Hailey Bieber & Ovarian Cysts

Dr. Amber Klimczak and Dr. Beverly Reed discuss Haley Bieber’s ovarian cyst. They review what ovarian cysts are, the different types of ovarian cysts, and what to do about them. They discuss how ovarian cysts can help us figure out why someone may be having fertility problems.

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. Today I've got a new celebrity story for you, Dr. K. do you know who Hailey Bieber is? I do know who Hailey is. There you go, Justin Bieber. Yes. And they're a very hot celebrity couple. Well, she has like a famous dad and uncle. Oh yeah, who is it, the bald one? Yeah, she's a bald one. Okay, she's a bald one. Yes, um, she's an influencer. She's always doing like little makeup tutorials. She's got that fresh look and everything. Oh my gosh, she's beautiful. Yes, yeah. And I think they recently had a baby. Um, and, um, and so I kind of, um, was just kind of looking through her history and she actually had a story a couple years ago about ovarian cysts and so I thought that's kind of interesting because that's something our patients go through. So she tells, um, the world really, which was nice of her to be open with this type of thing. She said, I have a cyst. the size of an Gosh, it's always food I know, they do always say everything is compared to food in medicine! That happens with pregnancy sonograms every week. Like, my patient will always be like, is my baby the size of her breast? You know, because I think the apps these days always tell people what, what size their baby is. So, um, but she actually said, she said, look, I don't have endometriosis, but or PCOS, polycystic ovary syndrome, but I've gotten an ovarian cyst a few times and it's never fun. And then she says it's painful and achy and makes me feel nauseous and bloated and crampy and emotional. Um, and so she said, anyways, I'm sure a lot of you can, um, relate and understand. We've got this. Um, so I, I love that she's so positive. I know. It's nice. I need to follow her. I like her. Yes, I love, I love that. So, but I thought it was, um, it would be kind of a good jumping off point to talk about ovarian cysts because certainly they come up all the time, and so I was going to ask you to tell us, what is a cyst? Right, um, so there's lots of different types of cysts, um, but really, I would say most commonly what we see is a follicle, which is kind of the shell or the house for an egg that's supposed to break open and release its egg that just kind of gets stuck hanging around for a long time. I'd say that's like the most common cyst that we see, but cyst in general just means something that's on your ovary that shouldn't be there. It's an overgrowth of cells, what type of cells are present and what they're producing really dictates what it is. Um, but I think the most common one that people see are just these follicles that kind of linger around. Yeah. And I know one of the most common questions I'll even get, um, And how do we pick up on these cysts? Usually when a patient is coming in for their baseline sodogram, we usually do this on cycle day two or three. And the reason, part of the reason we choose that time is usually on your ovary, all of your follicles are very small. And you shouldn't have anything that can be even confused with a cyst at that time of the cycle. And so if we see a little fluid sac or fluid collection on your ovary at that point, we call it a cyst. But a lot of times my patients will ask me, well, Dr. Reed, how do you know that's a cyst? It looks just like a follicle. And I say, well, The reason I know it's a cyst is because at this time of your cycle, you should not have a follicle of this size. Therefore by definition it's a cyst. Now admittedly if that same patient came back two weeks later around the time that she would be ovulating and she, and if I still saw it there, Then I would not be as sure because it, you know, assist can go away and she could have grown a new follicle on the same side. Um, and, and since a follicle and assist can look just the same, it does make it a lot harder to figure that out. Yeah. I think one of the biggest questions that I get from my patients is, is it bad? You know, is it going to hurt me? You know, and actually I have one funny patient and actually I can relate to this cause I have a lot of health anxiety myself, which every time we would see this. Persistence issue and say, am I going to die? Is this, is this going to do me in? You know, and, and I, I mean, I feel that way about stuff, you know, especially stuff that I don't really, you know, understand about my health. And so I think it's important to know that by nature, when we're calling something a cyst, that really is a benign term. We're not worried that it's anything else. That's going to be harmful to your overall health. And so I think you can feel reassured because a lot of women, I think really stress out when you tell them you have a cyst. It's just like panic mode, anything with your reproductive organs, you just really worry about it. Yeah. Well, and one of the things they'll say to me too, is they'll almost be in disbelief and they'll say, But Dr. Reid, I've never had a cyst before. Then I'm like, well, have you ever had an ultrasound before? And they're like, no. And I'm like, well, you don't know then. You, you could have had many cysts before because although some women may have symptoms like Haley Weaver did, many women, in fact, most women have no idea when they have a cyst on their ovary. Um, and, and so, you know, I think that's the hard part. Without an ultrasound, you just would not know. Yeah. And I know, I feel like I could talk about this forever, but you know, the other thing to kind of consider like with Haley Bieber is, you know, sometimes the person doing the ultrasound might be a sonographer, might not know to schedule it during a particular part of your menstrual cycle. So I do have patients that come in with ultrasound reports or even MRIs that show Ovarian cyst, right? And it's one big follicle, and I'm like, well, like, were you ovulating around that time? You know, there is such a thing as just, that's a functional follicle. It should be there. That's normal, you know. And so sometimes people might be having this chronic pelvic pain, and you, you get an ultrasound done at the, The mid cycle point where you should have a follicle and it's called a cyst. So you have to be careful to, you know, um, I see this a lot, you know, primary care doctors will order ultrasounds and, you know, they're, you know, doing a great job caring for overall health, but don't always know, you know, we got to order this at a particular time in the menstrual cycle. Exactly. Yes. Yes. So sometimes it's just normal and physiologic, um, to, to have a cyst. And so it's really all about when you're checking. Um, okay. So why would somebody get a cyst though? Why would you have that? Um, I feel like there's probably a couple of different things that I can think about where having a cyst can help me figure out what is going on with your fertility. So one of them is that when a woman starts running low on eggs. Her FSH level from her pituitary gland will try to stimulate the ovaries in a more robust manner. And sometimes it does that so strongly that the follicle is growing too soon or too fast. And so, you know, I said all your follicles should be small on cycle day two or three, but if you already have a big one, then that tells me that you are growing your follicle out of age. And so this is really helpful, I think, because I'm saying, look, when I see this, you're probably somebody who ovulates way earlier than you should be. And you're probably somebody who has periods that are very close to each other. And I kind of use this as an opportunity to say, Hey, let's trick your brain for your next cycle by maybe giving you some estrogen before your period comes that can lower your FSH. Thank you. And make your follicles all be very small. Like they should be. Yeah, yeah, definitely. I see that a lot too with my patients with lower, really low ovarian reserve, you know, almost towards even menopause that sometimes their brain is working so hard to move on to the next cycle that they actually rescue their follicle from the previous cycle. Right. So. Anytime I see a cyst on a baseline ultrasound, I'm usually getting hormone levels. And the most common cyst that we see might not be producing estrogen or progesterone, any hormones at all, or more likely just estrogen alone. Um, but sometimes they can produce estrogen and progesterone. I would say that's the more rare type of cyst. that I ever encounter and those can happen a lot when people are really low on ovarian reserve because they're kind of keeping this, this follicle or cyst alive from the last cycle your brain's working so hard. So that can be another even persistent cyst that we see on a baseline. Absolutely. So yeah, I think that population of women, women who are lower on their ovarian reserve is probably the population we see the most for cysts, but really they can happen to anybody too. Um, but sometimes when you have a cyst, sometimes it will be right after you've done a treatment cycle with us. So, let's say you did a treatment cycle. Let's say we gave you Clomid and let's say you grew two or three follicles. We triggered you, we tried to get pregnant. You didn't get pregnant. The next month you're coming in through your baseline and let's say I see three cysts. No, you have three cysts. Well, sometimes I'll look back and say, well, where were your follicles before? Were these follicles the cysts that I'm seeing today? And if so, it really makes me wonder, couldn't you be having an issue with ovulation? So, with ovulation, there's usually three things that should happen. One, the egg should mature. to the follicle should start to make progesterone. Those two things almost always happen. But the third thing that needs to happen is the follicle needs to collapse, it needs to pop so that the fluid in the egg can come out. And sometimes that doesn't happen. If it doesn't happen, it's called, um, let's see, Luteinized Unrestricted Follicle Syndrome, a big fancy word for your follicle didn't pop. Okay. And if that's the case, then you can end up having cysts the following month. And I think, again, that's so helpful because if I see that's happening, then we say, Hey, is there anything we can do to try to make that better? Maybe we should try, and this isn't proven, we don't know, but maybe we should try to give you double trigger injections. And maybe next time after we trigger you, we bring you in for an ultrasound three or four days after to make sure your follicles did pop like they were supposed to, but ultimately, if they're having trouble popping, sometimes that tells us, you know what, we might need to do IVF where we can put a needle into the follicle and just pop it. pull the eggs out that way. So I think it can be helpful in that respect too. Yeah, definitely. I would say the other time, probably more commonly when I see that happen, you know, when I've done a clomid cycle or a letrozole cycle, what I explain to a lot of people is you typically have one follicle or one egg that's always going to be your lead, right? It's going to be the first one out of the gates, but when we give you clomid, So when we scan you, we do your ultrasound or we're about to do your trigger shot, we look at them. We'll have one nice juicy follicle, but maybe we have a couple other ones and you might have even have some up and comers, right? You might have some smaller follicles that don't look like they're quite there yet, right? But you have other bigger ones and we trigger you anyways. And I would say those up and comers can often get a little bit of extra stimulation at the end. And then there are the ones that grow and then are stuck kind of in this intermediate phase when we do your next baseline. So. So often the ones we were going for, they did, they released, they're all good. But then we actually triggered these up and comers and gave them a little bit more support and then they're just hanging around. And so I would say that's probably what I see even more commonly when I do a baseline. Yeah. And that kind of reminds me of a common question I get where patients will ask me, Does clomid cause cyst? Okay. And because I think there's a lot on the internet, I think about clomid causing cyst. And I'm, and I say, well, kind of, okay. Cause to me, when they ask it like that, it makes it seem like clomid is a bad thing. Oh, clomid just causes cyst. But I think exactly what you're saying is, well, the clomid really is just making your ovary more active than it otherwise would have been. If you're not taking fertility medications, most women at most, will grow one follicle. That's your one chance you get. So if you have one follicle, that's one chance to grow a cyst. Okay. But if you're taking Clomid and let's say you grew three follicles, well instead of one follicle to make a cyst, you could have the chance to have three, right? And so while I don't think Clomid directly causes cyst, I do understand ovary more active and active ovaries are sometimes. So, um, in some cases, especially my low end patients, I'm like, you know what? Because I was trying to look for the positive. I'm like, at least your ovaries are active, right? Women who are menopausal, they don't usually process like that for the most part. And so I think, hey, at least your ovaries are trying to do something. Of course, it's frustrating when it's at the wrong time, but sometimes I think it's it can still be a good thing. Um, But I wanted to ask you because whenever you're doing a baseline sonogram you see cyst, of course the patient wants to know, well can we still try fertility treatment this month? And I know that every doctor is a little bit different with whether they would let that kind of go forward. So how do you decide if you're going to let somebody continue a treatment cycle, um, if they wanted to? Yeah, this is a great question. I think this is something that you and I differ on. Um, if I do your baseline ultrasound and we're going to start a medicated cycle and I see a big, um, simple, just like fluid filled follicle cyst sitting there on your ovary, I'll get blood work that day. And if your blood work looks baseline, you know, this is just a dormant follicle. It's not releasing any estrogen or progesterone. It's just. sitting there, then I let my patients start their medications. If it's active, if it's releasing estrogen or estrogen and progesterone, then I don't, I mean, I feel like I'm pretty similar. I may be a couple of exceptions. So, um, you know, I do kind of factor in size and how long they have it. So certainly I have some patients that they've had a cyst for years. You know, it's, and it's huge. Let's say it's a four centimeter, uh, huge cyst. It's always there. I think it's so cute. A lot of my patients name their cyst. Mm-hmm. It's my friend, my cys name Bob, like, um, so if it's a cyst I know has always been there, then I really just ignore it and, and um, move forward. Um, if it's a new cyst and it's big, then sometimes I'd like to just let it go away before we do another treatment cycle. If it's small, then I am trying to figure out, is it producing hormones, could it interfere, and things like that. One of the things I do worry about if it's a newer cyst, is when I give fertility medication, is there a potential for me to make the cyst bigger? I don't want to create any problems, I want to just decrease the stimulation, let it go away on its own. Um, but also if I think it's one of those cases, um, that we talked about before, where they have an out of phase follicle, I do think that can really throw off a whole cycle, just wait and I say, look, it's not good for this month, but let's start you on estrogen and try for next month. So I think it's really just can be so many different things and it just really depends on the patient situation. Um, I have looked at a study before to see, does it affect, um, your success rates when you have a system, you try to do a traditional treatment cycle and It does show lower chances of success, but some people still get pregnant. So I don't think it's unreasonable to move forward with it. Um, but sometimes we'll just kind of talk through with the patient, Hey, like what's most important to them. For some people, they say, gosh, I just want to keep going as fast as possible, even if it's lower chances. I want to keep trying. Other times I'll have people who say, look, we decided we're only trying one IUI and if it doesn't work, you know, and so then say, well, this is going to be your one. I'd really just wait, you know, so I think it can, yeah, definitely. Yeah. Um, okay. So what? Okay. Sorry. I'm looking at our questions here. Um, let's talk about the different types of sys. I think we've really been mainly focusing on just a single IUI. Simple cyst, but there are different types of cysts that you can have and they can mean different things. So can you tell us about some of the more common types of cysts? Yeah, so, um, you know, one of the other cysts that we see that I would say wouldn't really be called simple is a hemorrhagic cyst. So sometimes we'll put the ultrasound probe in and we might see a cyst that's more kind of white, kind of heterogeneous looking on the ultrasound. And typically that is actually one that's probably filled with blood and maybe on its way out. So Hopefully that is a good sign. You know, again, it depends on your menstrual cycle. There's actually a normal time that we would see that right after ovulation. And then that second half of your menstrual cycle in the luteal phase, we can see a normal cyst that would look like that, right? Um, and so, but a hemorrhagic cyst might be present on your baseline ultrasound where it shouldn't be, right? It shouldn't be there during that time. And usually that means it's probably going to be gone. You know, by the next cycle. I think these cysts are interesting because to me they have the most alarming name, but they're the cysts that don't matter to us at all. You know, I don't think any of us have any problem with cycling somebody if they have a hemorrhagic cyst. Um, but it's so hard because when you try to explain it to a patient, you can see the look on your, on their face when it's. You know, for us, it's no big deal. But you're like, yep, it's a sack full of blood on your ovary. And they're looking at you like, Oh my gosh, that sounds really bad. They're like, no, no, it's no big deal. Like this is normal. Um, and, and so really, um, these are ones that we don't worry about. Of course, we're always going to find. follow us as no matter what to make sure it does go away and get better for you. Um, but, but these are most of the time going to be gone by your next cycle and don't typically interfere with anything. Um, one tip for how to recognize one when you're doing an ultrasound is Yes, um, so you see this circular object, so a simple cyst just looks black on the inside because it's just clear fluid. With a hemorrhagic cyst, just like she was mentioning, it can look brighter kind of in the middle, and if you move the probe back and forth, it actually moves like jello. Some people call it jello time because it's a blood clot inside of there. And so you can kind of see it jiggle and then you kind of know, okay, that's a hemorrhagic system. Yeah. They can look strange though. And so I can understand why patients can worry about it. Yeah. I would say the other, I mean, especially in our fertility patients, the other common cysts that we'll see is an endometrium and I know we've talked about endometriosis on this podcast before, but endometriosis, if you remember, it's endometriosis. presence of, you know, glands and stroma that should only be inside the uterus, outside the uterus on places like your ovary. And when that happens on the cells that are in your ovary, they can actually bleed into its own little capsule and cause this little blood filled cyst. We sometimes call it a chocolate cyst that has a very particular appearance on ultrasound called endometrioma. Yeah. And I do think, you know, probably a couple of things about these. So one, I do feel like they're more likely to cause symptoms. They tend to be painful. that you can use to help people. Number one. Number two, you can still do a treatment cycle with them. Usually we can just kind of watch these as well, but I think it's so helpful because it lets us know that the patient by definition has endometriosis. Endometriosis is this condition when you have your period, it backflows through your fallopian tubes and implants in the pelvis, but usually the implants are so small that you don't really know most of the time if somebody has endometriosis based on an ultrasound alone. Um, But an endometrioma is a great exception to this because if you see an endometrial, uh, endometrioma, then you know they have, um, endometriosis for sure, and that can help guide you on their fertility treatment on, on what they should do next. Um, but what do you think should an endometrioma be surgically removed if a patient has one? I feel like this is such a matter of debate. I even sometimes debate this with my patients because I believe patients also have like, um, you know, an opinion about what they want these things out. You know, like I think the second anyone sees it on their every, they really are just like, want to get it taken out. They want to remove, they want to be done with it. Um, but that's not always, um, a super straightforward answer. And what I explained to my patients is they've done studies of women with endometriomas. And when you go into surgically remove an endometrioma, an endometrium from the ovarian tissue, almost always you're going to take along with it some of that good ovarian tissue, which means good eggs, good follicles going along with it. And so you can have decreased egg count or decreased ovarian reserve after those surgeries. Okay, and so often I'll try and encourage my patients while it depends on their treatment plan or if we're doing IVF I definitely like to stimulate their ovaries before and Remove as many eggs as possible as long as I can get to the eggs on that side, right? Sometimes the endometrioma itself could be in the way and I won't be able to access any of the follicles Um, but usually I can get to them. And so I really encourage my patients to cycle through first. And then if they want to have it removed and remove it afterwards. Yeah. Yeah. Yeah. And I think it's so, sometimes it can depend too on size of the endometrium and whether somebody is very symptomatic, they're experiencing a lot of pain and everything. But I think just we're so protective of the eggs, which is why we really like to avoid surgery. in people. Um, if we can that being said, and we know that endometriosis can really affect ovarian reserve and quality and everything. And I was actually listening to an endometriosis expert the other day, and I don't think this is published, but he was saying it is unpublished data. that they were showing that eggs that came from an ovary with an endometrioma had a higher chance of ultimately resulting in abnormal embryos. And so he was really trying to push the fact that, hey, he thought really any endometrioma bigger than 1. 5 centimeters should be removed. I was very surprised because that is against our traditional teaching there. And I'm a little bit skeptical because I'm like, you got to publish that data so we can all review that and, and, and see if that's true. Um, but I think in somebody who's maybe tried IVF a couple times, for example, and maybe they're not getting the results that they would have expected or should, it certainly could, um, benefit them maybe to have endometriosis, or excuse me, endometriosis and endometriosis removed prior to stimulating IVF. It's just things we're still trying to study and figure out. Yeah. Um, okay. What about germoids? Can you tell us about germoids? Oh, gosh. Germoids are like the weird stuff. So, germoids are, they are also by nature benign, right? Even though they can look pretty wild on ultrasounds. So, germoids are where you have cells that actually have mutated or grown from cells that can become anything. So, you can have this beautiful, There's a ball of tumor cells that really has bone and hair and all sorts of weird cells just growing inside your ovary. These ones I think a lot of people have heard of because they're just like those bizarre things that you see on the internet. Um, But they can look kind of solid and abnormal on the ultrasound and they tend to be present even in young women in their 20s and they just kind of hang out there and never go away. So usually once you find out you have one of these, every time someone does your ultrasound, they'll see it. And, um, a couple of interesting things I think, um, about Dermoids. I think one is kind of, as you mentioned, how it can contain all these different types tissue in our bodies. And I know both of us have done a lot of surgeries on women for dermoids. When you remove the dermoid, you can see all of this hair, teeth, all these things, right? Um, but I actually saw a really interesting one when I was at UT Southwestern where the way she presented, um, nobody knew she had a cyst at first. The way she presented is she was a college student and she had. Hallucinations, delusions, she essentially was going crazy and her family were like, they were just like, she was totally normal before, had no issues or problems. Suddenly she's going crazy. And so what they ended up finding out is this was because of her dermoids. So she had a condition called anti N M D a encephalitis. And the reason they think that women can get this is her dark germoid was producing neural tissue. And you know, your immune system is not used to seeing that. So it creates antibodies trying to attack it. And those antibodies affect the rest of your body and can cause very severe symptoms like that. And so I think that's like a really interesting one. We don't really see that very often. It's very rare to have that. I know, can you imagine? And thank goodness they figured out what it was. But removing that germline for her was very important. But the vast majority of other germlines we see, of course, are very benign and basic. But we do always recommend that you get them followed up over the long term, just to make sure that they're not growing or Um, becoming problematic because if they do cause you pain or if they get too big, then we do usually recommend removal. Um, okay. So, uh, you know, I think probably the biggest fear that everybody has whenever they have a cyst is do I have cancer? Right. And I think reflexively we're always like, no, no, no, it's okay. You don't have cancer, but I do think there are some things that are important to tell our patient in terms of safety when you have a cyst. Um, so the first thing is if you have a cyst that's really large, Admittedly, it can increase your risk of ovarian torsion. Can you tell us a little bit about that? Yeah. So I talk to my patients a lot about this. So ovarian torsion is anytime that the ovary is kind of big and large or lopsided, it can turn on itself. Okay. Um, and it has its little blood vessels, almost you can imagine like a little tube going to it. And then if it turns, right, it's going to cut off itself. blood supply. It can happen really with any ovary, but when they are big and have a cyst on it, and they're kind of lopsided, it's more likely to happen. This can present as all of a sudden sharp pain. Sometimes it comes and goes because it actually can be turning and then going back, turning and then going back. It can cause nausea and vomiting when it's happening. It's very, very painful. It is a surgical emergency. If you know you have a cyst and you start getting symptoms like this, you really need to go to the nearest emergency room because you might actually need surgery to detour or untangle that ovary and its blood supply and get all the blood flowing back to it where you can lose that ovary. Right. And it's interesting too because it's almost like an in between size cyst that's highest risk because if it's small, it's low risk. If it's a huge cyst, it's so big it usually can't turn. because it doesn't have the space to turn. So it's really kind of like an in between sizes that sometimes we worry about. Um, but, but sometimes just depending on your risk, that might be a reason why we say, Hey, even if you're not having problems, maybe you should get this removed because you would hate to ultimately be pregnant and have a cyst and be worrying about this type of thing as well. So that's why we kind of always discuss that with you too. And then in terms of cancer, you know, our patient population is so young and the risk of ovarian cancer is very low in that age range. However, it is not impossible. And so it's really hard because when somebody says, do I have cancer? I mean, you say probably not, right? I mean, but a very small percentage of people could have cancer. But how do we know that? Well, look, if you've never had a cyst before and then you get a simple cyst in a month, I'm not really worried because I know it's probably going to go away. But again, I like you to have a followup ultrasound so I can make sure it does go away ultimately. But if you're having a cyst that starts to contain concerning sonographic features, if it's getting bigger, it's not going away, you're starting to have other symptoms. Certainly I know you and I end up doing a further workup. Yeah. There's certain blood tests that we do to evaluate the cyst further. We may get an MRI. We may get in consult with the cancer doctor. And it's not necessarily because you have cancer, but just like, Hey, this one seems a little bit more concerning. Do we want to just check this out and make sure they're signed? Yeah. And I know sometimes I've scared my patients in the past with this, you know, I'm just overly cautious. So my protocol, what I always tell my patients is I think it's this. I think it's a Dermoid, you know, which can look kind of funny. But here's what I'm going to do. I'm going to check with my partner. I always get a second opinion. I always think it's, it's really important to get another doctor to take a look at any type of cyst that we think is unusual. And then if I really am still kind of on the fence about it, I will always order an MRI. And then I have a third opinion, right? The radiologist is looking at it in more detail and able to say, yeah, I also think this is just a benign Dermoid cyst. cyst. Um, and again, you know, very rare, but we never want to miss ovarian cancer. So we're just overly cautious with those things. Yeah. Yeah. Okay. And then I did want to end on a trick that Dr K taught me for cyst. So kind of back to the beginning when we were talking about simple cyst and um, you know, that you may have, let's say a baseline or it just won't go away. There are certain cysts that she taught me that we can try to trigger. to get them to go away. But do you want to tell t I've used it now a couple people it seems to work. I told you, you know, my trying to start their tre there, I'll get hormone l Up. What I'll often do is I'll actually have them take their trigger shot, which is an HCG trigger shot to help it to lutein eyes and collapse and go away faster. And typically what I'll see is, you know, two weeks later I'll bring'em in for an ultrasound and it's usually a collapsing, hemorrhagic cyst or completely gone, and it just allows me to accelerate treatment, you know, faster as opposed to waiting a whole month. Yeah, yeah. I think that's a great idea. I think maybe we need to do a study on that too because it does seem like it helps everybody, but you know, it's, I feel like, hey, sometimes it's just worth a try if you've got kind of a stubborn system. Yeah. Okay, good. Should we wrap it up for the week? Yeah. Okay. Thanks for listening. Thank you guys for listening. If you would be so kind to leave us a positive review on the podcast website or YouTube or even on our practice page for peak fertility, we would so appreciate it. And we will see you all next week. Bye!