Selected Podcast
Fertility and the Latinx Woman
Join Dr. Juan Alvarez as he discusses everything you should know about fertility as a Latinx woman. He covers the basics on fertility, the menstrual cycle and when to see a doctor if issues arise. He also shares common infertility diagnoses among Latinx women and why a healthy weight when trying to conceive can be the secret weapon for boosting fertility.
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Learn more about Juan Alvarez, MD
Juan Alvarez, MD
Dr. Juan P. Alvarez is board certified in both Obstetrics and Gynecology and Reproductive Endocrinology and Infertility. He completed his fellowship at the University of California, Los Angeles and Cedars-Sinai Medical Center combined program. Prior to his fellowship, he completed his residency at Emory University School of Medicine and received his medical degree from the University of Illinois at Chicago.Learn more about Juan Alvarez, MD
Transcription:
Deborah Howell: You know, fertility is a subject on so many women's minds these days, but are there differences in the fertility process for women in a Latinx community today? We're about to find out all about fertility in Latinx women with an expert in the field. I'm Deborah Howell, and our guest today is Dr. Juan Alvarez, a reproductive endocrinologist at Fertility Centers of Illinois.
This is the Time to Talk Fertility podcast. I'm your host, Deborah Howell. Dr. Alvarez, before we jump into talking about fertility in the Latinx woman, can you tell us why you wanted to focus on this in particular?
Dr. Juan Alvarez: Yes. The reason why I wanted to focus on this it's because one of my biggest passions is education, especially in the Latin community, as I am a Latino physician. And I do see a lot of Latin women who either don't have all the information that they need or they couldn't gather information from their practitioners about their own fertility. And I usually get lot of questions regarding the subject, in which I want to empower and be able to educate the Latin community.
Deborah Howell: Beautiful. So based on national statistics, the Latinx birth rate has dropped from 108 births per thousand women in 1990 to 65 births per thousand women in 2019. What do you think is driving this decline?
Dr. Juan Alvarez: Well, there are multiple reasons why the birth rate has been declining in not only the Latinx community, but all across the United States. There are certain factors all across different ethnic groups, such as putting off childbearing to later years. And we know that peak fertility is usually around the 20s for women. And now, more and more women are putting off childbearing until their late mid-30s. But more specifically in the Latinx community, it's sort of a little taboo to talk about infertility or fertility. And so most Latinx women really put off trying to see a physician or an OB-GYN or fertility specialists, because they don't know that this can be a problem and it could be a problem.
Deborah Howell: Got it. Now I know you'd like to bring us through the basics. So let's talk about the menstrual cycle first. What should women know?
Dr. Juan Alvarez: Women should know that they should have regular menstrual cycles. And usually, a cycle is somewhere between 25 to 35 days long. And it's usually very fixed. There's two parts of the menstrual cycle. There's the early phase called the follicular phase and then the late phase called the luteal phase. And so the cycle is very strict in the length, and that is because of ovulation. And so if a woman is having irregular cycle, that means that they're not ovulating regularly. And this will affect fertility, because a woman may be ovulating irregularly. And so if you can't time your intercourse at the time that you're ovulating, the egg only has about 24 hours in order to be fertilized. And semen only lasts in the genital tract for about 72 hours. And so if the timing between ovulation and intercourse is not aligned, then it's going to be more and more difficult for a woman to get pregnant.
Deborah Howell: And how can a woman confirm that she is ovulating?
Dr. Juan Alvarez: There are many different ways to know that someone is ovulating. The simplest would be through a urine ovulation predictor test. So right before ovulation, there is a hormone called the luteinizing hormone, which starts to rise, and this is the signal for the egg to ovulate. And so the luteinizing hormone also known as LH gets accumulated in the urine about 12 hours after it starts to rise. And so a woman can check her urine to see if she's starting to ovulate. And that will be a signal for ovulation. Some women also have mid-cycle pain. Some women also have breast tenderness when their progesterone starts to rise, and that's also another sign of ovulation.
Now, another physical sign of possible ovulation is cervical mucus change. As estrogen starts to go up, it's a signal that the egg is fully mature and ready to ovulate. And when this happens in the rise of estrogen, the cervical mucus changes from a dry sort of white consistency to more of a liquid egg-white consistency. And so all those signs can be a sign of ovulation.
Deborah Howell: Okay. Now, Dr. Alvarez, if cycles are irregular or a woman can't confirm ovulation, who should she talk to?
Dr. Juan Alvarez: She should definitely start talking to her OB-GYN about her irregular cycles and also any family planning that they have, because there are many different medical conditions that can cause irregular cycles. And so if a woman can plan ahead of time to figure out why she's not having regular cycles, it's going to be easier for her to be able to time her intercourse in order to get pregnant.
Deborah Howell: Okay. And what's the most common cause of irregular ovulation?
Dr. Juan Alvarez: The most common cause is polycystic ovarian syndrome. And so this is a syndrome where there is elevated male hormones called androgens as well as insulin resistance, which causes women not to have regular ovulation.
Deborah Howell: And how does PCOS affect fertility?
Dr. Juan Alvarez: There are different factors of PCOS that affect fertility. The main cause of infertility in women with PCOS is anovulation. Like I alluded to before, women with PCOS may have irregular ovulation. And so they cannot time their intercourse. And so if a woman is not ovulating, then she is not able to get pregnant. There's also evidence in women with PCOS that have insulin resistance. And so insulin resistance drives obesity, and we know that obesity as well has a negative impact on fertility.
Deborah Howell: And are there any symptoms to watch out for in PCOS?
Dr. Juan Alvarez: Yes. The most common symptom of PCOS is irregular periods. Women with PCOS also have abnormal hair growth, and that is due to the elevated male hormones, which are androgens. A woman can have hair in the male pattern way such on top of their lip, on their chin, their chest, their back, their upper arms, and all of these are signs of PCOS.
Deborah Howell: Okay. Now, how does a woman know if she has PCOS?
Dr. Juan Alvarez: The only way to know or diagnose somebody with PCOS is by doing laboratory tests. So, patients should definitely go see their OB-GYN with irregular cycles. And then their doctor is going to do a lot of testing, including a transvaginal ultrasound, to look at the ovaries to see if they have a PCO morphology or polycystic morphology as well as blood tests to show if they have elevated male hormones or androgens. And so that will make the diagnosis of PCOS.
We also have to exclude, so PCOS is really a diagnosis of exclusion. There are other conditions that also mimic signs and symptoms of PCOS such as thyroid disorder, elevated prolactin, or hyperprolactinemia, Cushing's disease. And so a full evaluation by an OB-GYN will determine if a patient has PCOS.
Deborah Howell: Fair enough. Now, I know that you said there's a strong connection between weight and fertility. How does one impact the other?
Dr. Juan Alvarez: There's several ways that obesity can impact fertility. One of them is through insulin resistance. So insulin resistance causes hyperinsulinemia or elevated insulin in the blood system. And insulin has a lot of different impacts on the body, especially on the ovary. So insulin can drive the ovary to make even more male hormones, which can cause problems which can make the PCOS even worse. And also obesity can have a direct impact on egg quality through a process called lipotoxicity.
So what happens in obesity, when circulating fat is no longer stored in fatty tissue, it starts to get stored somewhere else in the body. So this is one of the ways that diabetes happens, so direct lipid damage to the pancreas, which causes decrease in insulin secretion. So we do know that this also happens in the ovary. And so there can be accumulation of fatty substances in the ovary, which causes a problem in the quality of the egg.
Deborah Howell: So what should women strive for in terms of their weight?
Dr. Juan Alvarez: A woman should strive to have a normal BMI, which is the body mass index. And the body mass index is calculated by a woman's height and their weight. So a normal BMI is a BMI less than 25. A BMI of 25 to 29 is considered to be overweight. And then, a BMI of greater than 30 is considered to be obese.
Deborah Howell: Okay. That makes it pretty easy. Now, when it comes to diet, what foods should women choose and stay away from?
Dr. Juan Alvarez: So woman should have a nice balanced diet, especially with high fiber vegetables, such as broccoli, cauliflower, brussels sprouts, and also good mix of lean protein, which includes chicken and fish. And fish is great because it has omega-3 fatty acids, which is a great antioxidant in the body. I would also recommend antioxidant-rich foods like spinach and kale, tomatoes, and especially fruits that are high in antioxidants, like blueberries, mango, papaya, strawberry. And they should definitely, definitely avoid anything that has refined carbohydrates. So anything that contains white flour, such as breads, tortillas, pastas, any sugary snacks or drinks. Sugar is the number one enemy for anyone who's trying to lose weight. And they're usually hidden very well in sugary drinks. And they should also stay away from foods that can cause inflammation like processed meats, especially red meat, fried food, and any saturated fatty acids.
Deborah Howell: Okay. Let's talk exercise. What's a good goal to set?
Dr. Juan Alvarez: Well, a good goal would be to lose about one to two pounds a week. Nothing more than that. I never recommend patients to do any crazy diets. Women should know that if they are obese and they have irregular cycles, even losing about 5% of their weight, they can start ovulating regularly. So it doesn't have to be a huge decline in weight, but definitely trying to strive for a more healthy, balanced diet and exercise. What I recommend is at least 30 minutes of moderate exercise at least five days a week, to try to bring up your heart rate and to decrease daily calorie intake to 1500 calories per day.
Deborah Howell: Now, we all know that weight goals are ongoing and lifelong. And depending on when someone starts, it can take time. What should women keep in mind?
Dr. Juan Alvarez: Yes. They should keep in mind that this is a lifelong process. And no specific diet and no amount of restriction is going to be healthy or sustainable. This is why many of the fad diets don't work. People lose a significant amount of weight, and then they go back to their normal lifestyle, and then they regain the weight.
So when I talk to my patients, I usually like to tell them to have a different mindset, to think about portion control. So think about specifically what are you eating? Not if it's a specific diet. What are you actually putting in your body? And so by changing your mindset to a lifelong goal, instead of a short-term goal, is always the best, because also losing an extreme amount of weight really fast is also unhealthy. Someone can be malnourished, even if they're overweight, but if they do a very restrictive diet, it's not good for their health.
Deborah Howell: And conversely, a thin woman can not be getting the nutrition she needs either.
Dr. Juan Alvarez: Exactly.
Deborah Howell: What else should women know about fertility that we haven't covered?
Dr. Juan Alvarez: Well, the other aspect in the Latin community specifically, I would say is male hesitancy for any testing and/or treatment. Sometimes, my patients have their partners who don't think that they're contributing to the infertility, but actually about 30% of all infertility is due to male factor. And so I always think about infertility as a diagnosis of a couple for both the man and the woman. So definitely getting a semen analysis, also thinking about how weight impacts male fertility, diet and exercise for men. So the same goals for women, I would say it's the same goals for men. And usually, we mostly focus on female infertility and we don't focus on male infertility
Deborah Howell: Got it. Now, doctor, what Latinx-specific medical research can you share?
Dr. Juan Alvarez: So research has clearly shown that Latinx women do poor with fertility treatments, and this is most likely due to delay in treatment. And there a huge disparity in healthcare right now. And most Latinx X women, I would say, wait a long time or delayed treatment for several factors. One is because of lack of education. They don't really know that there might be help or that they need help. Two, cost of fertility treatments. Most insurance companies don't cover fertility treatments. And so It can be very costly to do an evaluation or to start treatment. And we know that if you delay treatment, outcomes are usually worse. So the earlier that somebody can see their doctor, do an evaluation and start treatment, we'll be more successful.
Deborah Howell: It makes me want to ask you, can you share some Latinx patients' success stories?
Dr. Juan Alvarez: Oh, yes. I have tons of stories. I've had patients who've come to me specifically because they have irregular cycles and I've talked to them about diet exercise, and they've been able to manage to lose weight and they've gotten pregnant on their own. I've also had Latinx patients who had diagnosis with PCOS.
And if that is the only problem that we find during an infertility evaluation, then there's many different medications that will help women get pregnant by just giving them a medication to help them ovulate. And I've had many patients who are successful with just giving them ovulation induction medication, having them do intercourse at home, and then they get pregnant because I was able to help them ovulate.
Deborah Howell: That is wonderful. And any words of hope or encouragement for our listeners?
Dr. Juan Alvarez: I would say, if you think you have a problem, don't delay seeing your doctor. We're all here to help. You know, we don't judge. Infertility is not a taboo subject anymore. More and more people coming out and saying that they have fertility issues. And by seeing a doctor earlier, your outcomes are going to be much better.
Deborah Howell: Well, this is such great information, Dr. Alvarez. Thank you so much for being with us today to share your expertise with us.
Dr. Juan Alvarez: Oh, thank you so much for having me.
Deborah Howell: That was Dr. Juan Alvarez, a reproductive endocrinologist at Fertility Centers of Illinois. To talk to a fertility specialist, call (877) 324-4483 or visit us at fcionline.com to schedule an appointment with Dr. Alvarez. And if you enjoyed this podcast, you can find more like it in our podcast library, and be sure to give us a like and a follow if you do. This has been the Time To Talk Fertility podcast. I'm your host, Deborah Howell. Have yourself a terrific day.
Deborah Howell: You know, fertility is a subject on so many women's minds these days, but are there differences in the fertility process for women in a Latinx community today? We're about to find out all about fertility in Latinx women with an expert in the field. I'm Deborah Howell, and our guest today is Dr. Juan Alvarez, a reproductive endocrinologist at Fertility Centers of Illinois.
This is the Time to Talk Fertility podcast. I'm your host, Deborah Howell. Dr. Alvarez, before we jump into talking about fertility in the Latinx woman, can you tell us why you wanted to focus on this in particular?
Dr. Juan Alvarez: Yes. The reason why I wanted to focus on this it's because one of my biggest passions is education, especially in the Latin community, as I am a Latino physician. And I do see a lot of Latin women who either don't have all the information that they need or they couldn't gather information from their practitioners about their own fertility. And I usually get lot of questions regarding the subject, in which I want to empower and be able to educate the Latin community.
Deborah Howell: Beautiful. So based on national statistics, the Latinx birth rate has dropped from 108 births per thousand women in 1990 to 65 births per thousand women in 2019. What do you think is driving this decline?
Dr. Juan Alvarez: Well, there are multiple reasons why the birth rate has been declining in not only the Latinx community, but all across the United States. There are certain factors all across different ethnic groups, such as putting off childbearing to later years. And we know that peak fertility is usually around the 20s for women. And now, more and more women are putting off childbearing until their late mid-30s. But more specifically in the Latinx community, it's sort of a little taboo to talk about infertility or fertility. And so most Latinx women really put off trying to see a physician or an OB-GYN or fertility specialists, because they don't know that this can be a problem and it could be a problem.
Deborah Howell: Got it. Now I know you'd like to bring us through the basics. So let's talk about the menstrual cycle first. What should women know?
Dr. Juan Alvarez: Women should know that they should have regular menstrual cycles. And usually, a cycle is somewhere between 25 to 35 days long. And it's usually very fixed. There's two parts of the menstrual cycle. There's the early phase called the follicular phase and then the late phase called the luteal phase. And so the cycle is very strict in the length, and that is because of ovulation. And so if a woman is having irregular cycle, that means that they're not ovulating regularly. And this will affect fertility, because a woman may be ovulating irregularly. And so if you can't time your intercourse at the time that you're ovulating, the egg only has about 24 hours in order to be fertilized. And semen only lasts in the genital tract for about 72 hours. And so if the timing between ovulation and intercourse is not aligned, then it's going to be more and more difficult for a woman to get pregnant.
Deborah Howell: And how can a woman confirm that she is ovulating?
Dr. Juan Alvarez: There are many different ways to know that someone is ovulating. The simplest would be through a urine ovulation predictor test. So right before ovulation, there is a hormone called the luteinizing hormone, which starts to rise, and this is the signal for the egg to ovulate. And so the luteinizing hormone also known as LH gets accumulated in the urine about 12 hours after it starts to rise. And so a woman can check her urine to see if she's starting to ovulate. And that will be a signal for ovulation. Some women also have mid-cycle pain. Some women also have breast tenderness when their progesterone starts to rise, and that's also another sign of ovulation.
Now, another physical sign of possible ovulation is cervical mucus change. As estrogen starts to go up, it's a signal that the egg is fully mature and ready to ovulate. And when this happens in the rise of estrogen, the cervical mucus changes from a dry sort of white consistency to more of a liquid egg-white consistency. And so all those signs can be a sign of ovulation.
Deborah Howell: Okay. Now, Dr. Alvarez, if cycles are irregular or a woman can't confirm ovulation, who should she talk to?
Dr. Juan Alvarez: She should definitely start talking to her OB-GYN about her irregular cycles and also any family planning that they have, because there are many different medical conditions that can cause irregular cycles. And so if a woman can plan ahead of time to figure out why she's not having regular cycles, it's going to be easier for her to be able to time her intercourse in order to get pregnant.
Deborah Howell: Okay. And what's the most common cause of irregular ovulation?
Dr. Juan Alvarez: The most common cause is polycystic ovarian syndrome. And so this is a syndrome where there is elevated male hormones called androgens as well as insulin resistance, which causes women not to have regular ovulation.
Deborah Howell: And how does PCOS affect fertility?
Dr. Juan Alvarez: There are different factors of PCOS that affect fertility. The main cause of infertility in women with PCOS is anovulation. Like I alluded to before, women with PCOS may have irregular ovulation. And so they cannot time their intercourse. And so if a woman is not ovulating, then she is not able to get pregnant. There's also evidence in women with PCOS that have insulin resistance. And so insulin resistance drives obesity, and we know that obesity as well has a negative impact on fertility.
Deborah Howell: And are there any symptoms to watch out for in PCOS?
Dr. Juan Alvarez: Yes. The most common symptom of PCOS is irregular periods. Women with PCOS also have abnormal hair growth, and that is due to the elevated male hormones, which are androgens. A woman can have hair in the male pattern way such on top of their lip, on their chin, their chest, their back, their upper arms, and all of these are signs of PCOS.
Deborah Howell: Okay. Now, how does a woman know if she has PCOS?
Dr. Juan Alvarez: The only way to know or diagnose somebody with PCOS is by doing laboratory tests. So, patients should definitely go see their OB-GYN with irregular cycles. And then their doctor is going to do a lot of testing, including a transvaginal ultrasound, to look at the ovaries to see if they have a PCO morphology or polycystic morphology as well as blood tests to show if they have elevated male hormones or androgens. And so that will make the diagnosis of PCOS.
We also have to exclude, so PCOS is really a diagnosis of exclusion. There are other conditions that also mimic signs and symptoms of PCOS such as thyroid disorder, elevated prolactin, or hyperprolactinemia, Cushing's disease. And so a full evaluation by an OB-GYN will determine if a patient has PCOS.
Deborah Howell: Fair enough. Now, I know that you said there's a strong connection between weight and fertility. How does one impact the other?
Dr. Juan Alvarez: There's several ways that obesity can impact fertility. One of them is through insulin resistance. So insulin resistance causes hyperinsulinemia or elevated insulin in the blood system. And insulin has a lot of different impacts on the body, especially on the ovary. So insulin can drive the ovary to make even more male hormones, which can cause problems which can make the PCOS even worse. And also obesity can have a direct impact on egg quality through a process called lipotoxicity.
So what happens in obesity, when circulating fat is no longer stored in fatty tissue, it starts to get stored somewhere else in the body. So this is one of the ways that diabetes happens, so direct lipid damage to the pancreas, which causes decrease in insulin secretion. So we do know that this also happens in the ovary. And so there can be accumulation of fatty substances in the ovary, which causes a problem in the quality of the egg.
Deborah Howell: So what should women strive for in terms of their weight?
Dr. Juan Alvarez: A woman should strive to have a normal BMI, which is the body mass index. And the body mass index is calculated by a woman's height and their weight. So a normal BMI is a BMI less than 25. A BMI of 25 to 29 is considered to be overweight. And then, a BMI of greater than 30 is considered to be obese.
Deborah Howell: Okay. That makes it pretty easy. Now, when it comes to diet, what foods should women choose and stay away from?
Dr. Juan Alvarez: So woman should have a nice balanced diet, especially with high fiber vegetables, such as broccoli, cauliflower, brussels sprouts, and also good mix of lean protein, which includes chicken and fish. And fish is great because it has omega-3 fatty acids, which is a great antioxidant in the body. I would also recommend antioxidant-rich foods like spinach and kale, tomatoes, and especially fruits that are high in antioxidants, like blueberries, mango, papaya, strawberry. And they should definitely, definitely avoid anything that has refined carbohydrates. So anything that contains white flour, such as breads, tortillas, pastas, any sugary snacks or drinks. Sugar is the number one enemy for anyone who's trying to lose weight. And they're usually hidden very well in sugary drinks. And they should also stay away from foods that can cause inflammation like processed meats, especially red meat, fried food, and any saturated fatty acids.
Deborah Howell: Okay. Let's talk exercise. What's a good goal to set?
Dr. Juan Alvarez: Well, a good goal would be to lose about one to two pounds a week. Nothing more than that. I never recommend patients to do any crazy diets. Women should know that if they are obese and they have irregular cycles, even losing about 5% of their weight, they can start ovulating regularly. So it doesn't have to be a huge decline in weight, but definitely trying to strive for a more healthy, balanced diet and exercise. What I recommend is at least 30 minutes of moderate exercise at least five days a week, to try to bring up your heart rate and to decrease daily calorie intake to 1500 calories per day.
Deborah Howell: Now, we all know that weight goals are ongoing and lifelong. And depending on when someone starts, it can take time. What should women keep in mind?
Dr. Juan Alvarez: Yes. They should keep in mind that this is a lifelong process. And no specific diet and no amount of restriction is going to be healthy or sustainable. This is why many of the fad diets don't work. People lose a significant amount of weight, and then they go back to their normal lifestyle, and then they regain the weight.
So when I talk to my patients, I usually like to tell them to have a different mindset, to think about portion control. So think about specifically what are you eating? Not if it's a specific diet. What are you actually putting in your body? And so by changing your mindset to a lifelong goal, instead of a short-term goal, is always the best, because also losing an extreme amount of weight really fast is also unhealthy. Someone can be malnourished, even if they're overweight, but if they do a very restrictive diet, it's not good for their health.
Deborah Howell: And conversely, a thin woman can not be getting the nutrition she needs either.
Dr. Juan Alvarez: Exactly.
Deborah Howell: What else should women know about fertility that we haven't covered?
Dr. Juan Alvarez: Well, the other aspect in the Latin community specifically, I would say is male hesitancy for any testing and/or treatment. Sometimes, my patients have their partners who don't think that they're contributing to the infertility, but actually about 30% of all infertility is due to male factor. And so I always think about infertility as a diagnosis of a couple for both the man and the woman. So definitely getting a semen analysis, also thinking about how weight impacts male fertility, diet and exercise for men. So the same goals for women, I would say it's the same goals for men. And usually, we mostly focus on female infertility and we don't focus on male infertility
Deborah Howell: Got it. Now, doctor, what Latinx-specific medical research can you share?
Dr. Juan Alvarez: So research has clearly shown that Latinx women do poor with fertility treatments, and this is most likely due to delay in treatment. And there a huge disparity in healthcare right now. And most Latinx X women, I would say, wait a long time or delayed treatment for several factors. One is because of lack of education. They don't really know that there might be help or that they need help. Two, cost of fertility treatments. Most insurance companies don't cover fertility treatments. And so It can be very costly to do an evaluation or to start treatment. And we know that if you delay treatment, outcomes are usually worse. So the earlier that somebody can see their doctor, do an evaluation and start treatment, we'll be more successful.
Deborah Howell: It makes me want to ask you, can you share some Latinx patients' success stories?
Dr. Juan Alvarez: Oh, yes. I have tons of stories. I've had patients who've come to me specifically because they have irregular cycles and I've talked to them about diet exercise, and they've been able to manage to lose weight and they've gotten pregnant on their own. I've also had Latinx patients who had diagnosis with PCOS.
And if that is the only problem that we find during an infertility evaluation, then there's many different medications that will help women get pregnant by just giving them a medication to help them ovulate. And I've had many patients who are successful with just giving them ovulation induction medication, having them do intercourse at home, and then they get pregnant because I was able to help them ovulate.
Deborah Howell: That is wonderful. And any words of hope or encouragement for our listeners?
Dr. Juan Alvarez: I would say, if you think you have a problem, don't delay seeing your doctor. We're all here to help. You know, we don't judge. Infertility is not a taboo subject anymore. More and more people coming out and saying that they have fertility issues. And by seeing a doctor earlier, your outcomes are going to be much better.
Deborah Howell: Well, this is such great information, Dr. Alvarez. Thank you so much for being with us today to share your expertise with us.
Dr. Juan Alvarez: Oh, thank you so much for having me.
Deborah Howell: That was Dr. Juan Alvarez, a reproductive endocrinologist at Fertility Centers of Illinois. To talk to a fertility specialist, call (877) 324-4483 or visit us at fcionline.com to schedule an appointment with Dr. Alvarez. And if you enjoyed this podcast, you can find more like it in our podcast library, and be sure to give us a like and a follow if you do. This has been the Time To Talk Fertility podcast. I'm your host, Deborah Howell. Have yourself a terrific day.