Prof. Dr. Ivan Kostov, MD completed his higher medical education at MU-Sofia in 1997. He specializes in obstetrics and gynecology, and obtained a master’s degree in health management in 2005. Prof. Dr. Kostov has extensive post-graduate qualifications in ultrasound in obstetrics and gynecology, colposcopy, gynecology endocrinology, operative gynecology, pediatric-adolescent gynecology, laparoscopy in gynecology, robotic surgery in gynecology on the Da Vinci robot, as well as numerous specializations in Germany, Israel, France, Slovenia, Italy, Turkey, USA. His career began at “Mother’s Home” as a specialist in obstetrics and gynecology and the surgical gynecology clinic of “Pirogov” already as a specialist doctor. In 2008 – 2010 he was the executive director of the Second General Hospital “Sheynovo”, from 2012 – 2017 he was the executive director of the First General Hospital “St. Sofia”, and since April 2017 he has been the executive director of the University General Hospital “Mother’s House” – Sofia. From 2014 to the present, he is a member of the expert council at the State Fund for Assisted Reproduction at the Ministry of Health. Prof. Dr. Ivan Kostov is also the chairman of the “Electronic Health Bulgaria” Foundation in the period 2004 – 2013, as well as an active member of the European Association for Telemedicine and Electronic Health in Brussels. – Prof. Dr. Kostov, what disease is endometriosis? Endometriosis is a major challenge for gynecologists worldwide. Endometriosis is a benign disease with a progressive course that occurs with a frequency between 5 and 20% of all women. Worldwide, the disease affects about 11 million women. The disease is associated with the development of endometrial tissue, which normally occurs in the cavity of the uterus and is “peeled” during menstruation, in atypical places – on the uterus, cervix, vagina, ovaries, covering the small pelvis, bladder, intestine, lung, in cicatrixes (scars) from operative interventions – Caesarean section, episiotomy. The development of this endometrial tissue in atypical places causes complaints in the patient. In addition, endometriosis is a socially significant disease that has pronounced clinical symptoms and significantly disrupts the quality of life (including sexual) of affected women. It leads to sterility and significantly impairs the working capacity of female patients. There is no consensus on the cause of the development of this disease. The disease manifests clinically with a higher frequency in more advanced reproductive age (30-40 years old), but, unfortunately, it is not an exception to diagnose it in adolescents as well. – What are the risk factors for the development of endometriosis and can its development be prevented? Certain congenital abnormalities of the female genital organs predispose to the development of endometriosis. Other risk factors are genetic – sisters and daughters of women with endometriosis suffer significantly more often. One of the most common theories explains,that based on the genetic factor in some populations such as Japan and North America, the severe form of endometriosis occurs more often. Early onset of menstruation, longer duration, and later onset of menopause are also associated with an increased risk of developing endometriosis. Some surgical interventions that open the uterine cavity are associated with an increased risk of developing endometriosis. The prevention of the disease is related to the conduct of regular prophylactic gynecological examinations, which should begin with the beginning of a woman’s sexual life and be carried out on an annual basis. It is also important not to delay the realization of reproductive intentions too much. In the event of subjective complaints or inability to conceive within a year, it is necessary to promptly seek consultation with a specialist obstetrician-gynecologist. – What complaints are observed in endometriosis and what are their causes? There is no specific complaint due to endometriosis. About 20% of women with endometriosis have no subjective complaints. However, the following complaints are common with this disease, with different degrees of expression and in different combinations: Painful menstruation – especially if it was not so before, due to the irritation of the “exfoliation” of the endometrial tissue, as well as substances , separated from her. Pelvic pain – usually accompanied by pain in the lower back and abdomen. In addition, endometrial tissue located in an atypical location leads to the formation of adhesions between the organs in the small pelvis, which also lead to pelvic pain and sterility. The pains can be very pronounced and disrupt a woman’s daily and professional activity, even incapacitating her. Painful sexual contacts – the reasons are the same as those listed; Painful micturition and defecation – the reasons are the same, in the advanced stages, the appearance of blood in the urine and/or feces is possible; Ovarian cysts – they are known as endometriosis or “chocolate” cysts because their contents resemble the consistency and color of liquid chocolate. They develop in the presence of endometrial tissue in the ovaries. In the advanced stages and with a large number of cysts, the ovaries are damaged – the release of sex hormones from them is affected. Irregular uterine bleeding – due to hormonal imbalance caused by endometriosis, as well as ovarian damage from endometriosis cysts. Infertility – it is related to the impaired ovarian function, the release of specific substances from the endometrial tissue, as well as adhesions in the small pelvis, disrupting the patency of the fallopian tubes. Psychoemotional distress and depression – are associated with sterility and significant subjective complaints in the advanced stages of the disease. Complaints are often underestimated by patients, which leads to late diagnosis and more advanced changes in the body. the changes,caused by endometrial tissue (and the complaints associated with them) undergo reverse development during pregnancy and menopause. – Is endometriosis treatable and which therapies are effective? Endometriosis is a treatable disease. There are two approaches in its treatment: medicinal – conservative with hormonal preparations, and operative. Because this disease often recurs, the best results are achieved when both approaches are combined. Modern treatment involves surgical intervention with a minimally invasive technique to confirm the diagnosis and assess the stage of the disease, remove any adhesions and cysts, destroy visible endometrial tissue, and check the patency of the fallopian tubes. The operation was followed by hormonal suppression of the menstrual cycle for a period of 6 months. After cessation of hormone therapy, the menstrual cycle is restored and a period very favorable for pregnancy occurs. The gold standard for endometriosis is laparoscopic surgery – recently, robotic surgery has been increasingly used, especially in severe cases. The robotic system with which we work at “Mother’s House”, Da Vinci is the gold standard – it is the most gentle and modern method of treating endometriosis – non-invasive, atraumatic surgery, which requires higher technologies and leads to faster recovery. With its help, endoscopic operations are much more gentle, since the abdominal wall is not opened. On the other hand, the robot’s camera is much more perfect than the human eye, and the surgeon operates with the help of a machine that gives an extremely good three-dimensional vision. Blood loss is very little, surgery is associated with much less pain, much faster recovery. A frequent complication of endometriosis is proliferation to neighboring organs, where the da Vinci robotic system has no analogue in the world for the treatment of this type of disease. Maximum ovarian reserve is preserved and adhesions are removed in the most precise way, thus preserving the natural anatomy of the woman. – What complications of endometriosis can occur if it is not treated or controlled? Delayed diagnosis, as well as insufficiently active treatment, can lead to significant damage to the female organism – damage to the organs in the small pelvis, ovarian cysts, sterility, premature menopause, damage to the function of the digestive and excretory systems, severe pain, which disable the patient. – Is there a risk of developing cancer as a result of endometriosis? Endometriosis is a benign disease. There is no evidence of a higher frequency of the most common oncogynecological diseases in patients with endometriosis. An increased risk exists for the development of some rare and specific ovarian tumors, but it does not exceed 1%. – What percentage of endometriosis patients are affected by infertility and can it be overcome? endometriosis,whether or not there are clinical symptoms, it reduces a woman’s ability to conceive. According to average data, about 30% of women with endometriosis are affected by infertility. And in patients with infertility, endometriosis is found in about 15%. Timely and energetic diagnosis and treatment of the disease, preventing the development of its severe degrees and complications preserves the patient’s fertility and allows her to become pregnant and give birth to a healthy baby. – Is it possible to get an ectopic pregnancy because of the disease? In patients with endometriosis, ectopic pregnancy is more common. This is mostly related to the impaired mobility and patency of the fallopian tubes, caused by hormonal changes and the formation of adhesions in the small pelvis. – How is pregnancy and childbirth in women with endometriosis? In patients with endometriosis, pregnancy is associated with certain risks. An increased frequency of spontaneous abortions, premature births, bleeding at the beginning of pregnancy, increased frequency of uterine contractions, low back pain, preeclampsia and abnormal attachment of the placenta – the so-called placenta previa. In pregnant women with endometriosis, the frequency of operative deliveries is increased, primarily related to the increased risks during pregnancy – premature births, advanced reproductive age, preeclampsia, abnormal attachment of the placenta.