
I
won't
be
a
part
of
the
future
because
I
am
not
specialized
in
basic
science
,
specialized
in
basic
science
.
So
I
can
only
participate
,
be
involved
in
all
clinical
trials
,
because
we
have
a
high
volume
of
patients
who
are
always
asked
to
be
involved
in
trials
.
Right
,
but
I
hope
as
soon
as
possible
that
someone
may
identify
a
curative
treatment
,
medication
for
endometriosis
which
is
not
hormonal
,
because
the
hormones
will
never
cure
the
endometriosis
.
They
are
very
Future Directions and Final Thoughts
Speaker 2
1:01:18
helpful
,
they
help
us
a
lot
to
prevent
recurrences
after
the
surgery
,
but
we
cannot
cure
the
endometriosis
with
hormonal
treatments
.
Speaker 1
1:01:26
Right
,
yes
,
and
that
is
one
of
the
biggest
misconceptions
I
think
a
lot
of
people
have
,
especially
again
going
back
to
that
knowledge
base
of
just
someone
that
is
not
an
expert
.
Speaker 1
1:01:37
If
they're
just
trained
in
general
GYN
,
they're
not
trained
adequately
to
address
it
,
and
so
I
think
there's
a
lot
of
misconception
there
.
Speaker 1
1:01:44
But
I
do
think
that
narrative
is
changing
,
which
it
does
excite
me
as
someone
who
you
know
was
diagnosed
when
that
narrative
was
very
prevalent
,
and
so
I'm
excited
to
see
how
that
has
changed
and
how
it
continues
to
change
because
awareness
is
coming
to
the
surface
.
And
I'm
excited
also
to
see
how
new
doctors
are
coming
up
and
are
excited
to
help
patients
,
not
just
fall
into
a
system
of
putting
band-aids
on
these
patients
.
It's
becoming
less
desirable
to
just
clock
in
and
clock
out
for
work
and
for
surgeries
but
to
truly
help
these
patients
who
are
in
a
lot
of
pain
and
have
a
desire
to
grow
their
family
and
otherwise
.
So
I'm
excited
to
have
that
approach
of
seeing
the
right
provider
who
can
address
whether
it's
beneficial
to
surgically
manage
that
or
what
the
next
steps
would
be
with
IVF
or
otherwise
.
So
what
would
you
give
for
those
patients
who
may
be
hearing
this
for
the
first
time
,
they're
getting
a
glimpse
of
hope
in
potentially
growing
their
family
.
What
advice
would
you
give
them
?
Speaker 2
1:03:01
So
my
advice
would
be
to
look
for
real
,
actual
specialists
in
endometriosis
,
to
have
a
long-term
follow-up
.
Ask
a
long-term
follow-up
and
not
just
a
minute
treatment
because
unfortunately
,
in
most
of
cases
the
surgery
is
possibilities
to
look
for
good
center
,
the
expert
center
.
Expert
center
does
not
mean
centers
with
a
high
number
of
followers
on
Instagram
.
I
was
speaking
last
week
with
Marcello
Ceccaroni
,
who's
,
in
my
opinion
,
one
of
the
greatest
surgeons
of
endometriosis
in
the
world
.
We
agree
that
we
have
surgeons
hyper-specialized
in
endometriosis
and
surgeons
hyper-specialized
in
and
it
is
very
important
not
to
confound
them
.
Speaker 2
1:04:02
So
I
think
patients
can
look
for
,
can
seek
for
care
in
centers
with
high
volume
of
surgery
,
high
volume
and
good
results
on
not
on
Instagram
,
but
good
results
on
clinical
trials
yeah
and
I
think
they
they
have
to
keep
in
mind
that
we
have
a
chronic
disease
,
yeah
,
which
may
recur
until
the
menopause
,
and
they
have
to
ask
for
a
long-term
management
,
a
strategy
until
the
age
of
50
.
Each
step
should
have
,
each
therapeutic
step
should
have
a
look
at
the
age
of
50
.
Why
giving
a
medical
treatment
for
six
months
in
a
woman
of
25
years
has
no
sense
.
After
the
end
of
the
treatment
there
will
be
another
25
years
until
the
menopause
.
The
strategy
should
be
long-term
.
That's
why
I
don't
stop
to
repeat
this
If
you
propose
a
strategy
,
it
should
be
a
long-term
strategy
.
Yeah
,
yeah
,
take
care
,
patients
wish
.
Patients
complain
,
side
effects
of
the
treatments
Right
,
if
you
propose
a
treatment
with
side
effects
,
it
will
be
given
up
after
six
months
.
So
we'll
not
cover
20
years
after
the
middle
,
until
the
menopause
.
Speaker 1
1:05:30
So
I
think
,
I
think
patients
would
choose
,
should
choose
,
the
right
place
to
have
their
long-term
management
not
only
their
surgical
technique
but
their
knowledge
of
endometriosis
,
and
it's
not
just
like
a
one
surgery
once
a
month
.
I
think
that
you
know
again
,
that
goes
back
to
that
experience
getting
that
in
there
.
I
wish
I
would
have
known
that
you
know
back
in
the
when
I
first
started
this
journey
.
But
I'm
glad
that
I
can
spread
this
awareness
to
others
so
that
they
can
have
a
better
outcome
from
the
beginning
,
not
not
try
to
catch
up
along
the
way
.
Speaker 1
1:06:17
So
it's
doctors
like
you
that
are
changing
this
for
so
many
patients
and
,
as
a
patient
,
I
am
very
grateful
to
providers
like
you
and
researchers
like
you
that
are
not
allowing
the
status
quo
to
be
stagnant
and
to
continue
to
push
the
barriers
of
endometriosis
care
and
knowledge
.
I
am
grateful
.
I'm
grateful
for
that
for
my
kids
,
if
they
end
up
having
endometriosis
,
so
that
I
have
some
.
I
have
those
resources
available
now
.
So
this
is
huge
for
not
only
future
doctors
but
for
patients
,
and
so
thank
you
for
that
.
Thank
you
for
taking
your
time
to
spread
the
awareness
,
for
the
education
that
you
give
not
only
the
doctors
but
to
the
patients
.
It
means
the
world
to
us
to
have
you
in
our
corner
.
So
thank
you
so
much
for
doing
that
.
Speaker 2
1:07:07
Thank
you
very
much
and
I
was
delighted
to
exchange
with
you
.
Speaker 1
1:07:10
Yes
,
yes
,
anytime
.
You're
welcome
anytime
.
No-transcript
.
Speaker 2
1:07:38
Congratulations
for
everything
you're
doing
.
Thank
you
For
spreading
information
,
for
spreading
hope
,
because
I
think
that
the
conclusion
of
our
exchange
is
that
patients
should
be
confident
.
So
the
endometriosis
is
not
a
disaster
if
we
can
take
care
about
patients
early
and
do
the
right
strategy
very
early
,
when
they
are
very
young
.
Honestly
,
I
always
spread
information
which
is
encouraging
and
the
results
are
encouraging
.
A
woman
should
keep
the
hope
and
never
,
never
give
up
.
Speaker 1
1:08:18
Yeah
,
I
agree
,
I
think
there
is
,
and
we
can
always
make
a
situation
into
something
better
,
and
that's
what
I
have
chosen
to
do
,
and
I
really
think
that
empowers
me
to
continue
advocating
in
my
journey
,
which
I
love
.
So
thank
you
so
much
,
professor
Ramon
,
for
taking
the
time
and
sitting
down
with
me
.
I
just
appreciate
you
so
much
.
Thank
you
,
thank
you
very
much
.
Thank
you
Until
next
time
.
Everyone
continue
advocating
for
you
and
for
others
.