Megan Markle & Early Pregnancy Monitoring and Loss

In honor of Pregnancy & Infant Loss Awareness, Dr. Klimczak and Dr. Reed discuss how Megan Markle publicly shared the pain of a pregnancy loss that she experienced. They discuss how we monitor early pregnancy after conception with fertility treatment. They discuss at home pregnancy testing, when to follow pregnancy hormone levels and how much they should be rising as well as when to start doing ultrasounds. They discuss pregnancy of unknown location, ectopic pregnancy and miscarriage. While this is a tough subject to tackle, the hope is that discussing it will help others who are going through the process feel less alone.

Transcript

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Hi, I am Dr. Beverly Reed and I'm Dr. Amber Klemczak and we are Two Peaks in a Pod. Well, hi everybody. Welcome back. Today, we are going to be talking about a little bit more of a somber topic, but we want to talk about it because this is something that many, many women go through. through. And sometimes it's hard because when it's a hard topic, people want to shy away from it. They don't want to talk about it, but sometimes it's better to be able to kind of talk through all the specifics. And so today we're going to be talking about early pregnancy loss and Dr. Kay, I wanted to share a celebrity story with you. Somebody who was brave enough to kind of share what they had gone through. So this is actually Megan Markle and she describes after changing her child's diaper, she felt a sharp cramp. Okay. She dropped to the floor with him in her arms. And ultimately she says that she knew as she was clutching onto her baby, that she was losing her second, which is really heartbreaking, you know, I know. So to go through that and then also be willing to share with the world, some of that vulnerability, um, I think is really hard. Um, but also when I kind of look at that, I can see it was very obvious to her what was going on. But I know with what we do every day, sometimes you can be undergoing a pregnancy loss and not even really know that that is going on. And so I thought, um, maybe we could talk about how do we monitor early pregnancy? What are we looking for? What are the different types of things that can go wrong? And um, and so I thought let's get started. I think it's a great topic. I think there's a lot of uncertainty during early pregnancy. Most women are so aware that miscarriage is a potential, you know, consequence in the first trimester or maybe, you know, even further in, but you don't always really understand what to look for or what's going on. going on. You know, I, myself, I'm a fertility doctor and I know when I went through a miscarriage, I wasn't really certain. You're not really certain, right? Um, and so you feel very unsure. And so I think it could be helpful to kind of walk through what are we looking for? You know, what do we expect to see? And, um, you know, there's always a gray area, right? Yeah, and you know, one of the first things that I wanted to comment on and maybe in the long term, we can really try to advocate for this is even, you know, the ability of a woman to get early pregnancy monitoring. So what really feels frustrating to me is if somebody is not doing fertility treatment, let's just say they get pregnant on their own. A lot of times OBGYNs see them for their first appointment at about 10 to 12 weeks along. And to me, that seems just so crazy because with our fertility patients, we are starting to see them from the second that they're pregnant, you know? Yes. Yes. And I just feel like there's, So many things that could go on or could get missed and all of that leading up to that 10 to 12 week period. And I think it's really frustrating for women to even not be able to have the option for early pregnancy monitoring. Right. Yeah. I think it's really isolating and I think we live in a world where there's a lot of information out there. And so, you know, if you're having bleeding and you know you're supposed to be around six or seven weeks and you can't get into your OBGYN, I think that that can feel really frustrating. Um, and then as You know, we see you as fertility doctors, maybe after you've had a loss, there's a lot of really valuable information that occurs in those few weeks where maybe weren't being monitored, that we would have loved to see what was going on and maybe unpack it a little bit more. So I do think there's valuable information, no matter the outcome of the pregnancy. Yeah. Yeah. Um, the first thing I just wanted to ask you is how do you feel about early pregnancy testing? So of course, you know, most of the time when we're giving our instructions, when we've done treatment or something. We will say go ahead and check for pregnancy on this day because we usually know that's a very reliable day where if it's positive It's a true positive. If it's negative, it's a true negative But of course these days with all these kind of early testing monitors We'll get a lot of patients who may be testing at home. Sometimes they tell us sometimes they don't Do you encourage that? Do you discourage it? Do you not care? How do you feel about that? Well, here's the thing i'd be a huge hypocrite if I didn't encourage it because I, you know, I say I'm like a drug addict with pregnancy tests, you know, I, you say like, I'm not going to do it this time, I'm going to wait, you know, I'm going to wait till I'm supposed to, and then you just find yourself peeing on that damn stick. I mean, it just happens. And you're like, I wasn't going to do it this time. So. Um. I understand being in that situation and you just have to do it. I will say a lot of them are very accurate. We have talked about this before. Some of our fertility treatments can trigger a false positive. So you don't want to take them too early, right? Cause that can really get your hopes up and then feel or be kind of misconstrued as a loss sometimes, which can be really confusing and frustrating. So, so. Certainly have to be thoughtful about the cycle that you're really testing in, but I understand the appeal. Yeah. Yeah. Well what Dr. K is talking about is a lot of times we will use a trigger injection when we're either doing, um, ovulation induction cycles or ADF and the trigger injection actually has pregnancy hormone in it. And so when we get that injection, it is expected that that pregnancy hormone will last in your system for on average, about seven to 10 days. But in some women, maybe shorter, some women, maybe longer. And so let's say you took a pregnancy test a day after your trigger injection, it's going to be positive. And that can feel really confusing because you might think, Oh my gosh, am I pregnant? And it's just the medication that is showing that. Now one strategy that some women will use who are avid early testers is they will do something called testing out the trigger, which means they will test when they know they're still positive from the trigger. They will keep testing until it goes all the way negative and then they know if they get a positive after that, that is likely to be a real positive. Um, but, a lot of pregnancy tests to go through too. They can be expensive. They can, they can. Yes, yeah, yeah. Um, I, um, actually was also an early tester and just like you said, like a drug addict. But you know what, here's the thing, I am such a good example because early testing for some reason did not work for me. for me. Um, and I would get negative, negative, negative. And I just remember that really discouraging feeling, um, that you have. And so I always warn my patients, especially patients that do embryo transfers that even if they're getting negatives all the way up until the day of your pregnancy test, please still come in for your blood tests. Please keep taking your medications because I would say probably about four or five times a year, I will see patients who, okay. You know come in they've given up they you know, they've been getting negative tests at home and then it's positive on their blood test Yeah, no, I've definitely seen that. Yeah. Yeah, and it might be due to hydration levels or just you know, any other thing but Importantly, you just don't want to give up too soon. But but I do think it's nice to be able to to test at home. And I really just love when people use their sharpie markers and they kind of put, you know, day five, day six, and they kind of line them all up. I'm like, Oh, that is really cool. And also too, I will say, I do think there may be some benefit from just knowing early on. So for example, I had a patient before where we did our embryo transfer and at home she was getting positive, maybe around day, you know, five, six, and it started getting darker. Then it started getting lighter. And by the time she had her pregnancy test with me, it was negative. But to me, it was helpful for both of us, even psychologically to know that, Hey, it sounds like we did get an early implantation and it just wasn't able to keep going. Versus if, you know, she hadn't had the testing, we wouldn't have known that at all. True. Yeah, very true. It can be helpful. Yeah. Okay. So when one of your patients, let's say she gets pregnant or from an IUI cycle, she calls, what's kind of your first step when she, when I call and say, hi, I have a positive pregnancy test. What do you like them to do? Our whole team jumps up and down. Yes. That's true. Yes. Yeah, we help here. Yeah. Usually we're just celebrating. We're always happy to get a positive result. And the next step that we do is we usually tell our patients to come on in for blood work. So we will get an HCG level on them to see where that level is at. And so, um, we'll talk a little bit more about this, but we are looking at the absolute value of that first, first HCG level, but it really depends on kind of how far after ovulation or your treatment you are for us to interpret that level. Yes. And okay. So this, I feel like it's already the first stress point for people, right? Because of course, whatever your number comes back as, you always want to ask, is that a good number? Right. Right. And it's a hard question to answer because, you know, I would say maybe the average person might have a level of about a hundred, but sometimes we see more and sometimes we see less, but it doesn't really have a way of discriminating or telling us. Is this going to be a good pregnancy just based on that one level? Right. Yeah. There's lots of people that have tried to study this. I think HCG levels are extremely difficult to study in terms of pregnancy outcomes, but we have some general rules that we kind of try to guide our patients by, um, you know, if that initial level is low, especially if we know exact timing. So for example, with IVF pregnancies, where we've done an embryo transfer, And we know exactly how far along you should be, then I think we have a little bit more guidance on the absolute value that we're looking for. I'm much more liberal with my interpretation if my patient has done a timed intercourse cycle where ovulation might not be exactly what we think, or conception might not be exactly what we think if we're doing even an IUI cycle, um, so those I think I'm a little bit more flexible. I do have some values that I kind of go off of. Yeah. Yeah. Interestingly, I would say too in the case that let's say the patient's getting a positive and your blood test comes back negative, right? You know, I used to just say, well, the blood test is more accurate, right? But one time many years ago where somewhere else I used to work It turned out that the blood test was wrong and the home pregnancy test was right So in those circumstances where there's a discrepancy, I usually will ask the patient to go back retest at home I'd like are you still getting positives at home? um And has your period come and and if that overall clinical picture is still looking like she could be pregnant then Yes Sometimes you can repeat, but I will say in, in most cases, of course, the blood is typically the most accurate. Yeah. And I mean, I think it should be mentioned that sometimes people are thinking, Oh, well, the higher number, the better. Yeah. And that's, that's not always the case. Um, sometimes higher numbers can tell us other things that might be going on. Yeah. Yeah. Um an initial hcg level that's way higher than I was expecting. Sometimes I think it could be multiple So it makes us more suspicious of having twins or other multiple pregnancies So it's not always a good thing. Yeah, or maybe it is depending on what you're looking for for us It's certainly not it makes us kind of sweat Um, and then you know We've definitely had some patients that have borderline levels on that initial hcg level that maybe on the lower side that ends up You know being okay. So the really important thing is not absolute value but it's a rise over time. And if you've ever been in this situation, you've probably heard your doctor counseling you. We have to recheck the level. Usually we do it two days later. And with that level it's hard to because over time this is really something that has changed. So traditionally many years ago, We were all trained. It needs to double the level needs to at least double every two days. Um, but then there were some subsequent studies and data and it showed that you know What that may not necessarily be the case and that even a rise as low as maybe? 33 or so can still be associated with a totally normal healthy baby And so really what that means is if you get a positive number and you are increasing in most cases, we're just going to keep watching you very carefully. Even if the rise is not as much as we want it to be, because we always want to make sure that we're protecting you and protecting the baby. Um, and even if we feel a little bit worried because we know it's still a possibility, we just know we have to monitor. Yeah. So I think the question that I probably get most often is. You know, my rise wasn't double. Yeah. Right. Um, what could be going on? Yeah, you know, and then that's where we really have to counsel our patients that we don't always know, right? But we kind of have three different options. Mm hmm On what could be occurring if your HCT level really isn't rising as we think it should Okay. Um, the first option is maybe you're just kind of an anomaly, right? And you have a perfectly normal entry unit or inside the uterus pregnancy that's going to develop. And we just keep monitoring. Yeah. Right. There's not really any intervention that we do. We just wait. And then we're going to do an ultrasound really near in the future after that to kind of investigate that. Um, the second one is that maybe this is an abnormally developing pregnancy. It's going to ultimately end in a loss, but it was inside the uterus. address. You know, everything was there, just didn't quite get going. Um, that level may drop over the coming days, but, um, you know, something to really keep in mind. The third one is the one that we worry most about. I think as providers and fertility doctors and OBGYNs is that it could be a pregnancy outside the uterus. And that's an ectopic pregnancy. So if we do see a sort of a, Fully rising HCG it's going up but not quite what we were expecting it to I think that this is probably the most scary outcome For me And I think that this is sometimes where we used that term you brought up which is So we call an hcg test a quantitative beta hcg test. This means we're not just looking for, is it positive or negative? We want to know how much hcg is being produced and it's great that we get to do really close monitoring, but when it's increasing, but it's not as increasing as much as we would like, it's stressful to the doctor. It's stressful to the patient and you know, and her partner, she has a partner, but the hard part is you just don't know what's going to happen until you wait. And so really we call it HCG hell or quant hell that you're in just trying to get a resolution one way or the other. Yeah. And we really do try and be transparent with our patients. You know, sometimes I think it's hard for a doctor to say to you, I don't know, I'm not sure, but here are three options that could be going on. Um, and we're going to do everything we possibly can to sort it out over the next few days, but you do have to kind of be or where, what sort of symptoms should I be looking for? What's important for me to know? Yes, absolutely. I was going to mention to you kind of back to the first part possibility where it may just be a normal pregnancy, but with an abnormal rise, one of the ones that's important for us to think about as fertility doctors, especially because you brought up multiples is sometimes you may have a pregnancy, for example, that's Started off as twins and maybe one kept going and the other one didn't. But you could very clearly see how that could cause an abnormal rise. So that is another reason why we wanna make sure we're giving the pregnancy as much leeway as possible, even if the levels may not be, um, looking great. But with that being said, you know, if you recheck a level and it's the same as it was before, or if it's dropped. You do know in those cases that that is, you know, extremely concerning, but I think it's hard because when you're monitoring that early where you haven't gotten to do an ultrasound yet, a lot of times the patient wants to know, well, was this a miscarriage? Was this an ectopic pregnancy? This is called pregnancy of unknown location. Sometimes we can try to make an assumption based on your clinical history and the overall presentation. But we may not really know in that case. Statistically, I think most of us will typically consider it a miscarriage because we know a miscarriage would be a lot more common than an ectopic pregnancy. But I do think it's frustrating that even with all of our modern technology and everything, we just don't know. Absolutely. Yeah. And you know, I think there's a lot of research going into this, you know, those biochemicals or those early pregnancy losses before we can even make it. to an ultrasound. We're really trying to research those, but it's just very difficult to study. As you can imagine, it's very elusive. It's so quick. We don't really have much to hang on to in terms of research. Yeah. Okay. Now, Dr. Kate, let's say your patient, um, got her first two levels done and they look great. Um, when are you doing your first ultrasound typically? Yeah. So I usually offer my first ultrasound about on five weeks, two days. So pretty early. Yeah. Um, and you know, we don't see much. I always have to counsel my patients. Sometimes they walk in expecting to see like a full grown baby in there. Um, and so what I tell them is this ultrasound is all about location, location, location. It's our real estate, um, ultrasound because we want to make sure that we have a pregnancy in the right location and the number of pregnancies we see. So those are my two most important findings in that first ultrasound. I figure out where is your pregnancy and are you gonna have one two, hopefully not any more than two Yes. Yes. Yeah. Yeah. Okay. So mine is pretty similar. I usually do my first around five weeks and five days So we're just a couple days apart, but I agree same thing and I do agree. It's It's so important to just let them know, Hey, we're probably not going to see a baby get the heartbeat or anything today. And it can almost be a little bit anticlimactic, but we're just looking to see, can we see that pregnancy sac? And sometimes you can see the beginnings of a little structure called a yolk sac, um, as well. Um, but at least we know it's a good start if we're able to see all of those things. Um, I did want to know in patients where you're following HCBS. CG levels, and let's say it's somebody who didn't get pregnant with your treatment, she just got pregnant on her own. You don't really know how far along she's, but you're following her levels. At what level would you schedule her for an ultrasound? So you, since you don't really have a date to go by. Mm-Hmm. Um, so I, I, again, I have paranoia. Yeah. About things, you know, I want to know as soon as possible if I have a pregnancy inside the uterus Yeah, and so I often will look and see if they know anything about their menstrual cycle Of course that helps me to figure out when it can bring in for an ultrasound I actually do kind of look at the absolute values of the betas and the HCG levels and I try and estimate on one I think I could see See something, especially from the first time I had a positive HCG, like when I came in for blood work and then I can kind of count forward. Um, absolute values. There's lots of numbers out there. I think with our really high powered ultrasounds, I usually see something at like 1500 and we used to use 2, 500. That's when ultrasounds really weren't as good as they are now, but I can usually see something. Yeah, that's the same number I used to is 1500. If we got a level high enough, it's at least worth taking a look and everything. Um, okay. But then, so whenever we do our ultrasound, you heard us say, we're looking for a little gestational sack in the uterus. But the hard part is what if we don't see a gestational sack in the uterus? And this is a really hard topic for patients. I'll be kind of more extreme. Let's say the level, the HCG level is 5, 000. And you do her ultrasound and you don't see a gestational stack in the, excuse me, a gestational stack in the uterus, you and I would both be thinking, Oh my gosh, she probably has an ectopic pregnancy. Right? Right. But what is so hard to grasp for patients is they want to say, well, show me the ectopic pregnancy. And the hard part is they often hide so well. You cannot see them on ultrasound unless they're really big. Yeah. So, you know, the most common location for ectopic pregnancies are out by the fallopian tubes. And if you can imagine, fallopian tubes are kind of just floating around and they're just like your bowels are there. There's a lot of other things that show up on the ultrasound that can kind of hide these early, early pregnancies. When we say we're looking for a gestational sac, we're looking for a little black circle and like a big of this. of your abdomen looking with sound waves. So it can be very difficult to identify. Um, and so especially with that high of a level, you, you get worried and you start looking and if you don't see anything at all, then you, you lead to this assumption, like we're talking about pregnancy of unknown location. Yeah. But I think that's so hard for patients to grasp because if you can show them. And, and sometimes we can't, if you can show them, here's the pregnancy in the fallopian tube. This is an ectopic pregnancy. We need to treat this. They always, okay. Yes. They want to move forward with the treatment, but if they can't see it and we can't see it, then they start to doubt and they say, well, how do you know? And I think the hard part is it goes to the fact of. Where is HCG hormone coming from? If it's not in the uterus and you have a clear view in the uterus, we know it must be coming from somewhere else. And therefore it must be an ectopic pregnancy in those cases. And it is so important to, um, do treatment because an ectopic pregnancy, if a pregnancy implants in the fallopian tube, it's a problem. The fallopian tube has, was not made to grow and stretch like a uterus was. And so as an ectopic pregnancy grows and stretches the fallopian tube, you worry What if the fallopian tube burst open? If it ruptures, it can cause bleeding. It can be life threatening. And so that's why we love to be able to monitor so early because in the fertility world, we're able to pick these things up very early. Whereas again, maybe patients who are just trying on their own, they may not see their OBGYN until 10 to 12 weeks may end up having to go in the ER or something if they're having symptoms of this happening. Yeah. I mean, in modern obstetrics, ectopic pregnancies are really one of the slowest. Scary things that remain out there. And that can really be harmful to you can be a surgical emergency. You need to know if you are a patient listening, you had a history of this, or you're worried about your levels. I mean, this is where you really think, okay, am I having any pain? Am I having dizziness, lightheadedness? you know, sharp pain on one side. All of that can be signs of ectopic pregnancy. And it is an emergency and you know, you should seek care. And I think it's important that you trust your doctor when, when, when we're trying to explain to you that it is a pregnancy that's there and it can be harmful to you. You always have your best interest in mind. We always want to support a pregnancy that we think is viable. Certainly, of course, but your health and wellness is our number one. Well, but, and even with that too, I think it's important to say, what if you don't trust your doctor? Right. And that can help come up sometimes. And honestly, it's even happened to me. I'm sure it's happened to many people. And what I really tell patients in that case is I don't want them to feel uncertain or worried. And so oftentimes I can just offer them a second opinion. Sometimes they'll say, Hey, would you like Dr. Quinzac to scan you too, just to confirm. Or would you like to go to a radiology imaging center? Or would you like to go to your ob gyn and get a second opinion? It's never wrong to get a second opinion as long as it's not going to significantly delay what's going on. Um, but I know for Dr. K and I, we wouldn't offer any treatment that would disrupt your pregnancy unless we knew for sure that this was, you know, some sort of high risk situation and that the baby was not going to be viable. There's certainly borderline cases. So let's say we do an ultrasound. The HCG level is 1500, which is kind of just the border of what we would both be excited to see. I think a lot of times we would say, you know what, let's again, look at the overall situation, see how our patient is feeling. And if we're able to watch for a little bit longer, just maybe give a little more time to progress, we certainly will, you know, do what we need to keep you safe to keep, um, the potential pregnancy safe if, if it's viable. Um, but, but these can be complicated situations. And imagine when you're in that situation, just the unknown is the hardest. It's, it's really tough and you know, you really need to communicate with anyone that's going to be treating you, you know, in terms of, Oh, I had fertility treatment done, or I had, you know, something else done to try and help you get pregnant. Cause sometimes you can have this and you might go to an emergency room that's not familiar with doing early ultrasounds like this, especially after having fertility treatment. There's lots of things that can be mistaken on ultrasound for an ectopic pregnancy. I've had that happen a lot. So anytime my patients can't make it to me and they have pain and early pregnancy, I always call the ER doctor. I'm like, look, let me see the ultrasound before you do anything. Because the reason why a lot of our patients don't want to have this treatment that we use for ectopic pregnancy is it can cause a really long delay, um, in your time to getting pregnant again, because the, the treatment for these that we often do is an injection called methotrexate. Methotrexate and you have to wait three months after that to get pregnant. So it can be a really big delay. So I'm very careful about giving that to my patients and really try and avoid it at all costs. Yeah. But I'll say, you know, one of the really positive things about a treatment like methotrexate is. If you identify the ectopic pregnancy early enough to be a candidate for methotrexate, it actually can, in most cases, completely resolve the ectopic pregnancy for you from just one shot. And that is it, you know, and that is really important too, because before we really have that as a treatment option, patients often have to undergo surgery, which I do feel like is more invasive. And when you undergo surgery, a lot of times they're removing the fallopian tube that was involved. And so for patients who really would like the maximum chances to keep your fallopian tube and to avoid surgery, I think methotrexate is just such a great option, but you're right. We don't want, we want to make sure you don't have to get it unless needed. Because, for example, if somebody is instead having a miscarriage, they can usually get back to starting to try to get pregnant again if they want to a lot faster. Whereas if you have an ectopic treated with miscarriage, it's true. Just like Dr. K said, oftentimes you're having to wait three months after the injection before you can try again. Um, okay. So, um, I wanted to kind of ask you when you, when you have patients that come in for that first ultrasound and you know, besides the neck topic, let's say you see a pregnancy sac in the uterus, but it's measuring a little small and maybe you just don't see as much as you want. What do you, what do you tell them at that point? What kind of monitoring are you doing at that point? Yeah, I actually think this is one of the really tough situations that we get into as fertility doctors because When you do something all day, every day, you can kind of just look at something and have a feeling about it, right? Um, and this is probably the same for any job that you do every day, right? If you're an accountant, you're just looking at some numbers. You're like, this isn't right. I know I'm looking at this. This just isn't right. And so I think that happens to us often, but we have to take a step back and we are always going to plan to monitor very closely moving forward and kind of cross our T's and dot our I's, but I do like to be very transparent about it. With my patients, if from the first ultrasound, I feel like something's off and then I just try and counsel them, look, this is what I'm seeing. This is what I would expect to be seeing. It's just not all quite there. Um, it doesn't mean that absolutely this isn't going to go in our favor, but I am, you know, strongly. Counseling them that it could be a possibility. Yeah. Um, and I think it depends on the patient too, but for me, you know, when I'm on the other side of things, I want to know everything that my doctor is thinking, right. I want to be like fully aware if there's something going on. Um, and I just recently actually had one of these pregnancies that went really well. Um, you know, this was just like one of those signs that I see sometimes, and we don't really know what to make about the data, but you know, Very close patient of mine of mine. I said, look, you know, I'm a little bit worried about how this is looking. Let's just keep doing ultrasounds weekly. Let's make sure it's progressing. And then we discharged her pregnant and everything went well. So, you know, every once in a while things really do work out. So that's why there's no intervention that we're going to do until we're absolutely certain that this pregnancy isn't developing normally. Yeah. And I think that's really hard too, because then in retrospect, you're like, gosh, did I create stress for the patient by, you know, Yeah, telling them my worries, but then if you have to write, you have to be open patients. Do you want to know? um And and so I think that can be hard too But I think another tricky situation is sometimes if you're doing your ultrasounds because I know we talked about the first ultrasound But of course we bring our patients back for subsequent ultrasounds too. We're looking to see Do we see development of the baby? Can we start to see the baby? And then after that, are we seeing the baby grow? And do we see heartbeat? We're looking for all these things, um, on our follow up ultrasound. And sometimes just from week to week, again, we'll kind of see, okay, everything looks like it's lagging behind. We're feeling worried and everything. But on the other hand, if you're also progressing, you just have to keep watching, right? You want, you can see this little baby's trying so hard and you want this baby to have the best chance. Yeah. Um, and so it just ends up being a tough situation on the patient's part because they just don't know how to feel like do I get attached to this baby? Do I just expect it's miscarrying? And when we don't know either, but we know we just have to keep watching you, you've just got to go keep going through. And I think this is really where it's helpful sometimes to ask for support if you feel, comfortable opening up to any friends or family to just be like, Hey guys, I'm going through something really difficult because of this, um, unknown situation. But, you know, I think one of the most important things is don't be afraid to love the baby, even if you're going to lose the baby, because what somebody pointed out to me and I thought this was just so important is. Doesn't every baby deserve to have somebody excited about it, even if it doesn't make it, you know? Yeah, absolutely. And and I think honestly, it's almost impossible to not get excited about a pregnancy. Yeah, you know, we see a lot of patients that struggle with recurrent pregnancy loss and they sit there and they tell me I just can't, I just can't get excited about this one. I just know it's not going to work out. I just can't and yeah, they're saying this to themselves, but you know, I've been there with them. You just can't help yourself, you know, like your hormones are changing and you get attached to any pregnancy. It's hard to not get excited about it. And so, um, I think, you know, we're here for it. We're like, we're going to be excited for you as well. And we're going to hope for the best throughout those weekly ultrasounds because we do, I mean, we do see miracles. I mean, we've seen like really incredible pregnancy progressions, um, that, you know, we even looking at the data and the research always can't explain. You know, we always leave space for that. You always leave space for something incredible to happen for our patients. Yeah, I agree. I say leave room for a miracle. And I think to you that's important as well, because we'll try to prepare you with what we're seeing. Like, hey, we're worried about this but let's also leave room for a miracle. And I do think if a miracle happens, amazing, great. But if not, at least you've had a little bit more time to process it too, because at the first time that we mentioned something, it can feel like such a shock. But if you've had time to think about it and process it from week to week, when you're coming in, I think that's helpful as well. And I will say just like from professional experience, you know, when I was younger in residency, we used to have a clinic, that was actually called beta clinic. And it was just for early pregnancies. Um, with bleeding, you know, something wasn't quite going right with ultrasounds and hcg levels And I kind of learned from my experience there that it's so much harder to go the other way To offer a patient reassurance, you know with the first ultrasound and you know Tell them, you know, I think it's going to be okay when you're not really sure and then have to like kind of back that Up, I think it's a lot harder than going the other way. That's just my professional experience Yeah, maybe not everyone has that experience Yeah. Yeah. So that's why I think I am a little bit overly cautious. Yeah. You know, you mentioned the bleeding too, and I feel like that brings up a good point, which is a lot of our patients don't experience bleeding like patients otherwise maybe would when they're having a miscarriage or an ectopic. And I think that's because a lot of our patients are on supportive hormones, right? So if a woman gets pregnant on her own and she starts to miscarry, her hormones drop, which triggered the bleeding to happen. And that's when she can start to get an idea that something is wrong, that something's going on. But I think in our patients, because of that, it can be more of a shock because we're supporting the hormones so well, they're not having any bleeding. And then they hear from us, maybe that their level has dropped or their ultrasound doesn't look normal. And it can, again, feel very confusing if you're not getting the typical signs and symptoms. Yeah. Yeah. All right. Well, we covered a really difficult topic this week, but again, I think it's just so important to talk about. We want our patients to feel like they're not isolated. They're not alone. We want that information to be out there. If you guys have any questions or concerns, let us know and we will see you guys next week. All right. Have a good day. Thank you guys. Bye.