Kofinas Podcast Series

[00:00:05] Kristyn Hodgdon
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to
From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of
the women's health topics that have long been considered taboo. From UTIs to endometriosis, we're amplifying
women's needs and voices because we know there's so much more to the female experience than what happens at the
doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the
expert in you. Now, let's dive in.
[00:00:41] Kristyn Hodgdon
Hi everyone! Welcome back to From First Period to Last Period. I'm your host, Kristyn. And I'm here today with Doctor
Melissa Montes. Hi, Doctor Montes!
[00:00:51] Melissa Montes
Hi!
[00:00:52] Kristyn Hodgdon
So happy to have you here to talk all about surgery for endometriosis. For those of you who don't know Doctor Montes,
she is a minimally invasive gynecological surgeon and fertility specialist at the Kofinas Fertility Group in New York City.
So welcome. I'm so excited to have you and really excited to dive into this topic.
[00:01:13] Melissa Montes
Thank you for having me.
[00:01:14] Kristyn Hodgdon
Absolutely. Before we go into treatment options for endometriosis, I wanted to start at the beginning. For those who
might not know what is endometriosis. And how do you know if you have it? How can you, how do you know if it affects
your fertility, etc., etc.?

[00:01:31] Melissa Montes
So that's a very common question we get during all of our appointments. I think we have a good group of patients who
might come to the appointments telling us that they have this diagnosis by another, by their general OB-GYN, but it's
never been well defined for them, and there's also a huge group where we diagnose it in the patients, and what I
generally try to do is just educate them about endometriosis. So I have to explain the anatomy of the uterus. So the
uterus is this muscular pouch, right? And that's what holds the baby when a woman is pregnant, and so it's a muscular
pouch. But the inside of that pouch, the inside of the uterine cavity, is lined by this glandular lining called the
endometrium. I always describe it as this glandular wallpaper that lines the inside of that cavity, and the endometrium is
the area of the uterus that sheds when a woman has a menstrual period. That is actually the blood that you see. That is
also the area where an embryo implants. So we don't know why necessarily, but some patients have cells within this
endometrial lining that backflow through the fallopian tubes into the pelvis. So then let me go more into the anatomy.
The uterus has two fallopian tubes attached to it. These are like two channels that allow communication between the
endometrial cavity inside the uterus and inside the woman's belly, alright? So during ovulation we're hoping that an egg
is produced, the egg travels through the fallopian tube, hopefully finds a sperm, then you have conception and a
pregnancy, and hopefully, that embryo implants and you're pregnant. When a woman has her period, there's a certain
subset of patients where cells from the endometrium backflow through the tubes and land inside the pelvic cavity,
inside a woman's belly, where these cells are not supposed to be, and they implant on the walls of the pelvis, and it
grows. And every time a woman has a menstrual period who has endometriosis, and sorry to be so graphic, but when
blood is coming out of the vagina, these implants swell, and they grow internally, and this can cause a lot of pain in
some patients who have endometriosis. One of the more common symptoms, yet there's 30% of patients who actually
don't have these symptoms, is pain with the period. And they usually describe the pain as, the day before the period
starts, this heaviness, pressure, bloating sensation in the lower pelvis, sometimes some GI discomfort, and then the
first day of the menstrual period, even more pain. And then sometimes, by the second or third day, the pain starts to go
away because not only is there the usual uterine contractions that happen with the menstrual period, but these implants
in the pelvis that are not supposed to be here, and those implants are what we call endometriosis, they become
inflamed, and they also start a whole cascade of immunological factors in our body that causes just this widespread
inflammation that can also lead to pain, also lead to scar tissue adhesion formation, making it more difficult for women
to get pregnant. So that is the etiology of endometriosis. Why some women have it, some women don't: we don't know.
But what's interesting is there are a certain subset of patients where you might see it more often. When the area called
the cervix, which is the opening to the uterus, if it's really tightly closed, we call that cervical stenosis. Sometimes, you'll
notice that the patient has very bad cervical stenosis; she might have endometriosis. In my practice, we get referred
patients who have certain uterine anomalies, meaning they were born with maybe a septum, like a wall in the uterus,
that is not normal, dividing the uterus into two cavities, sometimes a vaginal septum. Any kind of anomaly like this that
somehow alters the outflow of menstrual blood. We've noticed if you do a laparoscopy, you will see endometriosis. I
remember one time in my career, I had a 14-year-old that had these uterine and vaginal anomalies, and she was
complaining of pelvic pain, and lo and behold, she had endometriosis, and it had to have been because of this anomaly
how the menstrual flow comes out. So that is like one explanation of the etiology of endometriosis, which is this, we call
it the retrograde menstruation, this retrograde flow of endometrial cells through the fallopian tubes into the pelvic cavity.
[00:07:07] Kristyn Hodgdon
That's the best description I've ever heard of. And like just so clear and with the female anatomy and how it works.
[00:07:14] Melissa Montes
I wish I could show a picture also because I usually do that, and, Oh, okay, people get it. And I usually, in my office, I
have a model, and I always try to explain it, and they're like, Ah, I get it now, yeah.
[00:07:25] Kristyn Hodgdon
Yeah. No, I think a lot of people have heard the word endometriosis, but it's a complex topic, and I know that it can take
up to 7 to 10 years to be diagnosed. So why is that exactly? Can you dive into that a little bit?
[00:07:38] Melissa Montes
It's so interesting because I don't know if some women simply don't have pain. I remember when I was like in residency,
and you'd get these test questions, and I still couldn't tell you. They'd say, Oh, if implants were in a certain location in
the pelvis, that's associated with more pain. But I can only tell you in my practice in, doing surgery with the Kofinas
Fertility Group, I think for 18 years now, and I will, I'll do surgery, there were times where I was doing surgery three days
a week, now I do surgery two days a week, and I've seen the worst cases where women are shocked. They have
endometriosis, they're shocked that I'm telling them this, or they're shocked when they come to our office, we do an
ultrasound, and we tell them they have a huge endometriotic cyst in their ovary. And I'm thinking, Wow, this person
either has great pain tolerance or the pain that maybe they did experience with their period, they just assumed this is
what women feel, and so they're not going to complain about it.

[00:08:47] Kristyn Hodgdon
I think that's a big part of it with depending on who your gynecologist, like your regular gynecologist is. It could be like,
Oh, some women get heavy period cramps, and some pain is normal. They're not in your body, so they're not feeling
that feeling. And if you do have a high pain tolerance, like a perfect storm of different things can happen to make you
feel like it might be normal.
[00:09:10] Melissa Montes
Or they just don't want to complain, or they just, maybe it's just this discomfort and having to tell a doctor, Yeah, I have
painful periods, and it just doesn't sound like it's that important to discuss, but it's very important. And what I think some
patients feel like it's not appropriate care, but it totally is is birth control pills. I think birth control pills actually get a bad
rap. People think it could cause infertility. It's not the case whatsoever. It is completely appropriate that if someone is
not trying to get pregnant and they approach their OB-GYN and say, You know what, I've been having really painful
periods. It's very hard for me to function. It's affecting my lifestyle. The first line of therapy, if a patient is not trying to get
pregnant is medical therapy. Jump the surgery, it's medical therapy. And I should say it's appropriate to try medical
therapy if we don't see any certain masses or lesions that could actually be destroying ovaries; that's a whole another
conversation that we can get to, but it is completely appropriate to start birth control pills that can help stave off the
growth of endometriosis. And they say that if you start a medication like that, any kind of medication that kind of
suppresses ovarian function, like birth control pills, another medication medroxyprogesterone or a norethindrone or an
injection called Lupron, these are all things that can suppress ovarian function. If a patient takes any of these
medications and finds relief, it's usually believed the diagnosis is endometriosis unless otherwise proven. And the only
way you can completely diagnose it and appropriately diagnose it is with surgery through a biopsy. And true pathology
results were saying, Yes, these results are consistent with ending endometriosis. When, it would be nicer when I find
out a patient's told me, Yeah, when I was younger, I had pain, so my doctor put me on birth control pills. So I was on
birth control pills for a while, but now I'm coming off of it because I want to try to conceive a pregnancy. That's, I think,
that's actually great. You've somewhat preserved your ovaries and hopefully staved off any further endometriotic
growth.
[00:11:32] Kristyn Hodgdon
Yeah. Is it true that some women with endometriosis, because the birth control suppressed their ovaries the first time
around, can get pregnant like somewhat easily with their first, but then a lot of times experience secondary infertility?
[00:11:44] Melissa Montes
I feel like secondary infertility just means the patient hasn't been able to get pregnant since the first, but there isn't
always a consistent reason why. A woman can get pregnant at 37 and then decide at 43 years old, I want to get
pregnant again, because maybe later on they have a different partner or they just decide, No, I am ready to have a
second child, and you've got another issue. And it's just an age-related issue where patients who are 43 can get
pregnant, it just might be much harder. When I have patients who are actually sent to me to deal with chronic pelvic
pain, not just fertility, but with chronic pelvic pain, or their doctors send them to me because they have big endometriotic
cysts in their ovaries and they're not trying to get pregnant. So I will treat them surgically and then immediately put them
on some sort of medication for maintenance, birth control pills, or like I was saying, norethindrone, something so that
when they're ready to start trying or if they say want to cryopreserve their eggs, we can keep them at this healthy state
until they're ready to do that.
[00:12:54] Kristyn Hodgdon
Yeah, that's a great benefit. I feel similarly about birth control for PCOS. I have PCOS, and I always feel better when I'm
on it. My problem is that I've been trying to grow my family for the better part of a six years, so it's like when you can't
be on it that's when the issues arise.
[00:13:12] Melissa Montes
If you have PCOS.
[00:13:14] Kristyn Hodgdon
No, go ahead.
[00:13:15] Melissa Montes
No, you will grow your family.

[00:13:18] Kristyn Hodgdon
Yeah. I actually have five-year-old twins from IVF. And I've been trying to have a third through IVF for, on and off, for
two and a half years, and none of my embryos are sticking. So this conversation is actually very interesting to me
because your colleague Doctor Noreen recommended maybe a laparoscopy just because, to see what's going on in
there.
[00:13:40] Melissa Montes
So, yeah, so what's fascinating is that we've always known that endometriosis can cause fertility issues because it can
cause scar tissue in your belly. Your body produces all these inflammatory cells trying to fight endometriosis, and
inflammation causes adhesions, scar tissue, so it can be difficult to get pregnant because maybe the fallopian tubes are
sticky and blocked. There's adhesions preventing an egg and sperm from finding each other. alright? And if the
endometriosis causes a cyst in the ovary or there are implants on the ovary, especially if there's a cyst, not just an
implant, it starts to kill eggs, it makes egg number fewer and egg quality way poorer, alright? So we've always known
this part about endometriosis. Again, we've been doing this long enough. I remember what it was like to practice and do
IVF with patients before PGT-A, right? That's the test where we check if the embryos are chromosomally normal before
we transfer. And when PGT-A came about, and now it's something, it's a screening test, it's something that we want to
offer all patients so that we can help them identify the chromosomally normal embryos, where they should have a
higher likelihood of success, but then it doesn't work? That's when everyone started to think, Oh my goodness, we
really got to look at implantation. And implantation rates are greatly decreased if endometriosis is present. It just, this
highly inflammatory process can just interrupt placentation. There are just so many other mechanisms where you just
have poor implantation when endometriosis is present. If I've been working with someone where I knew it was really
difficult to get them to make a chromosomally normal embryo, we call it a euploid embryo, and let's say she's, it's just
harder as we get older, it's harder in our 40s, and sometimes women in their 40s have to do multiple cycles of IVF to
identify that normal embryo, I will always offer: Would you be interested in us doing a laparoscopy or I would highly
recommend it because I want to know I did everything to decrease the chances of this one embryo to implant. And if
implantation rates increase when endometriosis is removed, so you're trying to get rid of this highly inflammatory
process, we do it, and we do it all at our practice. What I'm very proud about our practice is that most fertility places,
most fertility fellows aren't, everyone's been trained to do surgery, but it's an art that is somewhat lost in fellowships,
and most fertility doctors, if there's a surgical concern, they will outsource to a minimally invasive gynecological
surgeon, right? And then that surgeon does a surgery, sends the patient back, and I'm sure the surgeon does a great
job, but is not always focusing on what it takes to go through IVF, what it takes to prepare the uterus for an embryo
transfer. When we do surgery, we also know what it's like to do an egg retrieval. We all, we know that the actual
technical aspects that go into doing a nice atraumatic smooth embryo transfer. And so having that knowledge when
you do the surgery, I'm always thinking, Now, what is it going to, what do I need to do to increase her success and
make it technically a better procedure for us to provide her with success? This is another point I always bring up with
my patients. The job of the fertility specialist is to offer, it's always been called assisted reproductive technology, and
that's absolutely correct. That is what we're supposed to do: provide different options to help someone get pregnant.
And there's typically two tools in the arsenal: ovulation induction with intrauterine insemination and in vitro fertilization.
And yes, you find success, you can help your patients this way. But what I'm also proud about in our practice, we don't,
it's not just about we use IVF, I believe in IVF, but it's going back to not just using that as a band-aid, but let's go back
and actually try to identify and diagnose what is the etiology of infertility here, and maybe we can actually treat it. And
I'm not saying all infertility issues need to be treated surgically, but there are a good number of things that can be
treated. Endometriosis? Absolutely. Fibroids? Absolutely. And there have been many times where I'll take care of
endometriosis surgically. And I always tell patients, If you're comfortable enough to have intercourse within the days or
weeks after we do surgery because you know, you're ovulating, and this is also, if I know certain things that happen
during surgery where it is safe for this individual to have sex, I always tell patients, please do. Because whenever
anyone gets pregnant without actually going through fertility treatment, a lot of times it's after we've done a full cleanup
with the laparoscopic surgery. We also do hysteroscopy, which I always describe the laparoscopy and the
hysteroscope as like telescopes. The laparoscopy typically goes through an incision in the belly button to look in the
belly. The hysteroscope goes through the cervix, which is the opening of the uterus, so we can evaluate the uterine
cavity, and we typically always do this before we transfer an embryo. But in doing that, we're also evaluating: Is the
cervix highly stenotic or very tightly closed? Are there any other factors inside the uterine cavity that could be promoting
endometriosis or just poor implantation, like polyps or fibroids, that we can take care of then and there? So the one
thing about both endometriosis or any other anatomical concerns when it comes to surgery, when it comes to infertility
issues, it's nice to be able actually to diagnose an issue, treat it, and still see if time is on that patient's side, meaning
their young, to try on their own because a lot of times they can have success. I'm never going to, we can't promise
100% for anything for IVF, IUI, or surgery, but definitely, to help treat the actual underlying pathology coupled with IVF,
this is how we find success a lot of the time.

[00:20:43] Kristyn Hodgdon
I love that, because as someone who has had five embryo transfers in the past two years.
[00:20:47] Melissa Montes
I'm so sorry. That's hard, yeah, yeah.
[00:20:49] Kristyn Hodgdon
Just to now go back and be like, Οh, maybe I should have done laparoscopic surgery. We don't really have a reason to
believe that I have endometriosis, but why do you think that it's an afterthought in some cases? Like, why did, why do
some doctors try to avoid surgery?
[00:21:08] Melissa Montes
I think two things. Number one, they have to outsource the surgery to someone else, right? Number two, and I always, I
just said this to some of my new patient yesterday: there is so much we can do to help a patient, and a lot of times, most
fertility doctors know what they need to do to help that patient get to get pregnant. Like, we usually always have an
answer to how someone can get pregnant. Our limitation, because this is not a primary care specialty, our limitation is
what a patient emotionally feels comfortable doing because no one ever thought that this, when you're a little girl, this is
not how you anticipated starting your family. And then there's always the financial consideration, what someone feels
comfortable doing financially; if their insurance covers or if it doesn't, very sensitive to that for all of our patients. And I
put it on the line, I'm very honest about that. Like, we can do this, and you may not be comfortable with this, but I want
you to know that I do offer the service. And if you're not comfortable, fine; we'll do what you're comfortable doing. But if
X, Y, and Z is not working, please let us consider this again. Because a lot of times the patient may not even be
comfortable with IVF. There's a lot of patients who just aren't comfortable having to see a doctor for fertility issues. They
usually come in and just say, I just want to check out my fertility. And then a couple of weeks later, you have the
consultation where you give them all the results, Okay, I'm going to lay it on it now. Are you ready for this? And it's hard
when, and so I think sometimes some women have to take that journey to the point where it's like, all right, it's like
jumping off a cliff of, Okay, I'm ready, let's do what we need to do.
[00:22:48] Kristyn Hodgdon
Yeah, I can definitely attest to, like, your instinct is so important and you have to listen to it, and sometimes you're just
not mentally ready for one thing at one point. And then all of a sudden, you are, and it's go time, and you're like, Okay,
I'll do whatever it takes right now. I have a short window, like, I might chicken out.
[00:23:09] Melissa Montes
Exactly.
[00:23:10] Kristyn Hodgdon
So what can a patient expect if they do come in for a laparoscopic surgery?
[00:23:14] Melissa Montes
So before we ever do that, we've typically been the ones that do the full workup on the patient, meaning I have done
most of the ultrasounds on my patients. Usually, before I even do surgery, I have a very good understanding about
what that ... is going to look like and where things are stuck, and where things are located. And so I think patients are, I
will always do another ultrasound, and I will talk them through the every aspect of their day at a consultation before, so
that when I meet them in the preoperative area, she changes into a gown, she has an IV in place because this does
require general anesthesia. And so that's a whole nother deal. A patient has to know she's comfortable with general
anesthesia, and then you want me to walk you through how what actually happens in the OR and stuff like that?
[00:24:13] Kristyn Hodgdon
Yeah, I think so.

[00:24:15] Melissa Montes
Okay. We usually start off with the operative hysteroscopy dilation and curettage. So after anesthesia is induced, she's
completely asleep. We start with the hysteroscopy so I can just evaluate the uterine cavity, take care of cervical
stenosis if it exist, take care of any other pathology in the uterus if it exists, and also, most importantly, even if the
uterine cavity looks perfect, sample the tissue in the uterine cavity, the endometrium, all right, where the embryo is
post-implant to make sure there is no inflammation, no infection, no precancerous cells, alright? And then, we move to
the belly, and we start the laparoscopy. The number of incisions usually depends on the amount of work that needs to
be done. Typically, the laparoscope goes through the belly button. The times when we change that is, if we're taking
out huge fibroids and we need more room, then we might put the laparoscopy a little higher in the belly button. But then,
but typically she'll have one centimeter, like a finger breadth size of an incision, 3 to 4 of them in her belly, right? In the
belly button is the laparoscope, again, that telescope so we can look at a full pelvis, the uterus, the fallopian tubes, the
ovaries, 2 to 3 lateral incisions on her belly, where we put in instruments to actually pick up the fallopian tubes. We flush
out the fallopian tubes with a blue dye called indigo carmine, so we can see if the tubes are indeed patent. We try to
clean up the fallopian tubes. We call, that's called a fimbrioplasty. Any scar tissue, adhesions, endometriosis, obviously,
cysts, polyps, fibroids: we can take care of during a laparoscopy. And we always have an assistant, usually our
physician assistants, who will either hold the camera for us or also hold an instrument for us throughout the procedure.
The length of the procedure depends on how much work needs to be done, how much pathology there is. Surgeries
can be anywhere from an hour and a half to sometimes three hours, sometimes a little longer, especially if you're,
you're taking out fibroids and it's a huge uterus. But what's great about laparoscopic surgery is because the incisions
are smaller, recovery is much faster. There is not as much pain that's usually associated with a larger incision. And our
patients, they walk out of our OR, and I always tell patients, Expect you will, you'll be walking around eating dinner,
sleeping in your own bed that night. And I think because we close our incisions with this nice superglue, patients tend to
be very happy with how the incisions look. It just looks like a little line and a very thin film of plastic that will peel off like
nail polish after a couple of weeks.
[00:27:06] Kristyn Hodgdon
And what is that, you said that they'll be walking around same day, but like recovery-wise, for trying again, what does
that look like?
[00:27:13] Melissa Montes
So it depends on what we did during the surgery. If, in the case of the myomectomy, we really need the uterus to heal,
before a woman gets pregnant. So that means trying on her own, and if she has embryos, we will not transfer an
embryo yet. That uterus needs to heal for months, alright? Endometriosis is a little different. Now, you might hear that
endometriosis has stages: stage one, two, three, four. So medically speaking, when you state, when a surgeon stages
something, if it, or I should say if a disease can be staged, that means the stage denotes the prognosis of a patient.
That's when a disease is staged. But when a stage of a disease does not always correlate to prognosis, meaning when
you think of cancer, stage four just sounds horrible. And so, usually those, we know the prognosis. With endometriosis,
you can have stage four, and that patient can still get pregnant the next month. So endometriosis is a disease process,
and I really hate using the word disease, but it's a pathological process that really should not be staged. It's not staged,
but surgeons will always use staging just so we can communicate with another surgeon how bad this endometriosis is,
or just to describe it to a patient. So stage one and two, you're going to see implants throughout the pelvis. Three, you
might start to see more implants on the ovaries. Stage four is now when you really see a cyst in the ovary, and we call
that an endometrioma. And that's where it's, you got to act surgically, be it if a patient wants to get pregnant or not. Like
I was saying, my patients who have chronic pelvic pain. If on ultrasound, their anatomy looks great, I have no, and
they're not trying to get pregnant, I have no problem treating them with medication. If medication is not working, I offer
surgery. If I see a cyst in the ovary, so sometimes these endometriotic implants, they land on the ovary, and they
literally will eat into the ovary, and with each menstrual cycle, they grow bigger and bigger, and it's like they're full of old
menstrual blood. And there are ovarian cysts that don't disrupt ovarian tissue; it doesn't kill eggs. Endometriosis does. It
eats into the ovary, killing eggs. It diminishes the egg number, alright? And it makes egg quality poor. And so whenever
I see an endometrioma, that's when I tell a patient that we have to surgically remove this to save your ovaries,
especially if you haven't been pregnant yet or wish to get pregnant, and then after that surgery, put you right on a
medication if you're not trying to get pregnant. They call these cysts "chocolate cysts" because this is going to sound
gross, when you take them out, they're filled with basically old menstrual blood, it looks like chocolate syrup, and they
call them chocolate cysts.
[00:30:17] Kristyn Hodgdon
I have heard of chocolate cysts. I didn't realize they were the same thing as endometriomas. That's interesting.
[00:30:21] Melissa Montes
Yeah, yeah, that's exactly what an endometrioma or endometriotic cyst is.

[00:30:26] Kristyn Hodgdon
I'm getting so many article ideas. It's cervical stenosis is something that I hadn't really heard of.
[00:30:32] Melissa Montes
Yeah, it's just something that we've noticed in our everyday practice. We tend to see this. And whenever I've had a
patient that has had some sort of congenital anomaly of the uterus, where you know that menstrual outflow is somehow
altered, we see these implants in the pelvis, you know.
[00:30:51] Kristyn Hodgdon
Wow, okay.
[00:30:53] Melissa Montes
Oh, for endometriosis, if, like I was saying, if the issue is just chronic pelvic pain, it's appropriate to use medication.
Doesn't work? Surgery. But for fertility, the standard of care is really to surgically remove it and then try to get that
patient pregnant as soon as possible. Because in pregnancy, you're looking at maybe a year, no menstrual period.
Literally, pregnancy can help any endometriotic implants that might still be there regress, alright? So pregnancy is
actually good for someone who's had a history of endometriosis. When, after a woman has delivered who's had a
history of endometriosis, I always tell them, before we discharge them from our practice, Okay, you're pregnant. You're
going to be with your OB-GYN. After you deliver, think about getting yourself on a pill until you're ready to get pregnant
again.
[00:31:45] Kristyn Hodgdon
That's great foresight.
[00:31:47] Melissa Montes
For maintenance between.
[00:31:48] Kristyn Hodgdon
Yeah, absolutely. I wish someone had told me you always think you could do everything ... hindsight 2020, but I think if
your patients want multiple children, I think that's such great advice.
[00:32:00] Melissa Montes
Yeah, yeah.
[00:32:01] Kristyn Hodgdon
What are your thoughts on silent endometriosis? I know you said some women don't have.
[00:32:06] Melissa Montes
Oh, it absolutely exists. Like I was saying, I still remember there was, we get patients like this all the time where we do
an ultrasound and their stage for endometriosis; there is a cyst. And I'll always ask them, like, I know this is
endometriosis. The only way you can absolutely, definitively diagnose it is with a pathology result that says
endometriosis. Like, you have to actually do surgery, provide tissue for pathologists to say, Yes, this is endometriosis,
but I think anyone who does ultrasounds, especially any fertility doctor, any GYN, you do an ultrasound, we would be
able to pick out, Oh yeah, that's an endometriotic cyst. And I will always ask patients, You don't feel this and I don't
know what it is about, I really can't tell you, but if we're saying silent endometriosis is just asymptomatic endometriosis,
I know that sounds terrifying, it exists, absolutely exists, and the only time you can see it on ultrasound is if it's a cyst on
the ovary.
[00:33:06] Kristyn Hodgdon
If it's a cyst. What about BCL6 and like the whole Receptiva?
[00:33:11] Melissa Montes
It's really hard. So I definitely have had, I've tried it a couple times and I am not well versed in this. I haven't used it
enough to have an opinion, and that's because I have absolutely, I've done the biopsy before and then realized, they
told me, You should do the biopsy during this phase of the menstrual cycle, so it was a waste. I've had patients where it
was negative, and then surgically, I find it, but I have not done enough of it yet. Like, I probably did, like just maybe four
biopsies last month, and that's because I'm trying to see if it's something that can help me, help the patient, and
explaining. That's probably the most I've used it, and it's just the past couple months.

[00:34:07] Kristyn Hodgdon
Yeah, I think more and more people are adopting it just because I guess it is that step before or that is that option
before surgery. So how many transfers in IVF would you say that you start, how many failed transfers would you say
that you start recommending, highly recommending laparoscopic surgery?
[00:34:27] Melissa Montes
I think part of it, also, I have to take into account the patient's age and how many embryos she has.
[00:34:32] Kristyn Hodgdon
Yes, okay.
[00:34:32] Melissa Montes
And it's never to say if you have multiple embryos, no embryo's expendable. If I have no, if I, she could have silent
endometriosis, but there is no reason for me to think that there is, I'm going to go ahead and try to transfer. After one
failure, I start looking for a reason because I want to know why did this not work. And this goes back to after PGT-A
became more prevalent and all practices started to figure out, trying to understand: Then why did I have a failure if we
know we transfer to a chromosomally normal embryo? You've got to look. It just, I know if I was the patient, I'd be like,
Oh, I would want to do something different. I'd want to figure out what could we have done differently. And that's, again,
within the parameters of what a patient feels comfortable doing. And what their insurance covers. But after one failure,
if I haven't done it already, I will offer.
[00:35:27] Kristyn Hodgdon
No, that's great insight.
[00:35:28] Melissa Montes
I couldn't tolerate.
[00:35:30] Kristyn Hodgdon
Yeah, yeah. You don't want to just blindly transfer embryos, yeah. And then if you do find endometriosis in the case of
IVF, do you typically, after you remove it, do you still alter the IVF protocol at all using like ... depression or anything like
that?
[00:35:47] Melissa Montes
Yeah, that's really interesting. So I will have my subset of patients who, and sometimes, I do feel comfortable based on
their age and their AMH, right? If that hormone denotes that they still have a larger egg number, right? Because I will
absolutely tell some patients, Okay, let's do this surgery. And I really want you to try on your own. And I'll even go over
their menstrual cycle with them and tell them what days of their cycle they should be having intercourse. And we will get
people pregnant that way. And then, I give them a timeline. If you don't get pregnant in three months, I'm begging you,
come back. Now, let's do IVF, right? Or, I will do surgery on someone, and it's stage four endometriosis. Let's say, I
know she's 40 years old, I know her AMH is not the best, I'll do that surgery, and then I'll tell her, No, we really, I
recommend we go straight into IVF as soon as possible, as soon as she physically feels comfortable after surgery, and
most patients go like maybe a month after, and I will stimulate the ovaries not based on how the surgery, what
happened during the surgery, but still based on her age and her image level. So the fact that I did surgery does not
change the dosage I think she should have. That's still based on age and the AMH.
[00:37:15] Kristyn Hodgdon
Yeah, everyone is so different; your circumstances, age, how many kids you want to have, etc., etc., all matter so
much. The other, only other question would be like, are there any lifestyle changes that you typically recommend to
your patients in the context of endometriosis?
[00:37:35] Melissa Montes
I wish. I think really the only thing is if they can medically take maintenance medication between pregnancies or before
wanting to conceive, being open to using birth control pills or something like that. I think the lifestyle change,
unfortunately, there is no control over if a woman has endometriosis, the lifestyle changes, honestly, being open to
medical therapy.
[00:38:06] Kristyn Hodgdon
Yeah, yeah. This was so informative for people who, whether they have endometriosis and are experiencing infertility
or someone like me, that maybe has had a bunch of failed transfers and wants to look at other options. So last
question, what would you rescript about the way people think about surgery for endometriosis?

[00:38:26] Melissa Montes
I think it just has to be someone's attitude towards surgery. And I don't think we could rescript that; it goes for each
individual. I think there are patients that come in and they're like, Let's do it. Let's do this first. I want to see what I can
do on my own. And there's some patients where I tell them, this is ultimately what I think we need to do, but if you want
to try another venue, I will hold your hand, support you through that process because you made an educated decision,
because I told you everything. But if this fails, please be open to this. So they take their journey towards it.
[00:39:05] Kristyn Hodgdon
It's so hard because surgery is really the only definitive way to diagnose it.
[00:39:10] Melissa Montes
Yeah, I know.
[00:39:11] Kristyn Hodgdon
It's, if you don't suspect that you have it, you might be resistant to anesthesia and incisions and the whole ... But then at
the end of the day, it's the only way to know for sure. So it's a Catch-22 but obviously a really amazing option. And just
to hear from your mouth that you can be up walking around that same day, it makes it feel a lot more ...
[00:39:36] Melissa Montes
Our surgical center is, and I'm very proud of this, it's our surgical center, it's the Manhattan Reproductive Surgery
Center. And so it's only our place. So it's nice because everyone who works there understands, everyone is, all their
patients are there to preserve their fertility, and they're very sensitive to that. And I want to say it's like we look at all
facets of fertility. It's not just always about IVF and insemination. It's about actually giving a diagnosis that we can treat.
[00:40:14] Kristyn Hodgdon
And sometimes the surgery is to get to that diagnosis.
[00:40:19] Melissa Montes
Yeah, yeah.
[00:40:20] Kristyn Hodgdon
No, that makes total sense. I love that you guys have such a customized approach and really want to get to the root
cause, because I can tell you how many times I've been told, You're so young and it'll happen eventually. And it's: Why
is this failing? I just want to know why.
[00:40:37] Melissa Montes
I know. There's a, and when we do our mock cycles, I'm assuming you might have done a mock cycle?
[00:40:45] Kristyn Hodgdon
Yeah, DRA.
[00:40:46] Melissa Montes
We also take biopsies for something called EIP, endometrial immunoprofile.
[00:40:52] Kristyn Hodgdon
Yeah, Doctor Noreen was telling me about that, and it was the first time I had heard of it.
[00:40:56] Melissa Montes
Endometriosis is, again, it's a highly inflammatory, pathological process happening in the pelvis, and so your body
creates these inflammatory factors trying to fight it. And these different inflammatory factors can be found in the blood,
can actually be found locally at the uterine level. And so when we do a mock cycle, we do the mock cycle, and we, the
day that we as we're supposed to do an embryo transfer, instead of doing that embryo transfer, we biopsy the
endometrium from the tissue so we know if that was the perfect time to transfer. That's the ERA biopsy, the endometrial
receptivity assay. And then EIP, endometrial immunoprofile: see if there are any inflammatory cells locally in the uterus
that can be disruptive to placental development. And whenever someone has had a history of endometriosis, we see
these inflammatory cells both in the blood and at the uterine level. So when we take these biopsies and that blood work,
when we do the real thing, the real embryo transfer cycle, we have the timing template based on the ERA, right, when
we should start progesterone, when we should transfer, and then based on the types of inflammatory cells that we have
found in the blood and at the uterine level throughout the embryo transfer process, there are different anti-inflammatory
medications we may add to tamper down those inflammatory, those specific inflammatory cells just to get us to
implantation, and then we start to wean them off towards the end of the first trimester, yeah.

[00:42:44] Kristyn Hodgdon
That's so awesome. I feel like inflammation is such a buzzword today because of media. And it's: What is inflammation
and how do I know if I have it? But I love the addition of that test because, obviously, the last thing you want is
inflammation in your uterus, and especially with like autoimmune conditions and anything that could create any sort of
inflammation.
[00:43:08] Melissa Montes
Yeah, yeah. Absolutely.
[00:43:10] Kristyn Hodgdon
This was so amazing, Doctor Montes. Thank you so much for your time and teaching us all about endometriosis and
the treatment options. Appreciate having you with us.
[00:43:19] Melissa Montes
Thank you so much. Thank you.
[00:43:24] Kristyn Hodgdon
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