The Fertility Revolution: How Endometriosis Surgery Changes Pregnancy Outcomes With Prof. Horace Roman

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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.

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Episode Transcript

Speaker 1 (00:00):
What if surgery, not just IVF, could make the
difference in your fertilityjourney with endometriosis?
In this episode of EndoBattery,I sit down with Professor
Horace Ramon, a world-renownedsurgeon and researcher, to talk
about his groundbreaking studieson fertility after
endometriosis surgery.
His research showed that nearlyhalf of women with colorectal

(00:21):
endometriosis were able toconceive naturally after surgery
and, for women who had gonethrough multiple rounds of IVF,
excision surgery gave many ofthem their first chance at
pregnancy.
This conversation is about morethan numbers.
It's about hope, options andthe power of treating
endometriosis at its root.

(00:41):
Tune in as I sit down withProfessor Horace Ramon to go
over all his work and so muchmore.
Stick around.
Welcome to EndoBattery, where Ishare my journey with
endometriosis and chronicillness, while learning and
growing along the way.
This podcast is not asubstitute for medical advice,

(01:02):
but a supportive space toprovide community and valuable
information, so you never haveto face this journey alone.
We embrace a range ofperspectives that may not always
align with our own, believingthat open dialogue helps us grow
and gain new tools.
Join me as I share stories ofstrength, resilience and hope,
from personal experiences toexpert insights.
I'm your host, alana, and thisis Endobattery charging our

(01:26):
lives when endometriosis drainsus.
Welcome to Endobattery.
Grab your cup of coffee or yourcup of tea and join me at the
table Today.
I am so honored to welcomeProfessor Horace Ramon, a
world-renowned surgeon andresearcher in the field of
endometriosis.
Professor Ramon has publishedsome of the most impactful

(01:51):
studies we have on fertilityoutcomes after surgery for deep
colorectal endometriosis.
His work has changed how wethink about the relationship
between endometriosis, excisionsurgery and pregnancy rates,
especially for patients who havestruggled with multiple failed
IVF attempts.
We're going to explore thattoday in a way that gives hope,
clarity and practical insightsto those navigating this journey

(02:13):
.
Please help me in welcomingProfessor Horace Ramon to the
table.
Thank you, professor Ramon, somuch for sitting down with me
and taking the time to help usunderstand some great work that
you're doing in theendometriosis space, as well as
understanding excision andendometriosis as it stands.
It is a complete honor for meto be able to sit down with you

(02:36):
and take this time and learnfrom you, so thank you so much.

Speaker 2 (02:39):
Thank you very much for inviting me.

Speaker 1 (02:41):
Anytime.
It's an honor for anyone to beable to sit in this space and
learn from one of the best inthe world in endometriosis
excision and you also teachendometriosis excision.
Can you start by telling uswhat inspired your focus on
endometriosis and fertility, andparticularly in complex cases

(03:02):
like colorectal and deepinfiltrating endometriosis and
fertility, and particularly incomplex cases like colorectal
and deep infiltratingendometriosis?

Speaker 2 (03:07):
Yes, so my story started in 2003 when I
discovered endometriosis, and atthat moment I was in the fifth
year of residency.
So I discovered this diseasevery, very late because it was
unknown.
Very, very few gynecologistswere aware about endometriosis

(03:29):
at that time and I had thechance to work with Professor
Michel Canis, the past presidentof the AAGL, and I saw him
performing this surgery and Ifell in love with the surgery of
endometriosis.
Before being gynecologist, Ihad the training in colorectal
surgery and in neurosurgery.

(03:50):
So I was four years, I had beena resident in neurosurgery.
So I was looking for aninteresting and exciting and
complex surgery in gynecologyand also I was looking for a
field where the research is notas developed and where I can

(04:11):
bring my contribution to thedevelopment of the knowledge.
And the endometriosis meets allthese criteria.
I stated that I will be anendometriosis surgeon in 2005.
And at that moment most of mycolleagues were surprised
because they did not understandwhat actually I want to do,
because for them endometriosiswas PO and generate analogs, and

(04:35):
me I said no, no, no,endometriosis is surgery, and I
started doing surgery in 2005.

Speaker 1 (04:41):
Wow, it's shifted and changed so much.
But one of the things that Ireally feel like is progressing
and is amazing is the work thatyou're doing to help many people
understand endometriosis muchbetter.
One of the articles that youpublished the high postoperative
fertility rate followingsurgical management of

(05:02):
colorectal endometriosispatients.
This study, when I initiallylooked at it, kind of threw me
for a little bit because I wouldhave never in a million years
correlated what your findingswere, which is fertility rates
and colorectal endometriosis.
Can you go over this study justa little bit and break this

(05:23):
down for people to understandkind of what this study entailed
, as well as what some of thesefindings were?

Speaker 2 (05:31):
Yes, now I will start with the onset.
So you have to know that in2008, I became a PhD in
epidemiology and clinicalstudies.
So I accomplished this PhD inorder to have the tools to
perform good level clinicalstudies and in 2009, I could

(05:53):
have a grant to open a largedatabase and to enroll
prospectively all my patients.
So since 2009, I have had withme a clinical researcher, which
is not involved in care but onlyin the management of the
database.
So this clinical researcher nowI have two clinical researchers

(06:14):
because the database is larger,but I always have had someone
taking care, giving preoperativequestionnaires to patients
taking care.
That may, I feel a surgicalquestionnaire and then calling
the patients one year, threeyears, five years, 10 years
after the surgery to see what'shappened during this interval.

(06:37):
It means that I have a databasewith now I think we have 5,000,
6,000 women who had surgerywell-done surgery, excisional
surgery with a follow-up whichnow is 15 years the oldest
patients have 15 years offollow-up and we have just today
submitted an article about 15years follow-up after colorectal

(07:01):
endometriosis surgery yearsfollow-up after colorectal
endometriosis surgery.
So this database allows me tostudy everything
post-operatively, what'shappened after the surgery, and
it also allows me to see thereal number, the real percentage
who is pregnant and who is not,how the pregnancy is achieved,

(07:24):
how long time after the surgery.
And I could, in this case Icould, publish studies which
show that after the surgery ofmost advanced, most complex
endometriosis, the pregnancyrate is very high.
And this happened at a momentwhere a lot of colleagues, a lot
of gynecologists, were tellingto patients don't have surgery

(07:46):
because you will be infertile.
And my answer was no.
Conversely, if you want to bepregnant, please consider the
surgery as a treatment of yourinfertility.
And of course, all my studiestry to put in the mirror
pregnancy rate in women who haveno surgery and have only IVF

(08:07):
with women who have surgery.
And I could demonstrate thatwomen with surgical management
of endometriosis have at leastthe same pregnancy rate that
women who have up to four IVFsuccessive IVF.
And right now in the worldthere are two randomized trials
comparing in a random manner,comparing IVF to the surgery.

(08:31):
One of them is in France,endofert, and the other one is
Bordeaux and Denmark it calls F4.
So I am involved in bothstudies, I recruit for both
studies because both studies thehypothesis is based on my data
and both studies try to showthat the pregnancy rate after

(08:53):
the surgery with naturalconception or post-operative IVF
, this pregnancy rate is betterthan in women who have no
surgery and are sent directly toIVF.
Wow, but the surgery is like theSoxer, like everything else.
Better than in women who haveno surgery and are sent directly
to IVF.
Wow, but the surgery is likethe sockser, like everything
else.
So surgery is not.
We cannot speak about surgery.
We speak about surgeons whoperform surgery.

(09:16):
So some surgical procedures mayrender the patients infertile
if the surgeon does not takecare at ovaries.
So we have a myriad of patientswho had cystectomy, bilateral
cystectomy, and their ovarianreserve went down at the point

(09:36):
that no IVF, nothing is feasible.
So the surgery is a very goodtool to improve fertility when
the surgeon takes care of whathe level, whereas not everyone
is.

Speaker 1 (10:07):
Does that change the fertility rate for those
patients depending on theirsurgeon'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 thatfootball players do not play
alike.
So you have Messi, ronaldo andPelé they are stars and then
there are other guys who playthe Soxer less and have less

(10:39):
results.
But the surgery is alike.
So you cannot, in some casesyou cannot compare the results
between several surgeons.
That's why all the studiesreporting results of the surgery
should be read from the firstrow to the last one, and to see
who performed the surgery, whoare the surgeons, where is the

(11:02):
center.
For example, the results interms of fertility after a
surgery done by the team ofMarcello Ceccaroni in the Negrar
Hospital in Italy, which is thebiggest endometriosis center in
the world, cannot be the samewith the results performed in
the hospital in a small town,even though in theory there is

(11:24):
the same surgery.
So it is politically correct tosay, yes, we are all at the
same level, but in theory thereis not.
That is not true.
So a good surgery for me inendometriosis takes care to the
excision which is done dependingon several factors on patient's
age, intention to get pregnant,features of the lesion, but

(11:47):
also, or more than the features,the symptoms which are related
to each lesions.
I think that a good surgeryshould completely excise all the
lesions which are symptomatic,while lesions who are not
symptomatic should be discusedcase by case.
Some of them can be removed andsome of them cannot be removed

(12:09):
or can be left behind if theprice to pay for this excision
is high.
In other terms, if one patientcomes with me, I receive a lot
of emails from patients wherethey sent me a picture with a
big nodule of the rectum andthey said what I have to do.
And my answer is I don't know,because with this nodule you can

(12:30):
have the surgery or you cannothaving the surgery.
It depends what do you feel?
Because if you have a bignodule of the rectum and the
patient is completelyasymptomatic by chance, it is
for sure that performing thesurgery increased the risk that
patient became symptomatic afterthe surgery.
So there are some I think I haveat least 10 or 15 patients with

(12:55):
very severe endometriosis and Isee them every year.
I tell them the surgery isjustified if you have just one
symptom.
And I ask them every year doyou have a symptom or you're
still asymptomatic?
They say I'm still asymptomatic.
Okay, see you next year.
So this is the philosophy ofendometriosis.
So the endometriosis is not acancer and should not be treated

(13:17):
like a cancer If the patientshould have a better quality of
life.
It means that you havecarefully to treat all the
lesions with or symptomatic, andyou have to take care at the
resection excision of lesionswhich are not symptomatic in
order to avoid new symptomswhich are sequelae of your
surgery.

(13:37):
And this is the same onfallopian tubes and on ovaries.

Speaker 1 (13:40):
It's kind of like essentially saying you're going
to eradicate lesions that arecreating 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'repointing to being valuable in
surgery?

Speaker 2 (13:59):
Exactly so.
A very interesting informationabout the postoperative
pregnancy rate after complexsurgery for deep endometriosis
was provided by a randomizedtrial.
I carried conservative toradical surgery for colorectal
endometriosis and the goal, themain endpoint, was the bowel

(14:32):
function after the surgery.
So the goal of the trial was toprove that if we perform disc
excision or shaving, you havethe same results than those
after colorectal resection,maybe with less complications
and with the same rate ofrecurrences.
So I enrolled 60 patients andthese 60 patients I carefully

(14:57):
followed them up at six months,one year, up to 10 years.
So this woman, this 60 woman, Iknow them as they were from my
family Because I met them sofrequently.
And 10 years after the surgery,the rate of loss of follow-up
is 9%, meaning that more than90% of patients came up to 10

(15:21):
years to tell me how they feel.
And I observed that among thiswoman who all had a very
advanced surgery with colorectalresection, parametrium
reimplantation of the ureter,very, very severe surgery After
the surgery, among the patientswho intended to get pregnant,
80% could be pregnant, and mostof them naturally.

(15:42):
And then I looked at inside thewoman who were pregnant, I
looked at who was infertilebefore my surgery, who came to
the surgery with the sticker ofinfertile need IVF, and in this
subgroup of women infertilewomen who had complex surgery
for correct endometriosis thepregnancy rate was 75%.

(16:07):
Wow, and even in this groupmost pregnancies were natural.
And for me, this study, withactually no loss of follow-up,
with very accurate long-termfollow-up, this study provided
me that proved me that thesurgery for complex
endometriosis improves thefertility rate.

(16:29):
And I put these results in themirror with studies done by two
friends of me, two Frenchfriends from other hospitals,
who reported the pregnancy ratein women with severe corrector
endometriosis who had no surgerybut only IVF, and both of them
estimated that if women withcolorectal surgery have 1, 2, 3,

(16:53):
or 4 IVF, they can be pregnantin 60-65% of cases, all
pregnancies or IVF.
Now, it is difficult to compare80% to 65% in two different
populations.
Right, I cannot state that mypregnancy rate is higher than

(17:14):
the pregnancy rate of the IVF,but I can state that if you
perform a complete surgery ofendometriosis, the patients will
feel better in the long runbecause 10 years after the
surgery they are still in goodshape.
The complaints are improved inthe long run.
Currency's rate on the rectum10 years after the surgery is 5%

(17:37):
and they were pregnant in 80%of cases.
So at least the same rate youmay have in the same patients
without surgery, with symptoms,with big lesions, bigger and
bigger, once one, two, three orfour IVFs are done.
So this allows me to state thatif you do a correct surgery,

(18:02):
there's no reason to befrightened by the risk of
infertility because you have.
Conversely, you have theopposite result you improve the
fertility.
This may happen even in womenwith low ovarian reserve.

Speaker 1 (18:14):
Wow, why do you think doing surgery in those patients
who had bowel or colorectalsurgery for endometriosis had
such a significant improvementin fertility?
What would cause that?

Speaker 2 (18:26):
Well, we do not know exactly If the patient has a
bowel endometriosis togetherwith ovarian fallopian tube
endometriosis.
It is obvious that removing thebowel endometriosis, together
with restoring the fallopiantube patency and removing the
ovarian cyst, of course, itimproves the fertility Right.
You may have infertile womenwith bowel endometriosis and the

(18:51):
fallopian tubes are almostnormal and the ovaries are
involved by only superficiallesions.
In this case, after the surgery, I am almost sure that they
will be pregnant naturally and Ithink that in this case the
endometriosis impaired thepregnancy in an indirect manner,
because it had beendemonstrated that endometriosis,

(19:13):
like the smoke, may affect thefertility at every level,
beginning with the quality ofthe oocyte, with the mobility of
the sperm, with theinflammatory ambience of the
pelvis where the meeting betweenthe spermatozoa and ovocytes

(19:33):
occurs.
So at every level endometriosismay reduce the probability of
pregnancy and I think thatcleaning the pelvis we give a
supplementary chance for naturalpregnancy.

Speaker 1 (19:48):
It's a remarkable finding.
I feel like a lot of uswouldn't have put those two
together, Although I think in alot of ways it makes sense,
because the more your body isfighting against itself and has
a diseased state, it would makesense that it's harder to become
pregnant.
It's not your body's not at itsoptimal.

Speaker 2 (20:08):
Then there is another factor of infertility, of
natural conception, which is thedeep dyspareunia we do not
speak about.
We do not speak enough aboutdeep dyspareunia.
But women with big rectovaginalnodules have less sex than
women who are not painful of agenital nodule, have less sex
than women who are not painful,and they may be painful, more

(20:32):
painful, during exactly thethree days of ovulation.
At that time they reduce thefrequency of sexual intercourse.
They may be involved too in abetter, in an improvement of
natural conception rate.

Speaker 1 (20:39):
Yeah, well, and it makes sense, with the
inflammation that we experienceoftentimes during our cycle and
when we're in a flare, why thatwould be so much harder.
And eradicating that disease isso important for that conception
, so your body can functionnormally and not have the
inflammation.
It makes a lot of sense fromthat perspective.

(21:00):
There was another study thatyou did which I think is
interesting because you touchedon the IVF and you know women
who had IVF previously maybe hadfailed IVF.
You did another study ofpregnancy rates after surgical
treatment of deep infiltratingendometriosis in infertile
patients with at least twoprevious IVF ICSI failures.

(21:24):
Can you touch on that?
Because I think a lot of peopledon't really know do they want
to try IVF first?
Do they want to potentiallylook at excision for
endometriosis first, and whatare the pros and cons of that?
But this study kind of lookedat 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 deependometriosis, and someone else
decided to refer them to IVF.
What's happened in France?
Four IVF or reimbursed, so forfree, wow.
So, as women know that theyhave four IVF for free, when
they have the second and thethird IVF failure, they think

(22:03):
about let's do somethingdifferent for the last one,
because after that it is notlonger for free.
So I have a lot of patientscoming to seek care and to ask
about their endometriosismanagement.
Once they had two or three IVFand I asked I was a professor in
Rouen at that time.
It was in 2016, I think 10 yearsago and I asked one of my

(22:26):
residents which was veryinterested in fertility.
I said let's look at all ourpatients who come with at least
two IVF.
Let's see if we do the surgery,what's happened after?
Anyway, as the patients arerecorded in our database, we can
very easily see what's happenedafter our surgery.
Right, and actually we put thethreshold to two IVF, but the

(22:53):
mean number of IVF in our Syriawas three, because the patients
go up to the four IVF and theycome to do something before the
fourth IVF, which is the lastone, which is reimbursed come to
do something before the fourthIVF, which is the last one which
is reimbursed.
So after three IVF failures,performing the surgery was
followed by a pregnancy rate of45%.

(23:13):
Now, 45% of course is very farfrom 80%, but let's put in the
mirror the results which can beexpected if the patients with
three failure do the fourth IVF.
And we have this information inthe studies I talk to you where
the patients did not have, inother facilities, in Cochin and

(23:35):
Tenron Hospital in Paris, wherethe patients went up to four IVF
without having surgeries.
In this study you see very, veryclearly that women who still
have colorectal endometriosisand go to IVF have a pregnancy
rate of about 35% after thefirst IVF.

(23:56):
Then if they go to the secondIVF 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 freeIVF, it means that something
happens, something does not workRight.

(24:17):
We should compare our 40%, 45%pregnancy rate, not to 80% but
to 5%, which would have beenexpected if the patient had had
the fourth IVF after threefailures.
So even in this patient, inthis patient, I think we can

(24:38):
improve something.
That's why, in our dailypractice patients who had two
IVF failures.
We discuss them in ourmultidisciplinary meeting and in
a majority of cases we proposethe surgery before the last two
IVFs.

Speaker 1 (24:54):
For the IVF piece of it.
I think a lot of people feellike that is their first line of
defense for infertility.
And you're saying that when yougo and have endometriosis
excision surgery by an expert,your chances even of naturally
conceiving are much, much higher.
And then if you do IVF, yourchances of conception are even

(25:18):
higher than if you would havejust 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 andthen you go to natural
conception or to IVF.
If the fallopian tubes aredestroyed or if you do not
achieve natural conception afterone year, you go to IVF.
So all these solutions takentogether 80% of pregnancy rate

(25:43):
in my series of patients, withactually no loss of follow-up.

Speaker 1 (25:47):
Wow.

Speaker 2 (25:48):
That's a huge.
But now the situation is moredifficult and this is just a
samurai.
We samurais, but we use everycase in our multidisciplinary
meeting.
Because if a woman has comewith an ovarian reserve which is
very, very, very, very low,almost zero, of course you can

(26:09):
do whatever you wish.
The results will not besatisfactory.
They can be pregnant, but thepregnancy rate is much lower.
If the husband has a spermwhich is completely abnormal,
naturally or IVF by IVF, it willbe difficult.
So but if you put everybody,all the patients, together, we

(26:31):
expect to have higher pregnancyrate.
And the two randomized trialswhich are ongoing right now have
the same hypothesis that in thegroup of surgery you expect a
higher pregnancy rate than inthe group of only IVF.
So we speak about pregnancy rate, but then we have to speak also
about the complaints the riskof growth of endometriosis

(26:56):
during the time necessary forIVF, risk of complication you
may expect after a big nodulewhen compared to a smaller
nodule you could have removedthree years earlier.
So all these factors takentogether, that in my daily

(27:17):
practice, if I see a patientwith infertility and severe
endometriosis, in theory 80% ofpatients receive a surgery and
20% are referred for the IVF.
So I can refer for the IVF apatient who has a deep
endometriosis but she's notsymptomatic Two ovarian
endometriomas, fallopian tubeswhich are not in good shape, so

(27:39):
the natural pregnancy is veryunlikely, and a husband with
abnormal sperm.
So here, when I expect thatthis patient needs an IVF, I
give her the choice for IVF andif she's not very symptomatic,
it is logically not to perform asurgery with risk of functional

(27:59):
sequeira and to propose her tostart by IVF sequeira and to
propose her to start by IVF.
And then for patients who tellme immediately my first goal is
the pregnancy and I want to goto the IVF, I just want to tell,
I just want to hear from you ifit is risky to do this.

Speaker 1 (28:20):
So there's like there's this balance between
starting IVF first and then ordoing surgical management first,
yes, and the surgicalmanagement 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 endometriosissuboclusive endometriosis, very
severe endometriosis,suboclusive endometriosis.
If I have a patient with a bigrectovaginal nodule which is
still feasible, where the discexcision is still feasible but
where the growth of the nodulewould require a low rectal

(28:57):
resection, in these patients Iadvise the surgery because I
said, look, if you do one orthree IVF and you come back
within two years and this noduleis bigger, we're not longer
able to do this conservativesurgery.
I am able to do this today andmaybe we will go to the more
aggressive surgery and the priceto pay may be a lower

(29:18):
acceleratory action syndromewith bowel sequeira, which are
related to the surgery, becausethe surgery should be done.
So I think it's in yourinterest to go to the surgery
right now because anyway I willtake care of your ovaries.
So it's happened, for example,that in this woman, if they have
bilateral endometriomas, thefallopian tubes are not in good

(29:41):
shape and during the surgery Iknow that they need an IVF.
After my surgery I may simplydrain the ovaries not to excise.
So I can excise everythingeverywhere, diaphragm everything
except the ovaries.
So for the ovaries I may put inthe front the pregnancy
intention and the preservationof the ovarian reserve.

(30:02):
It seems for me more importantthan the complete excision of
endometriomas Interesting.
We may combine this.

Speaker 1 (30:10):
Interesting.
You know, I've always heardthat you want to take everything
out regardless.

Speaker 2 (30:15):
Yes, in theory.
In theory, very specific cases.
For example, if you have apatient, painful patient, right,
let's say, 25-year year old,very painful, you see her, she
has an eight centimeterendometrioma on the right side,
a four centimeter endometriomaon the left side.
She's single.
So you cannot refer her for IVF.

(30:36):
She's painful, you have to dothe surgery.
The best attitude is not toremove the endometrioma, is not
to remove the endometrioma.
So in this patient, if someonegoes to remove, to excise the
endometriomas, the ovarianreserve will go down.
So I think the excision shouldbe forbidden under the jail.
You do this under the jail, I'mjoking.

(30:58):
It should be forbidden by thelaw.
In this patient you can do thesurgery to relieve the symptoms.
You can do a sclerotherapy or adrainage on both ovaries.
You reduce, evacuate the cyst.
You refer immediately thepatient to ovocet freezing.
You introduce a pill in orderto avoid that at the first

(31:22):
period the cyst come back Right.
So you freeze 15 or 20 OOCs andthen 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 chooseyour 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 youhave patients coming in saying I
want children, I'm not thereyet, but my endometriosis is bad
enough, I just need symptomrelief.
This is an avenue in which theycould go.
In these circumstances, do youhave them freeze their ovocytes

(32:04):
and then do you have hormonalsuppression 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 whohad, who have have already
frozen.
They all there, right woman.
Most of them will never needtheir OC because then the
surgery I did preserved ovarianreserve so they will be pregnant
naturally.
But the ovarian ovocet freezingis necessary when you have a

(32:33):
single woman, young, with goodovarian reserve and bilateral
big endometriomas.
Ovarian situation.
Second situation you have apatient with subocclusion
because of the big nodule of therectum.
She wants to get pregnant.
She is at the limit of theocclusion.
So you have to do the surgerybecause stimulating, doing an
IVF on a subocclusive lesion maypush definitively the patient

(32:57):
into occlusion.
It has been demonstrated.
I had patients like this.
So after the surgery, but shehas two big endometriomas on
each ovary.
In this case if you do acomplete excision move the
ovarian bowel endometriosis,deep endometriosis and ovarian
endometriomas the ovarianreserve will go down and this is
definitively lost.

(33:18):
So in this case I start bylooking at the fallopian tube.
If the fallopian tube, if thefallopian tube are in good shape
and if I estimated at the endof the surgery I could clean
everything, she can go to thenatural conception.
The natural conception islikely In this case.

(33:40):
I do a very careful cystectomyon each side.
Her reserve is good before thesurgery.
If the reserve is low or if thefallopian tubes are not in good
shape shape and I'm sure thatshe needs an IVF I certainly
won't remove the endometriomasby excision because the ovarian
reserve will go down and the IVFwill fail.
It is important to understandthat a patient who needs an IVF

(34:05):
needs a good ovarian reserve.
Right, it requires a goodovarian reserve.
The stimulation requires a goodovarian reserve.
The same patient if she goes tothe 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 ovarianreserve after the surgery may be
pregnant naturally in the samemanner as women with normal
ovarian reserve.
But if the IVF is most likelyit 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 Iwas going to say the experience
of the surgeon and the cultureof the surgeon.
That's why it's very difficultto standardize everything in
endometriosis and that's whyit's very difficult to create, I
think, software of artificialintelligency 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 thatnot every surgeon would even
consider or even know about,because it takes years of really
integrating yourself, not onlyon the surgical side of things
but also the academic andresearch side of things, to
really, I think, understandprobably some of the nuances of

(35:24):
fertility and endometriosis.
So I think that's probably oneof the things that I hear a lot
of people talk about is, youknow, 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, becausethis is what we do.
This is all I know.

(35:45):
You know, you hear aboutproviders 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, ifwe have data Right.
So in this case, unfortunately,the patient falls between two

(36:19):
studies, two results, and youhave to do with what you feel,
with what you smell, and thisbecomes difficult and that's why
I think there are 15 years Ihave stated that the
endometriosis surgery should bea subspecialty, and in 2011,.

(36:40):
So in 2005, I decided to becomean endometriosis surgeon, but
until 2011, of course, I alsodid over cancer and
sacro-colpo-pexi, but in 2011, Icould afford to stop all over
surgeries until I was havingenough endometriosis patients to

(37:02):
fill in all my program and notto take care about other
specialties.
And I think that at that momentI started understanding much
deeper everything.
Well, for example, in France butworldwide, there is a
discussion about what policy wehave to adopt.
Should we create expert centers?

(37:22):
Should we?
And if we create expert center,where we have to put the
threshold Volume of surgery, youneed to state I am expert, and
when this discussion is donewith colleagues, of course each
one tried to push the thresholddown below his level and they

(37:43):
say no, it is not demonstratedthat doing only this make you
better than having a moregeneralistic practice.
And I said I cannot agree withthis Because if I agree, if I
say you're right, it meanseverything I have done during
the last 15 years is for nothing, because I decided to do only

(38:05):
this.
If I consider that I could begood enough by doing only one
corrective endometriosis a monthonce now I'm doing 30, it means
I was completely wrong ineverything I have done.
So I was not right at all and Ibelieve I was right.

Speaker 1 (38:22):
Yeah, you know I equate this to you know, had a
lot of dental work done a whileback and I think of it like this
, and this is the best way thatI've been able to explain this
to people Dental, you have yourgeneral dentist.
They are good for yourcleanings, they're good for, you
know, just dental maintenance,right, and that's your general
GYN or family practitioner.

(38:44):
And then if there's somethingmore that needs to be done say
you need there's an infection orthere's something crowding of
your teeth, then you go see theorthodontist for the braces,
right?
So it's a different specialty,although maybe the orthodontist
could clean the teeth or youknow the dentist could, you know
, look at the infection, whoknows?
But then they say you need toremove your teeth, a tooth, well

(39:08):
, you have to go to the surgeon,you have to go to the
endodontist and you have to.
So there's so many differentsteps depending on what you need
done when it comes to dentalwork.
Yet there is not that when itcomes to endometriosis.

Speaker 2 (39:24):
We make it such a broad specialty if you will
Exactly, and this was happening30 years ago in cancer Right.
20 years ago it was stated onlythose who have a volume of
cancer surgery are allowed to dothis cancer, to continue to do
cancer surgery.

(39:45):
Right, it was very, verydifficult to make people to
accept they could not be goodenough to perform cancer surgery
but in two or three years thelow was should be agreed by
everybody, but it was verydifficult.

Speaker 1 (40:00):
Yeah.

Speaker 2 (40:00):
The problem is in cancer.
If you have worse results, youcan see immediately because the
survival rate is low.
Endometriosis is much moredifficult because the patient
will not die, they will just bepainful.
So it is very, very difficultin 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 manland, Right yeah, a confusion,
because they allowed the surgeonto say I can do this.
I can do this Because in socialmedia, everybody, everybody may
seem more beautiful than itreally is.

Speaker 1 (40:53):
Yeah, yeah, it is true.
I mean, I think there's a lotof times if the words look fancy
and the picture matches theword of fancy, then they must be
qualified and that is justsimply not true.
I think that's where a lot oftimes, our eyes can deceive us a
little bit on who we think isan actual surgeon and expert in

(41:13):
that field, and that's where Ithink due diligence is essential
.
Understanding how long someonehas done something, where their
training has been done, whattheir training is specifically
in, I think makes a hugedifference.
And it's not just fellowshiptrained, it's actual, like
integrative training and havinga large number of cases in your

(41:36):
repertoire before you can reallyExactly A large number of cases
and enough number of procedures, of complex procedures.
Yes.

Speaker 2 (41:47):
And we now.
We think that to state thatsomeone is has a high level in
endometriosis, it needs shouldperform at least one, at least
20 complex surgery a year.
When I proposed 40, then I wentdown to 20 in France and there
are a lot of colleagues who saidno, 20 is too much.

(42:08):
I said no, 20 means one complexsurgery every two weeks.
Like surgery every two weeks isnot too much.
And they said no, like this,you have to.
You have to put the thresholdat your level.
I said no, this was my level in2007, not now.

Speaker 1 (42:24):
Wow.

Speaker 2 (42:25):
So so the converse.
I think one complex surgeryevery two weeks is the minimal.
Feel yourself comfortable withthe complex surgery.

Speaker 1 (42:34):
Yeah, what qualifies something as a complex surgery?
I think that might be somethingthat could be a differentiating
factor, because some mightthink, you know, having a bowel
lesion is a complex surgery.
To you, what would be a complexsurgery?

Speaker 2 (42:48):
To state that something is complex surgery,
you need some criteria whichcannot be fancy, which should be
real.
One such criteria is the bowelsuture.
You need to perform a bowelsuture.
Nobody will do a bowel suturejust for the fun because a bowel
suture.
Nobody will do a bowel suturejust for the fun, because a
bowel suture is a riskyprocedure.

(43:09):
So a complex surgery for me andin what I propose in France, is
performing either a suture ofthe bowel, either a suture of
the ureter, either a suture ofthe diaphragm, either a complete
releasing, a completeneuralysis of the sci suture.

(43:31):
But the bladder is easier.
So you should not be very, veryexpert to be able to remove a
bladder nodule.
But these procedures have avery specific code and nobody,
nobody, even someone which isnot honest at all, will not do
it just for the fun and just toreach the number.
So they are procedures whichare required by a complex

(43:57):
situation, a complexendometriosis.

Speaker 1 (44:00):
Yeah, and you definitely want someone that
knows what they're doing whenthey're doing that, because it
could really damage the outcomeof not only longevity and pain
relief, but also, as we weretalking about, fertility, and
that's why having an expert whounderstands not only the
fertility aspect of it but alsothe endometriosis aspect of it

(44:20):
is really important to have both.

Speaker 2 (44:23):
And to state that your center is a
multi-discipline.
Now it's very interestingbecause in 2019, we have the
visit of the Surgical ReviewCorporation, because we asked to
have the certification ofCenter of Excellence in
minimally gynecological surgerybasic gynecological surgery and

(44:43):
we had an inspector who came andsee us and then the end of the
day, when she checked everythinga whole day of visit she said
it's very funny, but you haveonly one disease, you take care
only about one disease.
I said because you are inendometriosis center.
She said I have never seen this, but do you think we can create

(45:04):
a certification forendometriosis centers?
We said, of course, yeah, weare thinking about this and we
propose her the threshold,taking care not to put them very
, very high because the interestis to recruit.
That's why and honestly, nowthe Surgical Review Corporation
certification for complexendometriosis care and the

(45:25):
multisignal endometriosis careis based on our center.
It's the middle of our centerand 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,

(45:47):
a physician specialized in painmanagement Very, very important
the pain management specialistand then, of course,
physiotherapist and a very goodradiologist.
So all team and this teamshould meet together at least
once a month to discuss maybenot all the folders, because we

(46:08):
carry out 100 endometriosissurgeries a month, so you can do
stuff to discuss 100 medicalcharts, 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 wediscuss the most complex cases

(46:30):
and we choose this we spokeabout should the patient go
directly to IVF?
Should go to the surgery?
If we propose the surgery, whatkind of surgery we propose?
What we remove, exactly what wedo not remove, what we drain,
what we excise, so we'll do arobotic surgery.

Speaker 1 (46:49):
And then after that discussion I'm sure the patient
has a lot of say in this as welland then after that discussion
I'm sure the patient has a lotof say in this as well Then you
go back and present to thepatient what the course of
action would be, so that it'sthat informed consent piece as
well.

Speaker 2 (47:02):
Yes, exactly my goal is.
Then, once a patient had thediscussion with me, the goal is
that she says oh yes, now thisguy understood what I have.
I questioned and I knocked atthe right door For this.

(47:23):
A meeting with a patient maytake 30 minutes.
For the first time, it may takeone hour.
So we should not be into therush because, particularly in
complex endometriosis surgeries,is a long list of complications
, benefits to discuss, andeverything should be very, very,
very, very, very clear.
Otherwise there is a risk ofmisunderstanding, lack of

(47:48):
satisfaction, litigationlitigation 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 ofexperience under your belt
seeing all these differentpatients, I think what's
interesting is you know we'retalking about the experience
aspect of it and to get to thatpoint you have to do all these
cases.
But if there is a provider outthere who is walking through
that right now, if you couldjump back into time and tell

(48:20):
them one thing, one of the mostimportant things that you've
learned in this process togetting to where you're at, what
would you say?
That is what has changed themost in your outcome.

Speaker 2 (48:30):
I think everything changed.
Everything changed and even mypractice.
My surgical procedures havechanged.
So I do not hesitate to changeone of my approach if my study
shows that something else worksbetter.
What it changed is theknowledge, the general knowledge
In endometriosis.

(48:50):
Now it is maybe fourfold morethan when I started in 2003.
The number of publications withendometriosis in the world are
fourfold more numerous now thanin 2003.
It's incredible, the surgicaltools in 2003, we have only

(49:14):
small screens, no HD, no 3D.
Now I cannot imagine how Icould do the surgery at that
time.
And as I record everything.
I had recorded all myprocedures since 2005,.
So I have everything recordedon hard disk.
When I go back to these movies,I said, oh my God, it's

(49:35):
incredible.
I was a beginner experience andI could do this surgery with
good results using these tools.
This looks to me unbelievablenow, because now I carried out
all the robotic surgery, bigscreen, this.
So our, this or our operativetheater is very high technique.
But this was not the same 20years ago.

(49:59):
Then the strategies, thestrategies to manage, or much
more clear for everybody, the,the knowledge, the, the willing
to do to increase the quality oflife, was not.
We were not speaking about thisin 2003.
2003, the goal was to removeeverything, whatever the price

(50:21):
to pay.
Then the patient were havingself-catheterization low
anterior sexual syndrome.
I remember the people weresaying, yes, this shows that
it's a complex surgery, right?

(50:41):
I remember in 2010, I publisheda paper in Human Reproduction,
which is one of the top threejournals in the world in
gynecology and obstetrics, witha series of only 50 cases of
colorectal endometriosis.
Because in these 50 cases, Iasked a question which was not
asked before how are the bowelmovements after my surgery?
Because until 2010, if you lookat all the articles presenting

(51:04):
the bowel endometriosis surgery,the results were assessed on
the basis of dysmenorrhea,dyspareunia, chronic pain Right,
which are not directly relatedto resecting the bowel.
So you do not resect the boweland to say I resected the bowel
because the dysmenorrheaimproved or the dyspareunia
improved.

(51:24):
So it is shocking now to thinkthat we were resecting the bowel
without assessing the bowelfunction, the bowel without
assessing the bowel function.
I think that before 2010, onlythe papers of the team of
Marcello Ciccaroni was assessingthis dysfunction and then,
after 2010, quality of life, thefunction, the low anterior

(51:48):
recession syndrome become.
So I think the patients who hadthe surgery in 2005,.
25 are more fortunate thanthose 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 spokenabout endometriosis back then
for my first surgery and ofcourse I had ablation because
that's all they really knew inthe area that I was at and I
didn't know any different.
And even looking online, therewasn't a lot of information on

(52:23):
endometriosis.
So I think like looking back atthat and seeing how far we've
come with social media andseeing how you know good, bad or
indifferent, right, like we'vetalked about.
But I think the awarenessaspect of it has gotten so much
better and I do think that wecan get there from the surgeon

(52:43):
side of it as well.
But it's gonna take a lot ofwork and bringing awareness to
the fact that not every surgeonis created equal and we should
have a higher standard for oursurgeons.
And that's what's really trickytoo, because, you know, access
to care is also a big barrier toa lot of people.
But the outcomes in what you'resaying, the outcome of, you

(53:06):
know, quality of life, bowelmovements, everything in between
is significantly better whenyou have a true expert doing it
with a truly multidisciplinaryteam, not just two or three
extra people on your team, buttruly a multidisciplinary
approach.

Speaker 2 (53:24):
What it has always also changed is the teaching.
We have continuously fellowsfrom everywhere here in Bordeaux
because we have received morethan 400 surgeons from all
continents during the last sixyears for training and I always
tell them you cannot imagine howyou're lucky to start the

(53:44):
endometriosis surgery now in2025, because you have a lot of
movies, a lot of Me.
For example, I have a YouTubechannel with 1,000 surgical
procedures explained for free.
Wow, when I started me learningthe surgery, I had only one VHS

(54:06):
cassette with a surgery done byMichel Canis and this cassette
I think I saw it 10 times inorder to understand each step.
Now, on my YouTube channel,there are 1,000 movies you can
visit and see and I receivedmessages on the movies and one

(54:27):
of them a surgeon from Asia, Ithink.
He said you cannot imagine thenumber of patients who were
lucky to be managed by a surgeonwho saw your movies, because
this is training.
Not everybody can go take aflight, pay a flight, pay a
training somewhere, buteverybody can look at the
computer.

(54:47):
A wall surgery in full timewith my explanation.
I do a lot of live surgerieseverywhere in the world and I
record them.
I put them on YouTube.
So someone who's in I don'tknow in a less wealthy country
can look this surgery livesurgery at.

(55:08):
It has been in the room of theCongress.
This is something very new, andthat's why I'm sure that the
number of good surgeons now inthe world is much, much higher
than 20 years ago.
And this is the big, big change.
Unfortunately, because on theother side, on the other hand, I

(55:30):
think that the prevalence ofendometriosis is increasing, so
more and more surgeons to treatmore and more patients.

Speaker 1 (55:38):
Yeah, yeah, and that's a whole.
That's probably like a whole.
Nother discussion at some pointon 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 Italianprofessor, Paolo Vercellini.
He's a very, very, very cleverscientist and I like one of the
last talk because what he saidjoined what I was thinking.
So the endometriosis is adisease of the modern woman.

(56:15):
Why?
Because it is disease whichdepends on the number of periods
.
Women have never had so manyperiods, ovarian cycles during
their life, during the wholehistory 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 thewomen, of course, were living
less than now, but they werehaving 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 firstpregnancy is 30 years.
Dental countries they werepregnant more frequently, so
they were more frequently inamenorrhea related to
pregnancies.
Now Occidental women have oneor two children, rarely three.
The breastfeeding wasresponsible for amenorrhea too,

(57:16):
for each child for two years onaverage, while now women go to
work and the breastfeeding isvery short.
So it was estimated that in the19th century at the end of the
19th century so it's the time ofwhen Thomas Edison and the

(57:40):
Eiffel Tower was built At thattime the women were having less
than 150 ovarian cycles duringtheir life, while now we have
450, 500.
So only the number of cyclesexplain why we have more
endometriosis.
Because there are theseconditions to have an

(58:01):
endometriosis, to have periodsand periods and periods.
Then we have, of course, wehave the pollution which may
impact on our hormonal system.
We have a lot of stimulationfor infertility because the
infertility is going down.
So we need more and more.
So there is a kind of cocktailof factors which favor the
prevalence of endometriosis.

Speaker 1 (58:22):
Yeah, and also, I would imagine, because we are
having more cycles, the ovarianreserve as we get older, when
we're having kids.
A lot of people are having kidsolder, their ovarian reserve is
not nearly as high either,because they've had more cycles.
So it's kind of this loopingfactor of things that is
contributing to probably theinfertility rates, along with

(58:45):
the endometriosis rates, alongwith 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 treatmentfor endometriosis.

Speaker 1 (58:56):
Yes.

Speaker 2 (58:57):
A medical treatment which is not hormonal, which may
destroy the cells, not justblock their growth by blocking
the ovarian cycle, A medicaltreatment without side effects
and which is compatible to theintention of pregnancy.
We need it because I think thesurgeon will not be able to

(59:18):
eradicate this disease, and Ithink my opinion is now.
The prevalence of endometriosisis increasing, but once this
therapy will be available andI'm sure it will be available
the prevalence will decrease,decrease and maybe within 50
years the surgeries I do nowevery 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 or40 years or 50 years, there will
be less surgeons because therewill 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 theresearch end of it, because
you've done some amazing workalready, but you know there's
more to be done.
What are you working on nextthat excites you?

Speaker 2 (01:00:13):
So me.
I am an epidemiologist, so myclinical trials compare
treatments, compare surgicalstrategies, compare results,
estimate the results, assess theresults of our medical
treatment.
But the research, the research,the general research in
endometriosis should develop thebasic research in order to

(01:00:36):
identify on the cells, orendometriosis cells, a receptor
which may be a target of a newtherapy.
This should be the future.
Unfortunately, I won't be apart of the future because I am
not specialized in basic science, specialized in basic science.

(01:00:57):
So I can only participate, beinvolved in all clinical trials,
because we have a high volumeof patients who are always asked
to be involved in trials.
Right, but I hope as soon aspossible that someone may
identify a curative treatment,medication for endometriosis
which is not hormonal, becausethe hormones will never cure the
endometriosis.
They are very helpful, theyhelp us a lot to prevent

(01:01:20):
recurrences after the surgery,but we cannot cure the
endometriosis with hormonaltreatments.

Speaker 1 (01:01:26):
Right, yes, and that is one of the biggest
misconceptions I think a lot ofpeople have, especially again
going back to that knowledgebase of just someone that is not
an expert.
If they're just trained ingeneral GYN, they're not trained
adequately to address it, andso I think there's a lot of
misconception there.
But I do think that narrative ischanging, which it does excite

(01:01:47):
me as someone who you know wasdiagnosed when that narrative
was very prevalent, and so I'mexcited to see how that has
changed and how it continues tochange because awareness is
coming to the surface.
And I'm excited also to see hownew doctors are coming up and
are excited to help patients,not just fall into a system of

(01:02:08):
putting band-aids on thesepatients.
It's becoming less desirable tojust clock in and clock out for
work and for surgeries but totruly help these patients who
are in a lot of pain and have adesire to grow their family and
otherwise.
So I'm excited to have thatapproach of seeing the right

(01:02:41):
provider who can address whetherit's beneficial to surgically
manage that or what the nextsteps would be with IVF or
otherwise.
So what would you give forthose patients who may be
hearing this for the first time,they're getting a glimpse of
hope in potentially growingtheir family.
What advice would you give them?

Speaker 2 (01:03:01):
So my advice would be to look for real, actual
specialists in endometriosis, tohave a long-term follow-up.
Ask a long-term follow-up andnot just a minute treatment
because unfortunately, in mostof cases the surgery is
possibilities to look for goodcenter, the expert center.

(01:03:22):
Expert center does not meancenters with a high number of
followers on Instagram.

(01:03:43):
I was speaking last week withMarcello Ceccaroni, who's, in my
opinion, one of the greatestsurgeons of endometriosis in the
world.
We agree that we have surgeonshyper-specialized in
endometriosis and surgeonshyper-specialized in Instagram
and it is very important not toconfound them.
So I think patients can look for, can seek for care in centers

(01:04:07):
with high volume of surgery,high volume and good results on
not on Instagram, but goodresults on clinical trials yeah
and I think they they have tokeep in mind that we have a
chronic disease, yeah, which mayrecur until the menopause, and

(01:04:30):
they have to ask for a long-termmanagement, a strategy until
the age of 50.
Each step should have, eachtherapeutic step should have a
look at the age of 50.
Why giving a medical treatmentfor six months in a woman of 25

(01:04:54):
years has no sense.
After the end of the treatmentthere will be another 25 years
until the menopause.
The strategy should belong-term.
That's why I don't stop torepeat this If you propose a
strategy, it should be along-term strategy.
Yeah, yeah, take care, patientswish.

(01:05:15):
Patients complain, side effectsof the treatments Right, if you
propose a treatment with sideeffects, it will be given up
after six months.
So we'll not cover 20 yearsafter the middle, until the
menopause.

Speaker 1 (01:05:30):
So I think, I think patients would choose, should
choose, the right place to havetheir long-term management not
only their surgical techniquebut their knowledge of
endometriosis, and it's not justlike a one surgery once a month

(01:05:57):
.
I think that you know again,that goes back to that
experience getting that in there.
I wish I would have known thatyou know back in the when I
first started this journey.
But I'm glad that I can spreadthis awareness to others so that
they can have a better outcomefrom the beginning, not not try
to catch up along the way.
So it's doctors like you thatare changing this for so many

(01:06:21):
patients and, as a patient, I amvery grateful to providers like
you and researchers like youthat are not allowing the status
quo to be stagnant and tocontinue to push the barriers of
endometriosis care andknowledge.
I am grateful.
I'm grateful for that for mykids, if they end up having

(01:06:43):
endometriosis, so that I havesome.
I have those resourcesavailable now.
So this is huge for not onlyfuture doctors but for patients,
and so thank you for that.
Thank you for taking your timeto spread the awareness, for the
education that you give notonly the doctors but to the
patients.
It means the world to us tohave you in our corner.

(01:07:04):
So thank you so much for doingthat.

Speaker 2 (01:07:07):
Thank you very much and I was delighted to exchange
with you.

Speaker 1 (01:07:10):
Yes, yes, anytime.
You're welcome anytime.
No-transcript.

Speaker 2 (01:07:38):
Congratulations for everything you're doing.
Thank you For spreadinginformation, for spreading hope,
because I think that theconclusion of our exchange is
that patients should beconfident.
So the endometriosis is not adisaster if we can take care

(01:07:59):
about patients early and do theright strategy very early, when
they are very young.
Honestly, I always spreadinformation which is encouraging
and the results are encouraging.
A woman should keep the hopeand never, never give up.

Speaker 1 (01:08:18):
Yeah, I agree, I think there is, and we can
always make a situation intosomething better, and that's
what I have chosen to do, and Ireally think that empowers me to
continue advocating in myjourney, which I love.
So thank you so much, professorRamon, for taking the time and
sitting down with me.
I just appreciate you so much.

(01:08:38):
Thank you, thank you very much.
Thank you Until next time.
Everyone continue advocatingfor you and for others.