Kenya Moore & the Finances of IVF

Dr. Amber Klimczak and Dr. Beverly Reed discuss how much IUI and IVF treatments cost. They discuss things to know and watch out for when using insurance. They discuss how you can find the best prices on medication.

Transcript

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Hi, I am Dr. Beverly Reed and I'm Dr. Amber Klimczak and we are Two Peaks in a Pod. Hi everybody, welcome back. Dr. K, how's your week been going? It has been a crazy week. Yes, yes, definitely. It's been raining a lot. It's been raining, we had the election, everything. kind of wild this week. Yes, yes, yes. Um, okay. Well, I was looking through my celebrity stories as you know, I love to do. This is my stress reliever. And I actually came across an older story about a reality star. Her name is Kendra Moore and she is on a show called Real Housewives of Atlanta. Have you seen it before? Of course. Of course. Um, and, Um, and she actually had IVF, and, but what kind of stood out to me is she, so, and she lives in Georgia, okay, because Real Housewives of Atlanta, but she went all the way to Barbados to have IVF done. Interesting. So, I wanted to get your thoughts on this, um, have you ever known or seen anyone else who went to a foreign country to do IVF, and why would somebody do that? Yes. Yeah, I have had quite a few patients actually that have done this sort of medical tourism is what it's called for For any type of you know, medical procedures, but specifically my patients are seeking IVF elsewhere And I would say by far and wide the most common reason why people do it is for cost, right? We know that fertility treatment can be very expensive Expensive, especially in the us and so then they will find other places across the world that may be more affordable. Um, maybe the Barbados, none of my patients have gone to Barbados. Yeah. But that sounds nice. It sounds like a great vacation option, but yeah. Yeah. Yeah. Yeah, so I saw that I thought that was interesting and it is true. Like I am on social media quite a bit too and I've been seeing other forms of medical tourism. Like I know a lot of people go to Turkey for hair transplants and uh, cosmetic dental work. Gosh, I need a hair transplant. No you don't. Oh my gosh, you have beautiful hair. I just want some full Texas hair. Um, and so I always think that's kind of interesting and fascinating, but it's because they, I think there's high quality work for a pretty good price. But then I kind of think about, gosh, once you factor in taking off the time from work and airfare and hotel and all the rest of it, I do wonder how much money are people actually saving. And I also, you know, have anxiety about a lot of things. One of my fears is that I'm going to have to go to the doctor in another country. Oh, it's yeah. Yeah. Um, I know a lot of people go to Mexico. I don't ever go to Mexico because I'm worried. What if I go to Mexico and I have like appendicitis and they have to do surgery on me there and I'm in a place where, you know, I don't know anybody. I just, these types of things really scare me. You don't want to go to the hospital in Mexico and you don't want to go in jail. So the two places you do not want to be, the beach, great. Yeah. Yeah. So that's kind of one of my biggest fears. I don't know. Do you have those same fears? Like, would you go to a foreign country to get something done? I have a lot of concerns. You know, and honestly, I have some patients I care a lot about that have done this. Um, and we have a really, you know, long conversation about what do you really think the benefits of this are, you know, and are there risks? to me, you know, because things are just not as regulated. Sometimes it, it depends on the country, right? Um, and it depends on the quality of care that you're going to be getting there. Now I will have some patients that may be opting to go to a different country for IVF because their family is there and maybe they feel like they'll have more support and someone to care for them. So I can understand maybe that side of things, but when it's solely monetary benefit, um, we want to make sure that the quality that they're going to get out of it as is really worth it. Absolutely. And unfortunately I've seen some nightmare stories and I do realize it might be a little bit biased, right? Because if a patient went to a foreign country to get IVF and everything turned out great, they probably wouldn't be seeing me. Right. But I've certainly had some patients that went to, for example, to Mexico and had a terrible experience and then ultimately ended up seeing a doctor in the U S one of them was a patient who had a tubal reversal in Mexico. because it was so much cheaper. She had her tubes tied. She wanted to get them put back together and she did, but she got a horrible infection while she was there. She ended up having to stay way longer. She was hospitalized and Lord knows it probably costs so much more in that respect. And then it didn't even work. And ultimately she ended up having to do IVF and everything. And so when I've kind of seen and heard some of the stories of that, I'm definitely very hesitant. And my usual advice to patients is, you know what? I would really recommend staying in the U S um, because I do feel like we have really high quality care, um, at the majority of you at the U S clinics. And even if you're looking to save money, I do feel like there's really affordable options in the U S too, you know? Yeah, definitely. You know, you just have to kind of weigh the risks versus benefits. Yeah. And then I actually just on social media, so I'll post the other day. Um, it was by an OBGYN who is trying to reach out to other people. And she said, look, I'm an OBGYN. I'm not a fertility doctor. Okay. My patient is doing IVF in Mexico and the doctor from Mexico is telling the patient, you need to be on these meds. And so the patient then called her OBGYN meds. And then the OBGYN is like, I don't prescribe these meds. I don't even know. Am I giving the right doses? Is this the right thing? Is this the appropriate medication? And it would put her in such an uncomfortable situation and the advice from most other doctors is don't do it. Don't prescribe a medication you're not comfortable with. But then I did, I was thinking about the poor patient who's stuck in the middle of this too, because here she's already committed to doing IVF with this other doctor, but that doctor can't prescribe in the US. It's a tricky situation to be in. Yes. I've seen that exact same scenario. I have actually, I think three patients that were in that scenario. And even though I. do prescribe those medications, right? But if I'm not going to be the one doing the monitoring, I don't love to prescribe them for the patients. You know, it makes me very nervous. Yes, yes, yes. So anyways, I thought let's talk today all about the cost of fertility treatment, mainly IVF treatment, but we'll kind of touch on some other ones too, because really at the end of the day, we get it. We know fertility treatment is so expensive and So let's kind of talk through how expensive it is and what are ways we can help our patients to save money and what are some things that we really need to be thinking about, um, as we're, um, shopping around, too. Um, I will say the first thing that I will see in so many patients is they don't even want to come see you for the very first appointment because they're so afraid it's going to cost thousands of dollars when you're walking in the door, right? Yes. Absolutely. And in fact, I think it causes a delay in care and treatment, which actually can be detrimental to your fertility, right? To put off going to see a fertility doctor for several years, things can really change. So I think it's such important information to know that if you have basic insurance, right, you have regular health insurance, most of those policies will actually, um, Be able to bill just diagnostic fertility testing, meeting investigative tests, trying to figure out what's going on. So you don't have to have any specialty fertility insurance coverage to come see us just to see us for a consult, to do our testing, to see what might be going on with you. We build that through your regular insurance policy. Yeah. And I think patients are always surprised because a lot of times they'll be with their OBGYN trying to get their OBGYN to do all that testing because they think it's going to be cheaper with their OBGYN. But really it's oftentimes the same price and some OBGYNs love to do fertility stuff, others don't. So if you're in a situation where your OBGYN doesn't like to do fertility testing or anything, come see us. It's not going to cost you any more than it would with your OBGYN anyways. And even if you have no insurance at all, no help. A new patient appointment is 250. And so even that ends up being a lot more affordable than what most people would think. Now, I guess I should comment. These are our prices. Certainly elsewhere. It could be higher. It can be lower or whatever. Um, but, but 250 would be the self pay price. And if you have insurance, the vast majority of the time, we are able to bill it to your insurance for your first visit. And then the cost of your visit could be a copay or co insurance. It just depends on how your insurance is set up. But our front desk is usually able to kind of walk you through how they figured that out. Yeah. It's so important for you to know. Yeah. I think in some ways, even coming to see us can help you save money sometimes too, because when you see us for the new patient appointment, We review your history and give you the best advice on the testing you need. Sometimes I've seen where a patient was just given all the tests and when I look, I'm like, great. I mean, nice to see that, but she really didn't need this test or she didn't need that test. And so I could have had the opportunity to save them money by just using my fertility experience and knowledge to kind of better guide them on that too. Right. Yeah. And really That's what physicians are here for, right? We are supposed to be particular with the use of our resources, right? We don't just like throw everything at our patients. So we do like a very specific patient tailored approach to figuring out what's going on with you. Yeah. Yeah. Um, one of the more basic treatments that we do, and I do a lot of this are IDY cycles. So IUI stands for intrauterine insemination. And when I'm referring to an IUI cycle, usually what I'm referring to is some other things that I like to pair with it, like fertility medication and ultrasound monitoring and things like that. And so when I'm telling a patient about fertility treatment at almost every single appointment, as we're going through it all, and I end up recommending it for them, They always say, how much is it? Or actually they don't even have to say, because I know that's going to be a question. It's now just kind of on my presentation and I, and I bring it up because I know it's important because it would be important to me that I would be thinking the same thing. Right. And again, this can depend on whether your insurance has coverage. So one of the things we always look for with an insurance company is Is there coverage for testing, diagnostic coverage, and is there coverage for treatment? Okay, but even if there is no treatment coverage, a typical IUI cycle with us is roughly 1, 100. And that would include usually two ultrasounds, the sperm prep for the insemination, the physician performing the insemination and the cost of the medications. And when I tell that to people, they're usually shocked because they were like, I thought this was going to be thousands and thousands of dollars. And I'm like, well, that's idea. We'll get to that. But, but for basic IUI treatment, it's. so affordable. It is affordable. And I think that's another reason sometimes people just wait. They might know that they're a candidate for needing an insemination, but they're like, I'll never be able to afford it. I think the other important thing to know is that when we talk about doing inseminations, we may recommend, okay, let's try at least three of these, you know? So it's not just a one time thing typically with inseminations, which is a little bit different than IVF. So you kind of have to get into it, knowing that you might do part of it once. Yes, yes, yeah. Um, so that was IUI, but really what I kind of wanted to focus on too is IDF because admittedly when we bring up the price of IDF, it is so expensive. It's like buying a car, right? Not any car. I know. Cars are so expensive now. Yeah, I guess it depends what kind of crop, but it is so expensive. Um, and so commonly when I'm doing an IVF consult, when I'm telling a patient about IVF, when I'm recommending an IVF, again, this is a question that comes up. And you know, what's interesting actually is I've talked to a lot of fertility doctors, some of which don't even know their own prices for IVF, which kind of blows my mind. Right. Yeah. Um, they just, Oh, I don't know. I don't know. You know, talk to the finance person or whatever. Um, and although. I'm getting a little rusty. I may not know all the details of the pricing. I do know a ballpark, you know, amount, but I think what's hard is patients always want one number. They want me to give them one number. That's how much it is. But it depends, right? It depends on what options you're going to use on your dose of medication, where you're going to get your medication, right? So if I'm your patient and I'm saying, Dr. K, how much is IVF? Yeah. What do you say? So I overestimate. to me. So I always want my patients to be pleasantly surprised when they get like, we're at the end of this. And I don't want them to ever have a surprise later like, Oh, you didn't mention this, right? So I tell them a good number to have in their mind is maybe around 20, 000. Everything together. Okay. And I'm like, if you're going to do genetic testing in the embryos, it's going to be slightly higher than that. Maybe 22, 500, right? And then I walked them through what goes into that, right? Because if you actually ask us, how much is our IVF? Well, our IVF cycle is only about 15, 500. But that's not everything that goes into IVF. We're also going to require you to go to a pharmacy and buy very expensive medications. That could be four to 5, 000. We're also going to require you to be put to sleep for your effort. You don't want to be awake when we're doing that. So you're going to pay anesthesia as well. So I like for them to have this overall number in their mind. Yeah. And honestly, the most common response I get is, Oh, I thought it was like double that. Interesting. So I think there is a lot of misinformation out there about how much IDF is. And I think maybe. California, New York. I think some of these places it could be that high. Um, and what's out there when you just Google it, you know, um, you know, maybe we're pretty affordable, but yeah, that's the numbers. I think what's nice too, cause in the Dallas Fort Worth area, we have probably like 20 fertility clinics here. When you have so many clinics, it is helpful, um, because there's a lot of availability and everything. I think pricing tends to to be better. Um, but I, yeah, I just, again, on social media, read a patient who's at Kansas university, 40, 000. She was coded for one and return on one transfer. And I was like, what in the world? That's crazy. Um, but I will say to cost for, to perform idea have gone up. astronomically since COVID. And what we have to kind of factor in when we're performing IVF is the cost of um, media in the lab, the cost of supplies. And there's so many supplies involved with IVF, the egg retrieval needle and the tubing and the tubes and all of these things. And it is all very, very expensive too. So, um, I can certainly understand why the cost continues to go up. Right. But hopefully it won't always be like that. So. All right. So I want to talk about insurance coverage for IVF. I will say over the past probably five years, I have seen so many more people have insurance treatment coverage, which I think is amazing. It's great. Um, probably that's because we're getting a lot of these companies moving in from California and California tends to be a little bit more progressive and in terms of offering fertility benefits and everything. Um, But just because you have insurance coverage for fertility doesn't always mean you get to use it. So I thought maybe we can talk about some of those things too. Probably one of the main things is I'll have somebody who comes in, has done no prior treatment, comes in and says, okay, I want to do IVF, when can I start? And it's not that easy, right? Right. Yeah. So insurance loves to have strings attached. They want to make it hard. They want to make it really hard, right? Because that's how insurance makes money. Right. Yeah. And so. You know, often there's certain requirements that you're going to have to meet before insurance will approve or say, yeah, okay, you can, you can do IVF. Um, so, you know, there's certain diagnostic testing that we have to do. Sometimes insurance even requires us to do lower level treatment options like Insulinations or IRI cycles to make sure that's not going to work for you first, right? Even though there may be benefits to it to going immediately to IVF for some couples. Insurance, unfortunately, can dictate what we have to do before moving on to IVF. Right. So when a patient wants to do IVF, a lot of times we'll check with the insurance company and they say, you need to do a prior auth for IVF. And that's hard because number one, prior auth slow you down. It's going to take time to do the prior auth. It is a lot of work on our part as well. Um, so. The prior auth is us saying, look, we think this patient needs IDF, and then the insurance company comes back to us and they tell us, have you tried the cheaper treatments and is this patient a good candidate for IDF? One of the things I hate is a lot of times they'll disqualify patients if, if the insurance company thinks there's low chances of it working. So if a woman has low egg counts or a high FSH level or things like that, sometimes they will use that to disqualify the patient, which is so frustrating, you know? Right. Yeah. I think prior auths are just. Absolutely ridiculous, which I have heard that a lot of states are forcing them to go by the wayside, which is really nice. Yeah. But, you know, for the layperson that doesn't really know what that means, it's like a doctor saying, Hey, you need this treatment or you need this medication and then insurance saying back to us, but are you sure? Yeah. Yeah. Yeah. Are you really sure? And it's just, I feel like it's just so condescending. I'm like, we just told you our patient needs this treatment or this medication. Yeah. And then sometimes it can cause even like, several months delay, right? And a woman's body weights for no one, right? All this time you have to be lined up with your cycle. And so it can be really frustrating for patients for insurance to not approve. Yes, absolutely. Yeah. Um, and then I really kind of even should have mentioned this before I even talked about the prior off when you have insurance, you do want to make sure that your doctor. So if you have a certain type of insurance company and we're not in network with them, and you have a certain type of insurance company and we're not in network with them, you can always reach out to your insurance carrier to just say, okay, which fertility doctors can I see, which are in network, which are out of network and all of that. But I will say sometimes that really limits your options and we do see this come up with some of our patients. So let's say you have a certain type of insurance company and we're not in network with them. But you really want to see us, right? Well that's a decision that you end up making is to say, okay, well I can use my insurance and see this doctor here or maybe I feel like this doctor can care for my condition in a different or better way so I'm going to pay out of pocket to see this doctor. Or maybe not even pay out of pocket. Maybe it's just that your insurance would, maybe you wouldn't get to use as much of your benefit or something like that if you use a different doctor. And so it's just things to be, um, aware of in general when you're just kind of researching, um, around. Yeah, absolutely. Yeah. It's very important questions asked. The other thing that I get asked a lot is, well, what about this discount? IVF that I found, right? When people are calling around, they like to go to places that advertise really low cost IVF. And so I think this is like a really tricky position for our patients, right? Because some patients, they just flat out can't afford IVF. I mean, they don't have any coverage. Yeah. And so they call all around the country, and they try and find like the lowest IVF options that are out there. Yeah. And so, um, And I think that this is something that we really have to be prudent about protecting our patients, you know, is. Something's gotta give, right? Yeah. Right. We just talked about IVF is expensive. Yeah. Right. The lab, the media. Mm-Hmm. Right. The utensils that we use to inseminate the eggs. Mm-Hmm. The incubators that we place the embryos in, these are all very expensive components. Yeah. And so I've never worked at a low cost IVF center, so I don't know the details of how they're cutting costs, but you know, I think something has to be cut. Right. So and so I am always. cautious with my patients, right? And if you don't have an option, you don't have an option. But you know, I've just, I'm always a little bit weary. I don't know. How do you approach that with your patients? Yeah. And here's another situation where I probably have some bias, right. Is I've seen a lot of patients who went to places like that. Okay. And of course, if everything went great, they'd have their baby. And I never saw them, right. That's where my bias comes. And I would only see the people where it wasn't working. Right. But I've had a number of patients go to some of these really low cost places and they tell me I can really tell the difference in everything. You know, one of my patients made me laugh because she told me she suspected this place had robot nurses. And she said that because every time she would send an email to ask a question, question. She would get like this canned response and she would try to ask the question in different ways and she would get the same response and she's like, it's the robot nurse, um, and, um, and, and they say, look, you never see the doctor. Okay. You're, that's, that's part of how they save money, right? Is a physician's time is very valuable and expensive. And so a way that they save cost in that is to not see the doctor. And then even more shockingly, and they don't, I feel like they're not transparent about this. A lot of these places in particular, one in Colorado. doesn't even have real fertility doctors working there. So one of them has, I think it was, um, an OBGYN and a, maybe a nurse practitioner or something like that, running everything, doing the retrievals and the transfers and everything. And that just seems so shocking to me. I'm like, how can you not have had your three year fellowship? Training your board certification and everything. You don't have the knowledge and experience and You're treating these patients like that felt really shocking. That's that is scary And you know, I will say and you know I'm the only physician in my family and so my my family relies on me a lot Yeah, cool stuff and something that I've explained to them is yeah Did you know that you couldn't look up? Whether your a doctor is board certified or not. Yeah. And I think the average person doesn't know that. Yeah. Yeah. Um, and so I would encourage all of our patients, no matter what you're looking for, what type of care you're looking for, you can actually go online. Mm-Hmm. type in your doctor's information and verify that they're board certified. Um, so, but you know what makes it so tricky in the circumstance? So let's say you take that ob, GYN, you look him up, he is board certified. Right. And obgyn, this is why it's so tricky. Know, Dr. Kane and I are both. double board certified. We're board certified OBGYNs and we're board certified reproductive endocrinology and infertility specialists. And so really that is the question that I really think you should ask any fertility physician, physician that you're going to see to ask. Are you a board certified and fellowship trained reproductive endocrinology and infertility specialist? That's a complicated question to ask. It is an important question. It is. And they have to be honest about that. Yeah. Yeah. You just, uh, you have to be kind of savvy in the world that we live in. Um, so yeah, it's, it's kind of surprising. I think when you find out that your doctor isn't. Yes. Yes, absolutely. Okay. Some other insurance pitfalls to think about that you can have insurance treatment coverage. But a lot of times there's a max on it, right? So things for you to know, and you can ask your insurance company these things, or sometimes your clinic will tell you if they called and verified for you. Sometimes we'll say you can have a max of three IDF cycles, or you have a lifetime max of 30, 000 of coverage or, you know, 10 or 10, 000 of coverage. It's all different amounts. Okay. And so it's just kind of good to know what are you working with there? Okay. But here's a really tricky one, is medications. Okay, so, I love when people have insurance coverage for medications because those medications are so expensive. But, it is complicated to figure this out. Number one, you need to ask your insurance company. Is the amount of money I can use on medications related to the amount I can spend on my IDF. With some insurance companies, they're totally separate. So, it may be like, okay, you can spend 30, 000 for your IDF and 10, 000 on meds, okay? But with some insurance companies it's combined and I'll tell you a story I had on a patient before this was at my last clinic She went to get her meds and her and her insurance company said you have to use this pharmacy Okay, we use that pharmacy. They tell her your meds are 11, 000 what I'm thinking. This is crazy These meds should not cost 11, 000. I know patients that pay cash or self pay get these meds for 4, 000 But the insurance is like, well, then you have to use this pharmacy, but it's 11, 000. But the patient only has to pay a 500. Copay patient says, great. That's a great deal. I'm getting 11, 000 of meds for 500. So she does that. Well, then she goes to pay for her IVF with her insurance and her insurance company says, well, you had 15, 000 of benefit. You've used 11, 000 on your meds. You have 4, 000 of benefit to use on your IVF. So the patient says, I can pay for this IVF myself. And she didn't get to do her cycle. That's sad. Ridiculous. Yeah. So. I mean, and how could you know this if you've never been through this before? So make sure you have a clear understanding of where your medication benefit is pulling in from. Yeah. And I think it's important for us physicians too, because, you know, I think it helps us to guide our patients when we see how your insurance is working. You know, like I have a lot of patients that have just a flat. You have 8, 500, you can spend it however you, however you want, right? And we want to use that very cautiously, right? We don't want to waste a lot of money. Um, if we feel like a treatment cycle is unlikely to work, right? So it is part of the counseling that we do with you and something that, um, we kind of go over to make sure we're using it appropriately. Yeah. And in that patient situation, what I wish she could have. been able to do is just pay the cash price for meds at a different pharmacy, 4, 000 and then just use her full insurance benefit for her. Um, I'd be, I'm not like very transparent. But other things to know when you're using your insurance company is, is, so do they have a preferred pharmacy? And then each pharmacy usually has preferred brand names. Okay. So if it seems like a crazy price, ask them, Hey, you know, my doctor ordered Faulston. What if I use gone all out? Or my doctor ordered ganarelics. What if I use cetratide? So sometimes just switching the brand name may benefit you as well. So things for you to be aware of, know about, ask the questions because really you don't want to end up overpaying on silly things that should be covered for you anyways. No, absolutely not. Um, okay, let's see what else. Oh, shopping around for medications. So here's, um, I just kind of have interesting background from back when I was at my last clinic, I noticed these meds are expensive, right? So I have this really awesome nurse, shout out to nurse Julie. Um, and I said, Hey, can you just call around all the pharmacies and just get a price list for me? I just want to see what all the prices are. And so she gave me the price sheets and I found them on the lowest prices. I said, great, let's just preferentially send to this pharmacy because it's the cheapest. So I, We were kind of doing our due diligence for our patient. Well, when we did that, another pharmacy comes by and they say, Hey, why aren't you using our pharmacy? Well, we're using this other one. They have cheaper prices. As far as this is, well, we'll lower our prices for you if you switch to us. Right. And then before we know it, we have all these pharmacies who are having a bidding war to be our preferred pharmacy. And I really didn't even know that as a physician, you And I don't know if, if this is a common thing, but it really worked out for my patients because we're able to, um, offer really the best price, um, around for that. And so we've just kind of continued to do that. We do that now, um, as well. And you know, here's the thing. We love our pharmacies that we work with, but we always say we're not loyal to any pharmacy. We're loyal to our patients. Our patients are number one. And so we're always on the lookout for a high quality, good pharmacy that has really good pricing. And as the patient you should know the medications are exactly the same. Yeah, doesn't matter where they come from. They have the same efficacy. It doesn't matter if you use a different brand name, like Dr. Reed explained, they have the same efficacy. And so it really, you should shop around and find the cheapest meds for you. If you're with another clinic, you know, you, the doctor shouldn't have any alliance to use a pharmacy. For example, the only reason why we use the one we use is they're the cheapest. Right? Maybe we should bring this up. This was one of my pet peeves. There is a pharmacy that allows the physicians to become investors in the pharmacy. And I hate this. This is so unethical. And in my opinion, it's so unethical. And, um, and the business model is that the physicians, because they're investors are more likely to send the patient to a certain pharmacy that they they get a kickback from. I'm like, this should be illegal, you know? Um, and honestly, it's a fair question to ask as a patient too, to say, Hey, I know you sent my meds to this pharmacy. Are you an investor in this pharmacy? And whether you choose to use that pharmacy or not, I think that's something that they should be transparent about as well. Um, also, you know, a lot of times we're sending prescriptions electronically, but it is okay to ask your doctor for a written prescription because when you have a written prescription, that makes it easy for you to fax it or email it to any other pharmacy just to get a complete price quote too. Although I've already done the price shopping for my patient and I'm like, you're certainly welcome to try and try to call other. Pharmacies to see if you can get a price. Yeah, and I will say periodically my patients do like work for me every once in a while They're like, I'm just gonna check and then they come back and they're like, no, it was the cheapest Yeah, okay, I do have a question though, how do you feel about foreign meds? I'm asking you controversial questions. I know so I would say as a physician i'm hesitant. Yeah, um because You know, we don't know if they're regulated, right? We don't know if what's in them is actually in them, but I will say as a fertility patient, I can empathize. Yeah. Yeah. Um, and so it really, I've said this before, fertility patients are extremely vulnerable patients, um, and we get really desperate. And sometimes we're broke. Yeah. You know, sometimes we've gone through a lot of treatments. Yeah. and will really do anything. And so I have definitely let my patients use medications that they've got from other places. There's actually, I've had patients that have used leftover medications from, um, other friends, you know, that I haven't prescribed. Um, you know, of course I've sent them the meds that I think they should be taking, but I can empathize and understand, um, you know, on that level with them. I know one of my hesitations has been that You know, sometimes when somebody wants to do IVF, they're usually in a hurry. Like, I want to do IVF right now. And sometimes it just takes a long time for those foreign meds to get shipped over. And a lot of times they can get stuck in customs. And that can be really frustrating if you ordered it ahead of time, but it's stuck in customs. And then you can't start your IVF cycle because your meds aren't there. And so you end up having to pay out of pocket, but you also bought these other ones and then you have to spend more money. Yeah. And it's not uncommon too that we plan our IVF cycle, but then we end up having to add more medication at the end. And when we're using our local pharmacy here, it's easy because we say, Oh, just go pick up some more medication. But if you've ordered it overseas, you're really hosed at that point. It's not like you can get more medicine and you're really kind of forced to get more locally anyway. Right. And if they're sitting in customs, you kind of wonder what conditions they're storing. I know that's true. Yes. That would make me a little questionable. Yeah, absolutely. Absolutely. Yeah. Okay. Do you think we covered a lot of stuff today? Okay, good. Well, we'll wrap it up. This is helpful. Yeah. I hope it was helpful. If you want to hear more content like this, of course, let us know. You can give us suggestions for any topics you want to hear about and. If you would also be so kind, leave us a review, whether it's on our YouTube channel, our podcast, um, you know, venues, or even on our practice website, we would just so, um, appreciate any encouragement, um, that you find this helpful. Thank you guys. Bye.