Navigating Secondary Fertility Challenges


[00:00:00] Hi everybody. 

Hi, Christine. 16. You're the first one here. Good. 

Jack in the box passport. Voyager trending 2021. Hi everybody. We're just waiting for Dr. Grafana. She had a busy day in the office, in the hospital doing cases, so we're just gonna wait for her for a few minutes. But I do appreciate, hi Kelly. I do appreciate everybody jumping on and joining us. Uh, really happy to see everybody. 

I'd like to thank the marketing team, especially Sierra, for putting together tonight. Um, and I'm. Hey Karissa. [00:01:00] Hey Kendra. 

So usually I have my daughter Zoe, here for tech support on Insta Lives. Um, here's Shiva, but she's not available, so I'm trying to uhhuh you request here. 

Let's see. I think Shiva was able to join it. Here she is. Oh, hi. Oh my gosh. What a site for Sore Eyes. Hi. She . As you know, I just literally ran upstairs into my studio, which is my attic. From the office. I'm a little shiny. How are you, doc? Oh, it's so good to see you. One of my favorite people in the whole world. 

love our chat. You have to say that now that we're on live. How are you? I know. Great. Thank you for asking and I know it's been a really busy day for you in the office in the or so really nice of you to run home and join us. This is fun. This is the stuff I love to do. I know. Yeah, [00:02:00] I know, I know. I love spending time with you cuz she and I both love, um, getting the word out and helping everybody understand what they're up against and what the challenges are and how to move forward. 

And so that's like our favorite kind of passionate thing to do and we can do it together. It's even more fun. Like I say, if we can, this is what mine and Jenny's, um, motto is for tribe called V. If we can increase your knowledge, we will decrease your anxiety. Right? Oh, that's a great tagline. Did you not know that Dr. 

Hz? That I did, but I'm reacting for the camera here because Thank you. It's so amazing. I know. Yeah. So everybody, your knowledge decrease your anxiety. Everybody should check out Tribe called V because Shiva is really pouring herself, which we know is like a lot. Mm-hmm. into this and it's really about educating everybody on uh, a woman's journey through life. 

Right. Is that a fair way to put it? Yes, actually. I love that. I mean, cuz it's, it's everything. Right now we have a pregnancy program, but we're adding all this stuff about life, meaning anything that has to do with a woman's journey like herpes, HPV mammograms. Yes. Cancer, fertility. All the [00:03:00] things, relationships, all the libido. 

All the Yes. I think we can all agree. Nothing gets better with age. I think we can all agree with that. Right? Yeah. I don't know. I don't agree with that. Dr. Horowitz, certain things do not get better with age, but certain things do. Okay. I mean, I said all my young patients who go to college, these are not the best years of your life. 

You are going to actually get happier if you choose to. So, um, all right. But we're talking about secondary infertility. Yes. Today, by the way, I think you and I have talked about this before and actually. Sierra entitled This Secondary Fertility, I think I wrote, I wrote I, no, excuse me. I titled The Secondary Fertility Challenges with Shiva and Josh. 

I love that because as I like to say all the time, I dislike the word infertility. Yeah. Because it seems to imply you'll never be fertile. Whereas we know that secondary fertility issues, or even just like, I never refer to you guys as infertility specialist. I say, oh, you're like, we'll send you to like the specialist, the fertility doctor, because you're really a fertility doctor. 

You're just gonna enhance it. So, you know, I think you hit a [00:04:00] very important cord there. Shiva. I mean, I, I think. . And, and, and when you talk, words matter and words have, have, have, um, charged to them and carry weight. Mm-hmm. . Mm-hmm. . And I never consider myself an infertility specialist. I consider myself a fertility specialist. 

Right. Absolutely. Right. Yeah. And very few women are legitimately, completely infertile because that would imply a total inability to get pregnant. Yes. Right. To say you're gonna get pregnant, you might get pregnant on your own spontaneously. You might need help with oral medication, you might need injectables, you might, might need IVF or a donor egg, or a donor sperm, or a. 

But one way or another, you will. Right. You will produce a child if you want to. Right. Or if you, and you're open. And you're open to what we have to offer. Yeah. Yeah. Exactly. Good. All right, so let's talk about, let's jump in secondary fertility issues. Yeah. tell us what's the definition. Well, so, so, right, so we, so words do have meaning, right? 

Words do matter. And so what is secondary versus primary fertility challenges? Well, primary fertility challenges means you've never gotten pregnant having in having trouble with the first pregnancy. [00:05:00] Secondary, obviously then is having trouble with subsequent children. And, and it doesn't just mean the second, it means all past the first, right? 

Um, it also has a very small technical like sub definition that the first. That the first one was not conceived using fertility treatment. So if the first one was conceived using fertility treatments, the second one is still kind of considered primary in the sense that you had trouble conceiving on your own. 

Right. Just a little, little, little sub definition. Yeah. Meaning if we were gonna classify what someone has, we would still say they had primary fertility issues. Right. They knew have splitting hairs. Yeah. But I mean, tell me if you hear this phrase all the time to, because I literally hear this every single day. 

Mm-hmm. , I'll say, doc, I had no trouble with my. Yep. It was easy and I can't, I'm having trouble with my second or my third. What, what's the difference? It should be so easy. The first time was so easy. Right? I, I hear that a lot. Do. . Yeah. I mean, I hear that a lot, which is hence the reason I give out you and the fertility doctor's names a lot. 

Yeah. Um, I also hear a [00:06:00] lot, actually, and this is why I, I probably tend to send patients to fertility specialists earlier than many doctors. Yes. I hear a lot of. I had no trouble the first time. Why is it so hard this time? And I say, how long has it taken? Because I think we should review the definition, which is Sure, if you are under 35, in theory, according to the American College of ob, G Y N, you should try for essentially 12 months, right? 

Yeah. Before you should be considering yourself to have any issue. And if you're over 35, you should try for six months. Yes. So I have a lot of patients. First pregnancy, they got pregnant literally right away, which I always joke, gosh, that's a crying shame cuz second time around when it takes you 3, 4, 5, 7 months, you think there's a problem when there's really not sure. 

But to be honest, because as women we do get anxious and because in the modern world we do kind of wanna try to plan the things we can, which is not a lot, but the things we can, I do tend to say, listen, the definition is you. You don't have a problem unless it's been a year, for example. But if you want to go see a special. 

Have at it. Right, right. And [00:07:00] many people do. And I, and, and by the way, because I'm less of a rules person than you are and a protocol person than you are, while the protocol would be, don't refer to a specialist unless it's been, you know, six to 12 months depending on age. I think that discounts. The modern world and how much anxiety is placed on women, not on men who are making a lot of these ACOG rules, right? 

Because listen, we know that we can't plan everything, but I don't think, well, I wanna diffuse anxiety for my patients by telling them the guidelines and saying, don't stress out if it's not been a year right? I also wanna acknowledge and value the fact that. . We are living in worlds where we are a little bit older when we have babies, where we have careers and jobs and lives. 

Right. And we have to plan the degree that we can plan. So I never think it's bad to send people early. Right. Also, I mean, you know, protocols or, or, or anecdotes like that. I mean, they don't really treat the whole person. The whole person has feelings and emotions. Mm-hmm. and stress. , um, worried about this or job or timing or this, right. 

And, and, and I think that to ignore that part of it and, and say, oh, you [00:08:00] shouldn't see somebody, you shouldn't diffuse your anxiety shouldn't learn more, I think you're doing a disservice to people. So I always say, yeah, hey, look, you guys aren't just like sperms and eggs to me. You're a person. Let's talk about the whole person. 

And if this part of the person needs to come in, Come on in, why not? Yes, yes. Good. Yeah, I totally agree with that. I know you Okay. Okay, so secondary infertility. Yep. We defined is after, so I'm gonna go through a couple of the questions. Sure. I think your followers might have put forward. Sure. So what is. 

how is it diagnosed? Yep. We kind of said it, but repeat that and what is the most common reason for it. And actually the third to tie in is, yep, how long should I wait before talking to my OB about seeing someone? So maybe tie that in as well. Sure. Which we just re reviewed. But does that change anything? 

And the answer could be maybe, , right? So everything SVA said is true. Let's start there. All right, . Um, basically the same definition, uh, the same definitions for timing are, are true for secondaries, are for primary, um, about 12 months. If you're under 35, 6 to six-ish months. If you're between 35 and 40 after 40, come right in. 

Um, but [00:09:00] that also is, is if there's no obvious reasons for a problem. So if you're not ovulating, if your cycles are irregular, if you've had some major surgeries that you're worried about, you know, yes. Uh, some pelvic factor, if there's something wrong with your, uh, with your partner's sperm source, like there's some medical issues going on there. 

So if there's an obvious issue, don't waste time. Come on in. It makes no sense to punch a clock for, for no reason. Right. Right. So, um, let's see. How was secondary fertility diagnosed? It's, it's basically time-based. Um, actual pregnancy rates per month are not as high as everybody thinks. Right. So unless you're like 16 years old in the backseat of a car Right. 

It's only about 20% chance per month under the best of circumstances. Right. Which is still mind blowing. Right. I think to many of us as. . Um, because we always think it's higher. And, and especially because as doctors we see so many surprise pregnancies that, that number, even though I know it's true, yeah. 

It still confounds me. Well, you, you know, what we also don't hear is you only hear the one good news from people who curate it and put it on Insta or how they're gonna, how they're going to it. It, um, announce it to the world, but, but [00:10:00] you don't hear that maybe the dozens or hundreds of bad news is out there at the same time. 

So everybody thinks everyone else is getting pregnant on their first try. Right? Or everybody else thinks everyone's on vacation living their best life every minute of every day. Right. Cuz that's what we curate. Right? Right, right. And that, that's also not true. Right? That's also not true. Now the problem with that 20% number, Shiva, is that it's not a forever number. 

It goes down with time and it goes down with age. And this is why we stratify, right? So it's 20% first, 12 months after. Goes down to like four or 5% chance per month. Right? That's not point. Oh. And but, but is it safe to say that you, we don't really have numbers for What's the likelihood in the. First or second month of trying versus 12th month of trying. 

It's just that if it's taken you more than 12 months, we know that that cohort of patients is gonna have less likelihood. The cumulative rate in that first year should be about 85% of patients should conceive by then at least 15% who don't. That's, you know, one in. It's one in six people. That's why we're so busy and need and need some help, right? 

Right now, the same thing is true for the first six months after 35, it's about 20 ish percent for the first E [00:11:00] each. Six months thereafter, it goes down to like three, four, 5%. So that, that's why we make those distinctions is when you should come in and talk, right? But again, like Dr. Gani said, anytime you're anxious, anything that something's bothering you, anytime you have a nagging doubt, that's something wrong, come in. 

I mean, there's no reason not to talk. No reason not to get knowledge, right? Knowledge is power. She and I always say, . Mm-hmm. . Okay. So when we talk about the reasons I do wanna circle back cuz I think we are gonna talk about like inter pregnancy intervals and things like that, but yes, when you said, what if there's an obvious thing that you're thinking of like pelvic surgery. 

So a lot of times my patients will say, well, but I had a C-section. Do you think I have scar tissue now because of that C-section? And is that why I'm not getting pregnant? And my answer would, The likelihood of that scarring your tubes and decreasing the chance of getting pregnant is small, but it's certainly possible. 

Sure. So if it's gonna make someone feel better, and frankly, let's face it, if they either have insurance coverage or the ability to come and pay for it, then I don't think there's any harm. Because when you do some of the tests, you guys do like an H S G test that might [00:12:00] easily fix something like that. 

But what are some of the other obvious reasons, like you said, , you said not ovulating and surgeries, right? So let's, let's just go to the basics first of all. High M, mss, g i c u. All right. Second of all, um, let's just go back to the basics. Whenever any fertility issue or challenge is involved, usually about six main categories, we've, we've talked about this before, you and I, lots of times. 

Yep. So sperm male factor, 40% of the time there's a guy problem. All right? This is a team sport. I say that every time, and let's just review that when, when they come see. The man has to have his sperm checked, even if he just got someone pregnant that year before. Absolutely not. Okay. It's a team sport. We insist on it. 

You do everything in parallel, not in series. We don't make the woman go through like invasive tests and then do like the easiest thing in the world for the guy. No way. We're gonna do it all in parallel. I don't care about his discomfort or whatever. Right, right. All right. That leaves five things on the female side of the aisle, which of course women always shoulder a harder burden in everything. 

We know that. Right? Right. So we check the fallopian tubes cuz there can be blockage. Mm-hmm. , we check the uterus cuz there could be obstructions, polyps, scar tissue, [00:13:00] fibroids, unusual shapes to the u. Usual. Mm-hmm. , we check hormones like thyroid, prolactin, vitamin D levels, estrogens, progesterones. Mm-hmm. , we check perna. 

uh, or Preconceptual blood work to make sure you're healthy for pregnancy. Mm-hmm. , make sure you're not anemic or diabetic. We check preconceptual genetic screening to make sure the pels not carriers for the same things that could affect the babies, like cystic fibrosis and SMA and fragile X, right? 

Mm-hmm. . And then here's the big one. The eggs always comes down to eggs, right? Two main categories of egg issues. One is ovulation, right? I mean the egg coming out to play with the sperm, right? Um, typically a woman who has regular cycles is ovulating pretty reliably, so, . Hi Isabella. Um, and it typically someone who has very regular cycles is, is ovulating someone who has irregular cycles? 

That that's a real, that could be an ovulation problem. Right? Right. And that's a whole conversation that you and I have had in the past, but just leave it there. Right? And then the other main category of egg issue, and this really ties into secondary fertility challenges, is the biological clock, right? 

Mm-hmm. by definit. , [00:14:00] you're gonna be older for your second and third kid than you are for your first, by definition, it doesn't work the other way around, right? Mm-hmm. . And so there's a biological clock that we and I have talked about many times, right? Finite egg supply. A woman has a certain number and quantity of eggs that have to last a lifetime as we all get older, decrease in quantity and quality of eggs for every woman. 

It's not, it's not about any one person. I don't want, right? Anyone's, um, high Virginia. I, I don't want anyone's like ovaries to get defensive, but it's just true for everybody. Decreasing quantity, decreasing quality. of, of eggs. So ovarian reserve or how much gas is left in the tank. We check with FSH levels am H levels, ultrasounds of the ovaries, how big they are and how many follicles they contain, which is a proxy for egg count and age. 

Those are how we measure how much gas is left in the tank. And by definition, they go down with age. Right, right. And so, yes. So I wanna jump in really quick by the way, really quick, just to circle back. I mean people who are on this mostly are people who know you. So they know that you're a fertility specialist. 

But many patients will say to me or out, out on the interwebs, can't. , my regular doctor, just do [00:15:00] this workup. And I do want us to be responsible and say for other people listening in other areas where you don't have easy access to an R E I a, reproductive endocrinology and infertility, we'll say fertility. 

You should be called reps rfs, by the way. Yes. Wouldn't that be good? Um, you can't, some general OBGYNs will do. Not every single part of your workup that, that Dr. Harz mentioned, but a lot of them, yeah. Meaning the one thing I would say most of us, as for as regular. , we're not as good at Follicle cow. We're not as kind of deeply thorough. 

So I say to patients all the time, I send people to the fertility doctor all the time because I, it's just more cumbersome for me to do that work workout, right? In my practice when I'm seeing all comers, I'm seeing like 12 year olds and 90 year olds in pregnant patients and not pregnant patients. 

Whereas a fertility specialist is only doing this. So that's just so everyone knows. Some people out there might. All of this work up done with their generalist. And it doesn't mean your generalist is like taking on too much responsibility. It just means your generalist might be doing more than other. 

And some have more of an interest in the [00:16:00] fertility world and some people have more my more interest in menopause or in surgery. So everybody has their own little sort of niches in the OBGYN world, but a lot of the stuff we're all trained to do is OBGYNs. We just don't concentrate in it. We all know like what you do every minute of every day is what you're good at. 

Right, right, right. Um, I mean, there's doctors I rely on to do great jobs like Dr. Garran. Mm-hmm. , and, you know, there's some people when their stuff comes in, I have to kind of take a second look at it. Right. Depending on who they are and what I know about them. Yeah. Well, and you know this, or you might, I mean, I'm sure you know this by now, with all the patients who see from me, I don't do much of a fertility workup because I say to patients, I can do it. 

Obviously, it's not like the initial part I can do, but the challenge for us is getting the patients in for like, for the h s. For the saline sonogram, for all the blood work on time, for the semen analysis in the right. . Whereas in a fertility practice you can do it. Um, to me, I always say you can do it in a concerted effort and in a better way. 

So that's, I just wanna differentiate for anyone listening why you would see a fertility specialist initially versus your general OB GY for the workup, when you could theoretically see either. It [00:17:00] depends on your generalist. I, I think that's a very good point and, and like I said, some people more interested in it than others, but this is like all we do all day long. 

So I don't know how to do pap smears or interpret them. I don't operate that much anymore like you do, you know? So I just think it's what we, right. Yeah. Now here's an important point. I'd love to jump. , um, is why, what are the, in my mind, secondary fertility challenges and primary fertility challenges share many of the same origins, just like we talked about. 

Right? Right. But what are the distinctions? Today's about secondary, right? Right. Well, by definition you're older and as we go down the road in our life, we accumulate issues. So number one, you're older is a diminished ovarian reserve compared to when you were younger. Just by definition, even if it's not weakened, it's still. 

right? Um, that's number one. By definition, you're older. Number two, you know, we accrue things as we get older. Like, I, I wasn't born bald, I got bald, right? Mm-hmm. . And so as we get older, we accrue health problems. We get our sugars go up, we get pre-diabetic and then diabetic or insulin resistant. Our blood pressures go up in the thirties and the forties, not the twenties or the early thirties. 

Mm-hmm. . Um, we accrue surgeries in our uterus. We [00:18:00] grow fibroids more as in their thirties and our forties, and polyps and adenomyosis. Things that you're not born with, but you have to grow. Right. And I think that those things can accumulate and can give you more challenges as you, as, as a woman is having her second and third and fourth child, for sure. 

Right, right. So when do you, is there data on what is the most likely cause? Is there one single outlier that you guys see? Sure. It's what I say every minute of every day, every waking breath I take you ready? Right. It's the biological clock, right? It's the, the clock. So, so again, not the eggs popping out, not ovulation per se. 

But the quality of each quantity and quality, they walk down the path together. And there's a difference between ovulation cuz there are 48, 49, even 50 year old women who haven't gone through menopause, who are ovulating. But they have really, unfortunately no, and I say this not to be blunt, but really no chance to get pregnant on their own. 

Right. Very little chance. Just say again, not no chance. Just incredibly, very little chance. Very little chance. If you're 50 and you're getting your period, there is a teeny chance. [00:19:00] Sure. Can I say that? Just so you don't use birth, don't shirk using birth. Fair enough. It is the gem. Fair. Fair enough. You don't see them cuz they get pregnant with us. 

But again, you're right. I mean point, point being, even with ovulation at that age, the likelihood is so much less. . Yeah. Because the quality of their ovulation and Right. There's some, some really like very telling statistics out there. So life expectancy has, has like doubled in the last 75 years, right? 

Mm-hmm. , uh, practically doubled, I should say. It's gone up by about 50%. So it's not quite doubled, I use the wrong word. Um, the age at first baby has increased by like 40% over the last 50 years, right? As life pa, as life expectancies increase and as women have, thank God educations and careers, they delay childbearing. 

Right. And um, and, and that leads to a penalty of when you're building your family, unfortunately, right? Mm-hmm. . And so while it might be not too hard to get pregnant with your first at 34, that's a reasonable age, right? But that means you're having your second at 37, something like that, then you're, you're third at 40, right? 

Right. And those are harder ages, not, not impossible, any stretch, right? . [00:20:00] Not at all. I mean now, not at all. Not at all. But, but by definition you're starting later. Like the anecdote I've told a couple of times here with you and me together is that my mother-in-law, God bless her, graduated high school, got married to my father-in-law, had three kids, including my wife before they were 25. 

Right, right. Like that doesn't exist anymore. Right, right. Well, and it does sometimes with people who, with many of our patients who didn't intend it, but, and that's okay cuz they ended up being That's great. But it, but it is like, the fact is biologically we were. get pregnant and birth at younger ages, which is why I say all the time, listen, I love nature. 

I respect nature. And I also want us to appreciate when have we departed from nature and therefore we have to accept that we will intervene because we have not set the table for nature to show up at our party, right? So by having careers, marriage is all those things that I'm glad we have. That means like when I tried to get pregnant, as you know, I have three kids, but I had no in no fertility issues saved. 

keeping my pregnancies right. Right. So I got pregnant easily and part of that was just like you said, I had accrued a lot of weight, I had accrued a lot of stress. All [00:21:00] those things that can probably feed into it. So I do. I think that it's great to be older, as long as you are realistic, that it might be more challenging to spontaneously get pregnant on your own. 

Sure. And that's okay. And be, and be open. And be open to counseling and be open to help. . Yes. Right. Yes, I agree. Yeah, I think that that's a good way to put it. So, uh, you know, let's, let's circle back to the C-section question. Yes. If you don't mind, cuz that came up. So a about give or take a third of pregnancy, 30% of pregnancies are born by C-section. 

Is that a good number? Yep. Give or take. Mm-hmm. . Yeah. Give or take something like that. Um, and I don't think I need to tell anybody out there who's listening that pregnancy and c-section takes a toll on the body. Right. Anyone who's had one knows that. and there can be some issues. Theoretically you could get some, uh, some adhesions or scar tissue inside the wound cavity. 

You can get some adhesions or scar tissue in the pelvis and get some block tubes. It's unusual because Right. You know, you know, modern surgery and ob gyn surgery is so good and so controlled these days, but everybody heals differently in certain cases. Go certain ways. Right, right. Um, do you [00:22:00] see problems with your patients after a C-section, Dr. 

G I mean, I think that, well, and this is what I say all the time in, in an effort. Normalize and equalize and not incite anxiety about C-sections as opposed, I hate even saying versus, but C-sections versus vaginal deliveries. Yep. And again, I'm very transparent. I had one vaginal delivery. I had two C-sections by choice because my vaginal delivery was very challenging, which is not to say everyone should have a C-section. 

Right. But it's also not to say everyone should have a vaginal delivery. Yep. So you can have two separate issues. If you have a vaginal delivery, you sometimes have to deal with pelvic. Issues. If you have a C-section, you might have to deal with scar tissue. Like Josh said, you might have to deal more so than seeing scar tissue that blocks the tubes. 

Yeah. We do see sometimes that that lower uterine segment. The scar, yes. That we've created can be really thin. Yes. So not commonly, but I would say, Once or twice every couple of years, we do have a patient where that scar almost looks so separated that it hasn't fully healed, and that can sometimes lead to just blood that gets trapped and some challenges getting pregnant. 

Right. The, the bigger [00:23:00] issue becomes, and I think you and I were gonna talk about how long should you wait Yes. To try to get pregnant and in fact, today alone, I had. Several patients, but one in part, many postpartum patients in today for their like six-ish week postpartum visit. And a few of them, because they started out past 34, 35, 36, and now they're already talking about their second baby and they want to get pregnant and they don't wanna wait too long because they're older. 

And again, I always joke like it's all relative. I had my kids at 34, 38, and almost 41 . So when a 36, 6 year old is telling me, like, I just feel older, I, I wanna legitimize. Acknowledge that her eggs, of course, are biologically getting older, but I also wanna comfort her that the likelihood is she's going to have another baby. 

and we tell patients, which I think you do too, that they really should wait at least a year. Yes. After, by the way, vaginal or C-section. Yes. Not just because of the scar, but because of the in environment. We want that inter pregnancy interval to be at least 12 months, if not 18, though I have to be honest.[00:24:00]  

Well, pushing. Tell me what you say. Well, I mean, I'll tell you what the American College of OBGYN says. Yes. Um, you know, they say a 12 to 18 month inter pregnancy intro regardless of delivery mode. Right, right. I think 18 months is punitive. From the delivery to the next pregnancy. Correct. That's what the inter pregnancy interval means. 

Yep. Right. Um, I think 18 months is pretty punitive. I agree. Um, I also do think that there's a difference between vaginal delivery and c-section. If, if it was a traumatic C-section, in other words, if it was an urgent one, an emergent one, if there was bleeding or anything like that, but beyond just the healing of the uterus, would, would you agree that there's probably other things that go into. 

Increased maternal and fetal outcomes if you wait a year so that you know your bones, you know, gain back their calcium and their bone density cuz you know, pregnancies like leach it outta the bones or your, or your bone marrow to regenerate like, um, you know, iron supplies and being able to like, you know, alleviate anemia, even joints recover from the relaxant of pregnancy. 

Right. I mean, I think there's more to it than just healing from the delivery. Oh yeah. I mean, I think, listen, I say to every patient at their [00:25:00] six week visit, like I know we say like, six weeks, okay, you're done. I thought it really took my. 10 months easily, and that was without me nursing, and that was vaginal or C-section. 

10 months before I was like, oh, this is my new norm. This is how I feel. Right. Up until then, I was fine. I was working, I could cope with it. But your body goes through so many physiological changes, so it is important to know that even at six weeks, we're not saying you're done healing. So to your point, yes, I think that in an ideal world, I really encourage patients to wait a year. 

Yes. I will tell you, I don't say 18 months. That's punitive. It's not fair. Yeah, and, and I think especially when people are already anxious about getting older and. . And here's the truth I I though I really hit home the fact that many patients will either assume they're not gonna have a lot of sex, which is very appropriate because they're exhausted, they're tired. 

They might be nursing, , all these reasons. Sure. But because of that, they end up not going on birth control. because they think it's just gonna be a couple times. Right? And then they withdraw. And withdraw is not a hundred percent. [00:26:00] Yeah. At best, in the best data. 92%. Yeah. Hope. Hope is not a hope is not a plan, right? 

Hope is not a plan. Yeah. as at least by my third child. So I'll tell you that right now. I don't know if I've told you this, but. We in our practice, have record numbers of patients with short inter pregnancy intervals, inter interesting during covid. I mean, literally we, every year we would get a couple of patients who would get pregnant right away, like after their baby was born, before that. 

So they would be, you know, less than a year from that inter pregnancy interval. Occasionally what they call Irish twins, which is so, you know, derogatory. But now this last, I'd say five months, we have. legions, like literally dozens. Wow. I'm gonna guess like 25 to 27 patients. Wow. No joke. Wow. Who were pregnant in very short intervals like babies born less than a year apart. 

And then several women who were born, whose babies were like a year and a half apart, so they got pregnant at eight to 10 months. Knock wood, we have not yet seen complications in our particular patients, but the data would show that there will [00:27:00] be risk. Preterm labor. Yeah. And growth restriction. Yes. Again, outside of the C-section scar. 

But just because that intrauterine environment hasn't healed, we know that. Right. But then the scar, we do worry that certainly I would not want someone to try vaginally after a C-section if they've had less than a year. Right. That's that's a good point. And even towards the end of the pregnancy, they, it might thin out. 

So I do think it's good to, in an effort to not be so worried about secondary fertility, decide that maybe you're gonna try it a year, but don't kind of. and try earlier just in case, because the likelihood you'll be okay, but what if not right? You know, a challenge I have is someone comes in and they're 30. 

And they, you know, let's say they don't have a lot of time, you know, necessarily Yeah. You know, they're worried about their biological clock and they're, they pressure me to come in and start earlier. So I'll, I'll gauge whether it was a high-risk pregnancy or not. Whether they had growth restriction or not. 

Whether they had an urgent or bad C-section with tons of blood loss or not, um, or things like that. Yeah. And a lot of times we'll sort of start our workup getting ready [00:28:00] for either a transfer or a fertility treatment, like around 10 ish, week 10 ish. Something like that, right? Um, for an ultimate try about like in that 11th to 12th ish month, you know, kind of like, just like, you know, sneak in under the line, right? 

Because again, like we said at the beginning, you have to consider the whole person. The whole person is on protocol, on a page of an acog, you know, bulletin, right? The person is, hey, what are their hopes and dreams? What's their ultimate family size? What are their feelings about waiting and how it's gonna devastate them? 

And, and versus how much it might pr decrease their chances of having a second baby if you punitively make them wait. Versus, you know, trying to optimize maternal and fetal outcomes because that's what we do as doctors. So that, that I get challenged there a. . Um, I, I agree. And actually, by the way, just so you know, I, so many of my patients who, who see you or other res when they say, well, I have my embryos already. 

I'll just go back and I always say, listen, they're not even gonna let you transfer an embryo until about 12 months. Right, right. And let's just be clear. It's not to be mean, it's to take care of you and the next baby. Right. Right. Let's, it's, it's really to [00:29:00] optimize your outcomes. Let's be very clear about that. 

Yeah. Right. Yeah. So do you guys consider, so we have increasing numbers of patients, again, getting pregnant in their late thirties and early forties. Yep. And if they miscarry, yes. I will also, as you know, very frequently tell them that they can certainly try on their own again, because they got pregnant on their own. 

Yep. They do not have fertility issues per se, but, that because as they're getting older, their egg quality is getting older, their chance of a miscarriage and things like Down Syndrome increases. Yep. They are in a position where they have the opportunity to, instead of trying on their own spontaneously, go see the fertility people so that you can potentially do I V F S and then pick the embryos that are healthier so that the patient doesn't have to go through potentially another miscarriage that's not the same. 

So that's a very loaded, loaded statement and loaded question in a good way. It's loaded in a good way. So the question is, does IVF with pre-implantation genetic testing, um, can that treat recurrent pregnancy loss or just the increased risk of [00:30:00] miscarriage and down syndrome as we get older? So the answer's both yes and no in there, right? 

Right. The age-based risk of, of any pregnancy being chromosomal abnormal being a loss goes up a very quickly with age. So at the tender young age of 35, that risk is at one in four pregnancies will be a loss due to chromosomal, abnormal, uh, abnormalities regardless of how you got. , right? By the time a woman's 40, that number is 50%. 

Well, wait, I'm sorry. Let's go back. Yeah, hold on. At 35, your risk of a miscarriage is still the, it's 25%. It's 25%, one in four pregnancies, but all of those, but not all of those are chromosomal. Correct. Vast majority though, are gonna be chromosomally abnormal at the age of 50. 50% of the egg cohort is chromosomally abnormal at that point. 

Right. And 50% of pregnancies will be a loss at 40, probably due mostly to that. That reason right now at 42. , probably 75% of the eggs left are abnormal, and at 43 and above, probably 95% plus the rest of the egg pool is chromosomally abnormal. So that's why miscarriages is really that high. Yeah. Yeah. I'm soft peddling it a little bit [00:31:00] too, by the way, just so you know. 

Yeah. I mean, I'm only, yeah, okay. I'm just gonna take those numbers as statistics that I dislike and Fair enough. And I, I talk about 'em every day and I don't like them because that just sounds higher than you're, you are very good at statistics, so I believe your numbers. Yeah, but that sounds higher. What the optimistic generalist in me wants to Okay, fair enough. 

Wants, wants to proactively tell people, go see the fertility specialist. But the good news is, yeah, if you get pregnant, you will likely have a healthy pregnancy ultimately. Right. Socially, getting, getting back to, wait, hold on. Excuse me. Getting so, so the, the issue is as we get older at higher risk of chso abnormal embryos, which the vast majority of those will either not be pregnant or first trimester miscarriages very, very, very rarely do they ever escape the first trim. 

Um, and become second or third trimester losses, which is a catastrophe. Right. Or a sick child. So let's not, we don't need to be scared about those things. Right? Right. Um, but a miscarriage is devastating. I don't need to tell anybody that. Mm-hmm. . Um, and so IVF in the older age group, let's say 38 and above, , uh, the numbers [00:32:00] shift where PPG t is a really good option. 

Pre-implantation testing to identify good and bad embryos and only transfer single good embryo at a time is a very good tool. Yeah. That is different than recurrent pregnancy loss, which is a separate group of patients, which you and I will do another Insta about. That's a, that's a, that's a much bigger conversation that, we'll, that'll happen. 

Right. And, and I was talking about honestly, just a spontaneous pregnancy in the forties. Where a patient says, but I already got pregnant and this was great, you did get pregnant with a miscarriage. So you can try on your own, but then you might go through the heartache and anguish of either not getting pregnant or having another miscarriage. 

So then the question becomes, they're not technically having any secondary fertility issue, but do they preemptively go to you? Well, yes and no for purpose. Yes and yes and no though, because I would argue what's the. of trying to get pregnant. The point is not to have a positive urine pregnancy test or a loss. 

Right. The point is to have a baby in your arms. Right? Right. Exactly. And so if you get pregnant, sure. You could say that the plumbing's working an egg and a sperm got together, went through the tube and implanted the uterus. Great. The, it shows proof of concept. [00:33:00] The plumbing works. Right, right, right. But ultimately, the goal. 

is to have a baby. Right? Right. And if someone has a loss, they say, well, I have no trouble getting pregnant. Well, but you're having trouble having a baby. Right. So that's why I do think your point about, hey, if you're 38 or over 40 or older, better to come in sooner rather than later for those reasons. 

Right. Well, and the way I couch the conversation, I think you know this, I told you is. Are you telling me that a thousand percent you would like to have a baby? Because if you would, then I would personally say, let's be more proactive. If on the other hand your response is, you know what, if I get pregnant, it's great, and if I don't get pregnant, it's equally great. 

Which by the way, no disrespect to fertility doctors. I wish for women, yes, that we actually could feel that way. I wish we could. As I've said before, like I wish we could be happy with our journey regardless of whether or not it makes us mothers, and I know that. , um, inflammatory as an ob, especially talking to an r e I, but I, that's something I grapple with all the time. 

I never want to, to imply to women that your only happiness is gonna be through [00:34:00] motherhood. Right. But, but that secondary, that's a very, that's a very important point that everybody should, should hear, right? I mean, not everybody has to follow the same recipe for life, right? We all know that everybody lives their own life, right? 

But we really don't because we have so much societal pressure. So, but there's also a large drive to build your family. Like we all do feel that. , just some people, if I could help, maybe like just tailor that at the end. Some people want it on their own terms, right? If I can do it on my own, if I can do it in the privacy of my bedroom, I'm happy with that and I do want that. 

Right? But if it takes talking to this guy, I don't want it. If it takes, you know, taking medicines or doing a procedure, I, I don't, I'm not into that. So really, you know, do you want a baby at all costs, which means being open to what I have to offer, right? Or do you only want a baby? You can do it the way you wanna do it. 

Right, right. And I think that's, I think it's great to know what you want as, as a person, as a woman, and also to be open to the process either way, if you know that I'd really like to have one if it's spontaneous, but otherwise I'm actually fulfilled and [00:35:00] happy regardless. To me, that is like the most beautiful thing because that means you've reached a sense of, of calm and happiness. 

I do think that most of our patients aren't in that category. Most of our patients are willing to. I, I, I think you're right. And by the time they get to me, they certainly are. But here's how I phrase it with patients, and I, I think we're saying the same thing. I just say it a little bit differently, is I say to them, Hey, look, your goals are my goals, right? 

Like, that's what this relationship, you tell me what you want, I'll help you get it. I'm a problem solver, right? That's what I like to do, right? So if you tell me you're willing to do this, to get there, well, we'll do that. But if that's your goal, we'll just do that. Right? But if your goal is to, to be, to open all these other things, well, I have all this stuff, but I can't do what they don't want. 

Because if that's not how they want to do it, if that's not their journey or their. You, you know? Right. And so there, those are my goals. Well, that's a good point. Listen for the, for the, the listeners out there. That is a good point. So I will often say, when I'm gonna send patients to a fertility specialist, you have to understand that when you walk in that door, the assumption is that you would like to be pregnant. 

And that therefore because they're excited to get you pregnant, they're gonna do everything they [00:36:00] can to get you pregnant. And I say that because I think some patients, all of a. Hold on. I thought I was kind of just on a fact finding mission and all of a sudden I'm getting all this information and I'm being told all these things and it just seems like so much, and that is actually really true. 

It does seem like a lot, but I think the, the, um, the realistic side of you has to understand, like you said, , your goals are the patient's goals, right? And you assume their goal is to get pregnant. And so they have to walk in there knowing that. So I try to really manage their expectations. Cause I, the last thing I want is for them to think they're kind of going in for like a casual chat about possibilities in the, in the future. 

And all of a sudden they have like a list of, you know, semen analysis, blood tests, H three. You know, that's a really good point. And it's in my nature to say, okay, this is what we're gonna do. Let's get this done. Yeah. And that's in my nature as a problem solver. Right. So I, I like that aspect of it, but you are right. 

There are definitely patients who don't have that immediate goal, and I, I actually have to reign my ba myself back sometimes. So I really appreciate you setting myself up by success, by me too, you know, managing their expectations. I appreciate that. Yeah. [00:37:00] Well, I think I have a question for you, Shiva. Yeah. 

You ready? So a question I get a lot af when they're, when patients are graduating from me back to you or to their other OBGYNs. Mm-hmm. is, Hey, what can I do in the meantime after I deliver, before I'm ready to have that second baby? What can I do to optimize my chances for the second baby and make it as healthy as possible? 

Like, how do I be proactive moving forward? Right. And. Do you want me to, well, I wanna hear you say, then I wanna hear what I say. Okay. So, well, I mean, obviously like there's the, the chronic medical conditions. Let's say you had hypertension, try to get that under control if you had diabetes. Try to get that under control. 

Um, the two things I will address, one of which you touched upon, um, is vitamin D three. So let's talk about that in a second. Yeah. Probably one of the biggest things you and I both know that will indirectly help fertility and directly help a healthier pregnancy is also the thing that is the bane of my existence that you and I talk about a lot, which is weight. 

Because you've had your baby, as you said, you're older, you've accumulated things like weight, and now because the baby, you haven't lost all your baby weight and you wanna get pregnant. And then do [00:38:00] you balance, do I stop and wait to lose? 10, 20, 30, like in my case, what was, I need to lose 90 pounds, you know, 10, 20, 30 pounds before I try again. 

Because it will make your, uh, your ability to get pregnant better. And again, your pregnancy healthier or do you cut your losses? Cuz 10, 20, 30 pounds takes several months or a year. Right, right. And so there's no easy answer and I think that, , while I wanna always touch upon weight with patients because I think it's a responsible thing to do, I really wanna try to approach it always in a way that is not like shame-based. 

Cuz clearly I have, I have always lived with a weight problem, so I feel like I never wanna shame anyone cuz that's not valuable and not helpful. Um, but, but those are the obvious things you can do. Right. I do want you, you mentioned in the workup vitamin D three. So tell us, cuz you know that might, you might know this, this is like my favorite vitamin ever is Dietrich. 

Yeah. It's actually, so vitamin D is not it. People call it a vitamin. It's actually a very powerful hormone in the body. It's a hormone. Yeah. Right? Mm-hmm. , it's got a huge, um, role in [00:39:00] metabolism of bone. It's got a huge meta, uh, role in metabolism, uh, uh, like in function of the kidney. Mm-hmm. . Right. Um, and a lot of other things that we don't actually know about. 

We do think that there's a relationship between low vitamin D and perhaps pregnancy complications. It's a little nebulous. It's being worked out, but like, well now they're saying preterm labor and preeclampsia. Preeclampsia, preterm labor. . Yep. Mm-hmm. . Yep. And breast cancer and colon cancer among other cancers. 

Oh, that's interesting. I knew colon cancer. I didn't know breast. That's actually very interesting. Yeah. I mean, again, good correlation because many people now listen, many people have the world are D three deficient because as I say, unless you're walking around naked, you are not gonna be getting a D three from the sun if you're wearing clothing or sunscreen or have a job. 

you're not getting enough from the sun, but so are you guys, because you mentioned it as part of your workup. I know you check all of our patients. I know all of our patients who come from your practice are on D three, which I love. But is that a new guideline or is that what you guys, we've been doing that for years. 

I don't think, it's not part of A S R M. It's not part of acog. Okay. We are trying to stay up to date on the literature. We know [00:40:00] that there's definitely a link between pregnancy complications and low vitamin. . Yeah. It is a, it's an active area of research about fertility issues like male fertility issues like sperm or female fertility issues. 

An active area of research. It's, it's unsettled right now, but I think it stands, the reason the healthier you are, the healthier you should, your fertility is innovate and some did about, about recurrent pregnancy loss. ND three, I think. Like, I remember seeing data from India where they're very, they have a very high rate of Vitamin D three deficiency, super high. 

Oh my gosh. Super high. Yes. Right. And, and I remember seeing some data from there, but I, I haven't seen it in any of our, I'm gonna follow up on that. I, I actually don't know enough to talk about that one. Yeah, yeah. But suffice to say for everyone, Pretty much everyone on our panel right now probably needs to take some vitamin D three because they're probably low unless they're walking around naked, right? 

So, so what I always tell people, when people, what do I do? I like clean, healthy, living. The same things that make you healthy, heart, healthy and clean, healthy living you should be doing. I can't stress enough to repeat what you said about if you have a chronic medical condition, get it under control. Oh my. 

you [00:41:00] know, get your act together about it. Like if you have uncontrolled hypertension, that is horrible for pregnancy complications. Right. And you will do better if it's under control with medicine before you get pregnant. Same thing with diabetes. Oh yeah. I mean, those are two of the biggest. Yeah. Thyroid and guess th Oh, thyroid. 

You know, check in on that. Um, I, I would also say that, you know, we accrue, um, not just medical issues as we get older. We accrue like, like habit issues as we get older. So you. 10 year olds don't smoke cigarettes, thank God. You know, things like that. So if you're a smoker, if you get more secondhand smoke, you know, things like that that accrue as we get older, you know, people, a lot of people smoke weed these days. 

You know, it's the same thing as alcohol. You know, I don't, I don't have a judgment on it, but those things have negative impact on male and female fertility. Right. Right. Mm-hmm. . So, oh, you know what we should talk about for a sec? Male secondary fertility. Ooh, let's talk about that. Let's talk about that. 

Like team sport, I always say it's a team sport, even if a guy doesn't wanna recognize it or a woman doesn't wanna like, you know, bother their partner. Right? Right. Um, but men have the same or doesn't have [00:42:00] a partner. We still need the sperm to get pregnant, but then you get to just pick the sperm. So it's different. 

Who needs to do to get pregnant? We don't need a guy around, you know, come on. We really don't. No, we don't. I think we know that. Yeah. Yeah. So, so men are just as, um, susceptible and even more so perhaps to some of these issues. Hypertension, diabetes, um, central adiposity, which is like an apple shape, like a big beer gut, like a lot of us guys have. 

Um, that is very bad for testosterone levels, very bad for spermatogenesis, which means making sperm. Mm-hmm. . And so guys have the same issues. Right? So libido goes down in men as they get older. Testosterone levels wa um, the biological clock does affect men, but not really as, as it's much more mild. It's much, it's much more mild in men. 

Doesn't kick until the fifties. Not fair. And even very mildly at that. Right. Right. But all of those things that, you know, uh, uh, weight accrue as we get older, high blood pressure, diabetes, uh, guys can have surgeries, guys are drinking, smoking, you know, weed, the whole thing as we get [00:43:00] older, they accrue. 

Right. And so this is not just a female issue for sure. Right. . Yep. It's a team sport. It's a team sport. So I think, I think we've talked a lot about secondary fertility challenges. Mm-hmm. , um, I think, again, the, the message to maybe if I, I'll tell you how I want to conclude, then you tell me how you want to conclude. 

Yep. I think the issue is always, is. , be curious, be proactive. Be your own advocate. Mm-hmm. , if you feel like something's wrong or you're anxious or you have, you're curious about what could be next or you're anxious about what's around the corner, come on in. Yes. There's no one's gonna turn you away. Shevas door's always open. 

My door's always open. Um, and, and just be proactive with your health, but that includes your fertility health. I think that's really, I. . Yeah, I mean, I think that all ties in. Let's answer this quick question and then I'll tell you in my, my closing words. So, is vitamin D three in a prenatal enough or should take, should you take a separate supplement? 

Big question. Cuz it depends. The, the prenatals typically only have like 800 to 1200. I haven't seen one that has more, uh, and that's 800 to 1200. [00:44:00] I use international units. Yeah. Uh, the data for pre-term labor and pre-eclampsia was actually with 4,000. . Oh wow. Out of medi, out of, um, South Carolina. I actually say to patients, I don't tell every single patient they should take 4,000, but I say, if you want to look at your prenatal and then add up to 4,000, you can, or you can get your level checked. 

And ideally you want your level to be, if you're kind of using the old guidelines, they say above 30, but you and I would both agree above 40 would be ideal. Is the number you like, you like 40 I, well, because I deal with a lot of the perimenopausal ladies like me. See, I'm hot and schnitz right now with my peri, with my menopause. 

So you're glowing and you're glowing and beautiful. I'm glowing Our sweet spot for per, for menopausal like flashes. There's some data about a sweet spot of 50 to 70. Oh, not higher, not lower. What, what's a, what's a number That's too high cuz every once in a while I'll see people on the vitamin D drops, which is hyper concentrated. 

Oh, it drops. The only times I've seen someone. The drops. Yep. And they make me nervous cuz sometimes people come in with 80, 90, a hundred. I don't know if that's good. I, I don't know [00:45:00] what I can, I can do that. Here's what I have gleaned and found. If your, if your internist sees you at 89 0 a hundred, they freak out. 

Yes. If your, if your integrative doctor sees you at 80 or 90, they don't freak out. Okay. Since I am neither nor I'm in between, I like it to be between 50 and 70 because the data that I have seen, not so hard and concrete, but okay, some anecdotal data in myself, in my patients, and then some data in the literature is a sweet spot of 50 to 70, again, for perimenopausal and postmenopausal symptoms. 

Can I extrapolate that to pregnancy? No, but we know that last year or two years ago, they used to. 30 is the lower limit of normal. And now a lot of the guidelines are changing to at least 40. So certainly you're not even close to overdosing if you're in the, your fifties. But yeah, I wouldn't want patients to be above 70 or 80 when they're pregnant because we don't know the effect of that. 

But the drops, the drops freak me out cuz they don't, you know, really hyper concentrated drops because it's for anyone who's taking drops. It's not a drop, bur it's a drop. So you pull up your dropper, that dropper has like 50 drops in it. Yeah. [00:46:00] So I think those patients are like, oh. Because I don't need instructions. 

I would just take, they'll think it's a drop. Sure. Um, but yeah, so vitamin D three, which by the way is one of the easiest things to take because you can, yeah. You can take like an entire week's worth all at once. Um, my, I tell people to take it with food. Uh, Shiva, do you agree? Is it a fat soluble vitamin? 

Uh, here's the truth. We know it's a fat soluble vitamin, so of course it'll be beneficial if you take it with that. But I also am a huge fan of what I call the low hanging fruit, the easy. Right. And I think that the more constraints we put on people, like things that are twice a day dosing or things that have to be taken, I think that then we lose the value because very few people will really be able to stick with it. 

And very few people, let's face it, especially when they're pregnant, are fasting all the time. Yeah. So I usually just say to patients, to me the easiest is take it every night before you go to bed. Put it next to your toothbrush. I doubt your stomach is completely empty before you go to bed. Especially if you, I wish, I wish my stomach were empty before I went to bed. 

Yeah. I wouldn't have any, so, so yes, it's the right answer academically to everyone who's listening. But in [00:47:00] Shiva's real world, she tries to make things easier because then I think we'll have more buy-in. Right. Shevas keeping it real. That's what she's doing. So, okay, so my like little, yeah. How do you wanna conclude? 

Tonight's like little chat we've had. I always love hanging out with you and all of our friends on in stuff. That's so fun. How do you wanna. . So I wanna conclude a little bit of piggybacking on what you said, which is, I love that you said be proactive because anyone who watches knows I say I all the time about any part of your health is be proactive but not paranoid. 

What I never wanna hear from people, that's one of my isms. I call it proactive, not paranoid, like, and it could apply to anything. , you have something slightly irregular on your mammogram. Be proactive. Get it fixed, yes, but the likelihood of it being cancer is still low. And by the way, even if it's cancer, God forbid you will likely be okay cuz you got it fixed Early. 

Paranoia only leads to avoidance. Too much stress. It never is a healthy thing. So when patients say, I'm so paranoid I'm not gonna get pregnant, I say all the time like, okay, don't be paranoid. Be proactive about it. It ties into what I also say about nerves versus. nerves are [00:48:00] normal, but don't be scared about it. 

Right. So be proactive, not paranoid. That's it? Yep. Um, oh, and my sister just came on. Oh my gosh. Okay, everyone. My sister . My sister. Hi Nuen. A judge. Nuen my sister who's a judge and she's actually the chief judge of all of Miami-Dade County. So if you like, wanna see a total badass, she is the Chief judge of Miami-Dade County. 

Um, she is gonna be on Ashley Banfield's TV show tonight. What is it called? Nation something? Nish. You gotta tell me. Ashley Banfield, the former c n n reporter, is now has her own news show and my sister's gonna be on it tonight at 10 o'clock talking about covid testing in the incarcerated population and whether or not do I have that right Nish. 

Um, so everyone watch Ashley Banfield's show. You just gotta Google Ashley Banfield show. Um, and look, see, someone said, I told them to be proactive and now they have a baby. Yay. Hey, day. Um, so one last, one last thing to just wrap up here. First of all, I wanna say thank Dr. Graf. I love ying it [00:49:00] up with her. 

We know that, but everybody here should check out her tribe called V. It's really an amazing, uh, resource for women at any stage in their, in their journey, you know, through life. And, um, I can't think of anybody. I would. to guide me through that journey in life than you. Thank you. I love it. I have to say, so far we have our pregnancy program and it's so fun because we, there's an ebook, we do two lives a month. 

Our, our members have really been like excited cuz they, they learn a lot of stuff that even, even those of the women in our program who are my patients already, Don't get to hear all the stuff cuz we just don't have time in the office. So I know for anyone who wants to join, go to tribe called V and then there will be more stuff as my life gets a little calmer. 

We'll talk about menopause, pairing, menopause, all those things. Um, okay. Ashley Banfield, news Nation, 10:00 PM Eastern Watch my crazy sister. I'll be short, Sheva. Thanks. Love you as always. I'll talk you later. Thanks everybody. Who, who chimed in today? I love seeing all the, the familiar faces and names. 

Thanks. And I know that your immediate people want me to [00:50:00] remind you. Please, please, please. Can you, when you hit end, see if it will. Yes. Record. And I'm gonna do a quick screenshot so everyone smile. 

Okay. Hold on. Smile. One sec. Let me do a quick picture. Okay. Hold on. Wait, wait, wait. Hold on. Make me look good. I'm so shiny. Bye. Okay. All right. Bye love. See you later. Bye. Take care everybody. Bye.