Two Peaks in a Pod

No More Needles: Sydney Sweeney’s Fear Meets Fertility’s Future

• Beverly Reed • Season 3 • Episode 9

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Dr. Amber Klimczak and Dr. Beverly Reed discuss Sydney Sweeney's severe needle phobia. They also open up about their own personal medical journeys which includes their fear of needles. They discuss suggested interventions to deal with blood draws, injections, acupuncture and more. They introduce their new option to ditch the shots for IVF.

Watch this (Season 3, Episode 9) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

https://www.youtube.com/@peakfertility

https://podcasts.apple.com/us/podcast/two-peaks-in-a-pod/id1694248202

Links are in @drhappyeggs IG bio.

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber k Clack. And we are two peaks. Two peaks. In a pod. In a pod. Well, hi everybody. Welcome back. I have, um, a story that I think you're gonna relate to Dr. Okay. Okay, good. Okay. So, um, there's a pretty famous actress named Sydney Sweeney. Do you know her? Yes. Okay. I know all about Sydney Sweeney. She has some assets. What do you mean? What does that mean? She's kind of known for her, Bo. She's not like a rock. And don't you know this about her? I didn't know I did see her. She's beautiful. Yeah, she's, but I guess I only saw a headshot she's known for. I'll ask my husband. I'm sure he'll know. He'll, he'll be happy to do the research. Yes. Yes. Um, well, so pretty well-known actress. And it was interesting because I saw an interview that she gave about a movie that she was in, and she was opening up about her fear of. Needles. Ah, yeah. And I thought of you right away. Yeah. She would just really vibe with us. I know she would totally fit in. Um, and so what she was saying is she said, well, I'm scared of needles. And the interviewer was kind of like, okay, sure. And she's like, no, you don't, you don't understand like. I, it's a true phobia, like I'm terrified of needles. And it's to the point that when she has to get a shot, she said she physically has to be held down, pin down to get a shot. Look at the pediatrician. I know. And I saw that and I'm like, oh gosh, I hope she never has to do any fertility treatment or anything like that. Right? Because that involves a lot of needles. But then I was like, if she did need to have fertility treatment, sydnee. We're your place to go. Yeah. Yes. We've got lots of ways to help with this and I think a lot of it is largely based on our own personal experiences, right? Yes, absolutely. Do you wanna share a little bit about how you feel about needles? Yes. I will say like I think I've grown up a little bit past having to be held down this Yes, yes. No, no one's had to hold me down anytime recently. These are little, I think it would be easy to hold you down. Um, but yeah, I mean, I agree. I mean, I think it's something genetic, right? Like humans probably have a genetic predisposition for wanting to be scared of needles. Like a lot of us don't want that to happen. It definitely makes sense, right? Our brain is like, Hey, let's not stick something sharp that could harm me into my body. Yeah. So it's our just natural instinct. Um, so I'm always fascinated when needles don't seem to bother people at all. Yeah. And it is. I think it's also interesting that it can get better. Mm-hmm. You know, with just like exposure. I mean, definitely when, I mean when I was starting medical school even, like, it's okay, I can poke anyone else. Mm-hmm. Right. I can do it to anyone else. Yeah. But the thought of it going into my body Yes. Really got me. Okay. Let me tell you my medical school story. So in medical school, you have to learn how to draw blood and start IVs mm-hmm. On each other. Yes, and I was panicked, like even thinking about this. I would get hot and sweaty and I'd be like, oh my gosh. And so I started an IV on my partner and she passed out and I was like, I cannot do this. And so I paid somebody else$50 to take my. Stick for me. Oh my gosh. I remember John Simmons. Thank you John. He was one of my classmates. That's hilarious. He took my stick for me. Um, and'cause I just, I couldn't do it. I was too scared. Yeah. Kind of crazy, right? Yeah. I think the drawing of the blood is the worst needle. Yeah. Of all the needles. Mm-hmm. Yeah. Yeah. Um, and so I think that's something you and I really connected on because we both had this fear of needles and everything. And I will say for me, I really do feel like it. It impacted my medical care in a negative way. Um, because when I was pregnant, I was a bad patient. I was supposed to get my new OB labs. I didn't wanna get them done. I delayed them like, you're done to get them done, or you just delayed it. I mean, I, I should have had them done a lot earlier than I did. Um, and for some of my pregnancies, I was supposed to get progesterone injections and I really tried to like bargain with the world. Is there any other way to get this progesterone in my body without having to take a shot? Um, and you know, and finally I did it, but I, you know, had to have the nurses. Yeah, I guess kind of hold me down and give them to me. Um, it was not easy, but I will say I found over time, the more times I had needles, the more I did become desensitized to it, because I would really work it up in my mind to be this big thing. And then after it happened, I would be like, oh. That's it. Yeah. That wasn't, that wasn't even bad. I didn't even feel that or whatever. And so having repeatedly done that over time, it did get better. But then what I noticed is the longer I go without a blood draw or a needle stick, it starts to come back that, yeah. Phobia or fear. So I do think desensitization in a way is very helpful. Um, but, but it can, you can definitely relapse into it too. I still don't like to have blood drawn. Yeah, me either. Um. And I'm kind of annoyed with my insurance company'cause they make me do it every year, even though I'm like pretty healthy. I'm like, I don't wanna have this blood drawn. Um, but um, I also just wanted to share probably the most extreme case that I saw. This is back before I was a fertility doctor. This is when I was an OB GYN. And we had a patient that we had to meet on the ethical committee about because she said, look, I'm pregnant. And I have a severe needle phobia. And she said, you know, I understand that you may need to start an IV on me at some point. And she was like, I, I'm okay with that, but you're gonna have to hold me down. And in that moment, I'm going to tell you. Don't place the iv. Oh gosh. Okay. So that's a huge ethical problem, right? Yeah. Because you know, let's say she needed an emergency section or something. Yeah, we're in an emergent situation. We need to start the iv. But she's telling you, do not start the iv. And she said it's so hard for her because she said, look, I have this phobia. Intellectually, I know I want my baby to be safe, and so you're just gonna have to do it against my will. But how can you do that? Yeah.'cause you can't assault a patient. Yeah. Right. That's crazy. Somebody can revoke their consent at any time. Yeah. And so it was, um, it was. Kind of interesting to have to kind of talk through all the things, but ultimately they had to come up with this plan of, okay, if she were in an emergent situation and this needed to happen, they would have to have two doctors come and evaluate her capacity to say, okay, she's currently incapacitated in this moment because of her severe phobia to make this decision. Therefore, we have to use her prior wishes, which were to. Start the IV and everything. That's a hard situation. Right. Well, and also you don't have time during an emergency C-section. I know, right? Right, right. So, wow. Yeah. Yeah. Crazy. So that's one of the most extreme cases I've seen. Yeah. But I think probably more commonly when we see the needle phobias, they tend to be a bit mild. And so I just thought we can maybe kind of talk about some of the things that are special about our clinic here at Peak Fertility, but really anybody could do anywhere. To try to really alleviate a lot of the stress of needles. And so first I thought we would just talk about genetic carrier screening. Um, this is something that all fertility patients are offered. It's a way to see do you carry anything in your genetics that you could pass on to a child that could cause a major medical problem? And traditionally, this was a blood test. But do you wanna tell them about one of the other options we have now? Yeah. So especially with the company that we're working with, they do offer a saliva based kit. So you actually collect your saliva into a little tube. But I haven't done it this way, but my husband's done it. He said it was kind of hard to get a enough of it in there, but, um, you just collect your saliva into tube and they can run your genetics off of that. Um, and I have confirmed recently with this company that the accuracy is exactly the same as with the blood samples. Because I did have a patient that was concerned about that. Mm-hmm. And we confirmed it doesn't make any difference. Now I will say I don't love the saliva. Mm-hmm. For a couple reasons. It takes longer. Mm-hmm. In my experience, it takes about three weeks longer. I don't know why. Yeah. Um, it's just slower than the blood. Mm-hmm. And sometimes, like I said, you can maybe not collect enough. Mm-hmm. Or if you don't, if you eat or drink or chew gum or smoke before, even though they tell you not to. Mm-hmm. Um, it won't, it won't run. And then it's three weeks later before we figure that out. So yes, I know you, Dr. K is always on the move in the hurry. She doesn't want a genetic carrier screen Yeah. To slowing her down. But I think it is such a nice option for people who have more time, or for people who are really stressed out by needles to say, look, you don't necessarily have to have a blood draw for this. You could always do a saliva kit. Mm-hmm. And the other nice thing about doing the saliva kit is you could always do it from home. Instead of even having to come into a clinic or a blood draw location as well. Mm-hmm. So that's kind of the very first thing we can help with. Um, the second thing is I do think we're really thoughtful about blood draws overall. So yes, most patients, we are recommending that you get some blood drawn when you come in. But if you've come from another clinic and you've already. All these blood tests done recently, there's no reason to make them do it again, right? Mm-hmm. Um, usually as long as it's within the last six to 12 months, we will just request your records for you if you're okay with that, and just kind of check off that you've had any testing that needed to be done. And then when we do need to, um, order new patient labs and things like that, I oftentimes we're trying to consolidate that to get it into the least number of blood draws, um, you know, possible, uh, over time as well. Yeah. Yeah, absolutely. Yeah. When somebody has to get their blood drawn, and I think you've even had your blood drawn here too. Mm-hmm. I have too. Mm-hmm. Um, have you ever kind of used some of the special things that we have to, to help people have a better experience? Yeah, I've definitely tried out buzzy. Mm-hmm. I think, um mm-hmm. We've talked about buzzy before. Buzzy is a little a vibrating design. Device that you can put on your arm and the idea is that it distracts the nerve and you don't really feel that needle entering into the arm. Um, I think it works. I think so too. I've tried buzz too. The girls have drawn blood on me multiple times and really I didn't even feel it. I think my brain was so focused on like, why do I have this weird vibrating thing on my arm? It really takes. The attention away. So I think that's great. Um, so these are things you can request. If you see us, we don't necessarily routinely use them on everybody'cause most people don't really mind blood draws, but if blood draws bother, you just request it. We're happy to help. Mm-hmm. Um, another thing that can help but does require sort of thinking ahead is numbing cream. So, um, if you would like us to order some numbing cream for you, we're always happy to do that. Usually for the numbing cream to work, you have to have applied it about 30 to 60 minutes ahead of time. And since you never quite know what side they're gonna draw your blood from or anything, you might have to apply it to both sides. Um, but we're always happy to help that too, just to make it, um, as comfortable for you as possible. And then let's talk about needles. Mm-hmm. Okay. Do you ev, like when they draw your blood, do you watch, like do you see the needle and everything? I usually look away. Yeah. Me because Me too. I, I actually think that's mainly my problem. Yeah. Is I get like that kind of lightheaded disease. Mm-hmm. You know, we call it a vasovagal reaction. Yeah. I don't actually get it anymore. I used to get it a lot. Yeah. I now, I've gotten my blood done so much. Yes. Yeah. Um, but I try not to watch. Mm-hmm. But I do think one of the things that really helps for us is that we use tiny little butterfly needles. Yeah. They're the smallest little blood draw needles that are available. Um, and it really spoils us because when you go to Lab Corp and Quest, some of those big blood draw centers, they use the really big needle. Yeah. Yeah. Yeah. I love those little butterfly needles. Mm-hmm. I mean, they're so cute. I love the name. Yeah. Anything named Butterfly. I'm gonna laugh. Yeah. Um, but I'm sure people might say, well, why doesn't everybody use them? Okay, here's the thing. They are really expensive. Yeah. You would think the bigger the needle the more expensive it is. No, it's the opposite. Yeah. The smaller and more petite the needle is, the more expensive it is. But hey, we are willing to shell the big bucks for our patients. Yeah. And for ourselves really too. Um, okay. Well I wanted you to kind of tell us more about this device that you were telling me about that may even replace a lot of blood draws in the future. Mm-hmm. Can you tell our audience like what's coming in future years? Yeah, so there was a really interesting publication that just came out last month. This is out of Columbia. Um. Up in New York and they were testing out this device, um, where it actually, you place it on your arm and it pulls blood from the capillary. So it's a bunch of, I would call them microneedles, tiny little needles in a little circular device that you can't even see. And they just place it on you. And apparently you don't really feel the pain of a needle injection. You don't see the needle at all. You just see the circular device. Um, and they have done sort of. Case studies right at Columbia to show that the hormone levels during IVF and fertility treatment are accurate when drawn with this device. So I thought that was really interesting, kind of on par with what we're trying to offer at our clinic. So I'm extremely interested in this device. That is so exciting. I definitely wanna know more about that too, and see if we could maybe get that and test it out a little bit. That sounds great. Mm-hmm. Yeah. Okay. Well, let's kind of talk about fertility treatment, because I know before I became a fertility doctor, when I heard kind of the concept of fertility treatment, I do automatically think of a lot of needles. But now being a fertility doctor, I actually see that most people don't really need that many needles to get pregnant. Right? And so I thought we could maybe just talk to our audience about just basic fertility treatment. Um, how many fertility shots are usually involved. So let's say I'm your patient. And you have given me a plan of doing a ch Clomid cycle or something. Mm-hmm. Can you tell me about how many injections I would need during that cycle? Yeah, so I usually would just use one injection. If we're doing something like an oral medication like ch Clomid. Mm-hmm. Um, in time intercourse, or even an insemination cycle, I use one injection to help time ovulation. Perfectly, that's called a trigger shot injection. It's a really tiny needle. Mm-hmm. I will say it's a very easy injection to do. A lot of times it's just a prefilled syringe. Mm-hmm. I haven't had a lot of patients complain about the trigger shot, um, injection, but it's just once for the whole cycle. Yeah. Yeah. And I know if we have patients that are concerned about it, they've never, you know, given or taken an injection or anything, we often will offer if the timing for the injection works out to even give it to them in the clinic sometimes. It's just nice if somebody else can do it. For you, or if it's during a holiday or weekend, um, you can actually even hire a private nurse from a different company to come to your house and give you your injection as well. Um, but yeah, I think people do great with it and I think most people would be surprised to know, again, for a basic fertility treatment cycle you're looking at, at most. One little injection. Mm-hmm. Not a big deal. Mm-hmm. Okay. But then gotta talk about IVF. Okay. So when I think of all those needles, it is true traditional IVF does involve a lot of injections. And so, let's see, I think if we did like a traditional IVF cycle, the, the normal way you can count on maybe two to three injections per day. For about 10 to 12 days. But you might be surprised to know too, some of the doctors I've worked with in the past, they would give twice daily dosing. I know. So that means that could be so, I mean, what, four to six injections per day? Like, oh my gosh. Like I, I just saw someone as a second opinion that did one those cycles and I felt really bad and I tried not to say anything. Well, it's usually the older doc. I know, I guess in the older days they kind of thought that worked better, but there's been studies showing you don't have to split your dosing, you know, throughout the day. That once daily dosing is does just as well as that. But I think if they've just always done it one way, sometimes it's hard for them to change. But I know it doesn't have to be like that. I know, but poor patients. Yeah. Yeah. Yeah. Maybe the only exception I would make to that is when we do our microdose Lupron cycles. Sure, yeah. The microdose Lupron, you do have to, um, dose, you know, morning and night. But, but besides that, most medications you can just do once per day. Mm-hmm. So, um, so that's kind of the traditional way, but we really like to think about all the other options as well. And so some people, sometimes you may have heard of something called Needleless, IVF, and really that term will probably kind of cover two different strategies you could do these days. But the first more traditional strategy is to try to just use oral pills instead of using injections. And so I just wanna get your thoughts on that. How do you feel about needleless IVF using oral medications only? Mm-hmm. I think it would be appropriate for a subset of patients, but not all of'em. Yeah. So when we think of just using oral medications to stimulate your ovaries, overall, we're going to get less of a risk. Right. Yeah, because it's much lower dose, it's less stimulation to the ovary. And that might be appropriate for some patients. Mm-hmm. But certainly not all of them. Um, and then in order to prevent you from ovulating, we would probably, I guess, use another oral medication, which again, can be appropriate in some patients, but not all of them. And then ultimately, I mean, you really have to take a trigger shot. What could you use to replace the trigger shot? Well, they do have a nasal spray, um, that's equivalent to Lupron. Interesting. They do that. I guess they could do that. Yeah. Yeah, yeah. Um, but yeah, you know, I think it's a great concept, but it wouldn't be my favorite because I guess if somebody asked the question like, could this work? I would say, sure, it could work. But if you asked me what would work better doing a cycle with these injections or the oral medications, I think the injection cycle would give you a better outcome, lower risk of cancellation or any problems like that. Um. So, so I think it's a cool concept. I would do it if I had a patient who really wanted to do it, but if they were asking for my recommendation, I think it would stick more with the traditional way. Mm-hmm. I agree. Mm-hmm. I agree. But that being said, are there any other things we can do to try to kind of decrease the number of injections maybe, and one thing that sometimes we'll do if the patient is open to it. Is maybe trying to combine all of your shots down to just one shot, um, per day. Um, have you had any patients doing this recently? Or what do you think? When we first opened, I had some patients mm-hmm. That were more into this. Yeah. But now I feel like my patients have shifted mm-hmm. And their priorities. Like patients are so scared of messing anything up. Yes. Yeah. Um, that they're like, Hey, I'm already at this point that I'm doing IVF. Yeah. I just wanna do it like. The safest, most traditional by book way. Yeah. Yeah. So I haven't had a patient in a long time inquire about mixing their injections, but from everything we can see that's out there and available, it's probably fine to mix'em. Yeah, yeah, yeah. So the concept is that these medications, they are usually just, just. As being given individually from the manufacturers. And if you are by the book person, that's what you should do. Follow, follow all the labeling and everything. Um, but I know there was at least one study where they said, look, what if, instead of taking, for example, three separate injections, we combined all of the injections and gave them as one shot. And, um. So probably the easiest way to do this with the more traditional medications is manipu is usually given in a vial, it's a powder. Um, you usually add liquid to the powder, and so you do that as usual, but then you can squirt your fem or um, gal f into the vial, and you can squirt your either gana relics or cetrotide into the vial and mix it all up and then draw it all out and give it as one. Now, you definitely should not do this on your own. You would only ever talk to your doctor about it to see if it's an option for you. And we do not officially recommend this, but we say, look, sometimes you're factoring in multiple different things. If for a patient. Their body is creating so much stress for them over taking three injections. We may discuss the risks and benefits of combining the shots into one. Um, but I agree, like I thought this was great. Um, but when I talked to my patients about it, I got a lot of hesitation because you, again, this is. All new to you, you're feeling kind of stressed out about, what if I mix it up incorrectly? What if I do something wrong? And so I will say most people tend to like to, um, stick to kind of the normal way. Yeah, I know. Because I would say like our beginner IVF patients mm-hmm. Are very timid and wanna do everything like by the books. Yeah. And then like our pro level IVF patients have done it so many times. Yeah. They're like immune, they like whatever. There's not really a good patient in between, you know. Well, and you know what too is kind of funny. I'm sure you've seen where you do IVF and you have your baby and then you take the baby picture where you put all the shots you took mm-hmm. Like making the heart around the baby or something. And I'm like, if we go totally needleless, how are we gonna take that picture? It's true. Um, so yeah. But, but anyways, it's kind of nice to know that there's options, um, there as well. Um, okay. So I wanted to tell the audience about our new device. We are actually gonna be starting this today. Um, and so I love this story. There was a fertility doctor who needed to do IVF. She had a needle phobia herself, and she made the observation of, Hey, other people are able to use. Insulin pumps, why can't I just give my fertility medication in a similar way? And so she actually tested this out on herself first, and it worked. And then she did a study and she showed in her study that the patients who used the little pump had equivalent outcomes to other people who took their injections the traditional way. And I mean, you remember when I told you about it? I was like, oh my gosh, this is so exciting. I cannot wait to try this. And so we ordered some. For our patients, our medical assistant, Chandler. I mean, she's so wonderful. She has volunteered to be our Guinea pig. She what? She I thought you were gonna do it on yourself. No, my gosh. The person with the needle phobia. No. Um, and Chandler said these things don't scare her. You know, she has tattoos and everything. She's tough. Yeah. Yeah. And so she has volunteered to be the Guinea pig. I love it. Um, so we're gonna do that this afternoon and if all goes well, I have a patient who wants to start this tomorrow. Great. Okay. And, and so we'll see if she has as good of an experience as we're hearing from other people. Um, but the concept is that you install this little pump. Now you do usually have to install two of them during an IV Fs cycle. So each one lasts roughly about five days. And so then they would be injecting their medication through some little tubing instead of having to give all the shots. Um, and so I'm really. Excited for us to be able to offer this now too. It's exciting. Mm-hmm. But I will say, I told you that I had to put an insulin pump in myself. So when I was in Oh, when, well, when I was in medical school, Uhhuh, um, we did some work at Camp Sweeney. Mm-hmm. It is, um, you know, the camp for pediatric children who have diabetes. Mm-hmm. And so I guess. I can't remember exactly how it plays out. Mm-hmm. Maybe before you go. Mm-hmm. Or they want you to experience, you had to put the bump in. I thought it hurt. Oh no. So I'm really curious to see how Chandler reacts. Oh no. If Chandler's super tough. I think we need a, we need to try it. How about you? I've tried. Well, I'll say this is, we just got the little teeny tiny Okay. Maybe it's smaller. Yeah. The one that I is pretty bad. Yeah. Maybe look at it and see what you think because it's teeny tiny. And um, I've talked to some other doctors who've been doing it at their clinics. I mean, they said it's, you don't really feel it or anything. Okay. Wow. So I'm like, okay, that's good. And I kind of believe it'cause I've done recently like a continuous glucose monitor mm-hmm. Or things. And those are tiny. The continuous glucose ones are like this. Big. Right. Okay. Yeah. Yeah. And I didn't even feel those at all. Mm-hmm. So, um, but yeah, I, I do think I'd be a little scared to try it on myself. Okay. Um, okay, so now let's move on. So you've done your IVF, right? You've got your embryos, you're ready to do a frozen embryo transfer. Unfortunately, this is where the worst of the needles comes, right? Yes. So, I completely agree. Can I just say, I'm so jealous of Europe. Have you heard what Europe has? No, tell me. Europe has subcutaneous progesterone. Oh. Like here in the us, progesterone is such an important hormone to support your pregnancy when you're doing a frozen embryo transfer. But the only form we have to give here is intramuscular, which means you have to get a shot in the muscle of your upper buttock. Um, and. Gosh, it's just to get through there. Well, probably for most people, not for everybody, but for most people, you need a bigger, thicker needle. Yeah. It's not fun. These are the progesterone shots I had to do, although not every day. I had to do'em once a week. I mean, they're not fun. No, they're not fun. And you get lumpy butt, it makes lumps. Okay. But subcutaneous progesterone, so just for our listeners that aren't medical, that would be more so like the injections that you do during IVF where they're just right underneath this. Skin. Tiny little needle. Yeah. But would that be as effective as intramuscular? I know. I have some concerns with that. I know. Here's what I'll say. Although I'm very jealous of them in Europe, and I'm like, why can't we have that too? Like is it just because our FDA takes so long to prove things? That could be part of it. But the other part is that, I don't know, maybe it's not as effective. Mm-hmm. And I will say a lot of times I'll see studies from Europe or data, and from what I can tell. It looks like the US does have higher live birth rates mm-hmm. When compared to other countries for our IVF treatments overall. And so I am always very hesitant to switch to anything without some kind of comparison to our own data. Um, there was actually a big study that compared vaginal progesterone two, the progesterone shots, and we were all hoping that vaginal progesterone would do great. And indeed they had this. Same pregnancy rate, but vaginal progesterone alone and a frozen embryo transfer cycle had a much higher miscarriage rate and they had to stop the study early because of that. And so that's why we've really tried to continue for most patients, unless they just can't do it progesterone shots,'cause we know that's what's gonna give you the highest chance of bringing home a baby. But that kind of brings me to, um, maybe talking a little bit more about natural cycles, right? Yeah. Yeah. And so do we have to do progesterone shots, right? Well, one thing we should say is there's also ways that we can make this easier on you. There is some data to show that you don't have to do your. Progesterone and oil injections every day. So you should ask your doctor about that if it would be an option for you and if we think it would be a good fit for you. Um, so other ways to really limit the amount of injections you have to do during an embryo transfer cycle would be to do like a natural embryo transfer cycle or a modified natural cycle that entails we actually. Will let your body grow in agro follicle that's going to ovulate and release a lot of your own natural progesterone to support that pregnancy that we're gonna create. And so your body really gets us most of the way there, right? And instead we just give you a little bit of supplemental vaginal progesterone on top of that. Um, and it allows us to avoid the intramuscular progesterone injections, which are just so dreaded. Yeah, so, you know, it sounds so great. So of course you could say, well, gosh, why, why didn't I do that? Why didn't my doctor offer it? And I think there's probably a couple of different reasons. Um, first is probably not all places can offer it because it means that there's no predictability to when your embryo transfer will be, because we're just relying on when your body will be receptive. And for some clinics, they may only offer embryo transfers during. Certain times of the year. Um, so for example, if you live in a more rural area, it could be that they have to especially fly in an embryology team to do embryo transfers. And if that's the case, they may only be there for a certain period of time. They can't just wait on your ovaries to ovulate. Um. And so that's why some places have to do programmed cycles. I think here we have the luxury of having, um, multiple embryologists here year round. And so we are able to kind of do them whenever we want. Um, but there's other reasons why sometimes they may not be a great option. First, some women don't grow an egg and ovulate. Right, right, right. Um, so if your body never makes those hormones anyways, that could be a lot more difficult. And it's not to say you can't do maybe a modified natural cycle where we're having to kind of. Prompt your body to take those steps, but sometimes it can feel frustrating to, um, maybe not have those options. But, but I think that's where it's great to have, um, the backup option of a program cycle. But beyond that, program cycles are so nice for scheduling, so. If you're my patient, I can tell you your three appointments that you're gonna have, baseline sonogram, lining check, embryo transfer. You can ask for your work days off. We can say, look, let's get it scheduled. Everything will be very predictable. But with a natural cycle, it drives my patients crazy'cause we'll say, Dr. Reed, when's my transfer gonna be? When do you need to see me for my appointments? And I'm like. We'll see. Yeah, because we just have to monitor very closely. You're gonna need more appointments, more blood draws and all these things. So in that case, it can kind of work against patients. And my patients aren't planners. I'll tell you what. Yeah, absolutely. I agree. Mm-hmm. I always count my patients, if we're gonna consider a natural cycle. Probably one of the biggest downsides is also. It could be canceled, so natural cycle transfers are much more likely to get canceled. I quote my patients about a 10% risk of getting canceled during a natural cycle because if you ovulate before, I'm ready for you to, or your lining just doesn't get thick enough by the time your body's ready to ovulate. We'll have to cancel because we're not gonna risk putting the embryo into a lining that's not timed appropriately. Yeah. And then I'll say maybe one other group of patients where I just feel a little bit more hesitant about is maybe patients where I suspect they have some level of progesterone resistance. That means that at a normal level of progesterone, maybe your body's not always responding like it should. So some women that might be more prone to progesterone resistance are patients. With PCOS or endometriosis or something like that. And in those patients, because I know they're kind of resistant to it, I like to give higher levels of progesterone, which I'm usually able to easily do with a program cycle now that is kind of just my opinion there. Um, and it'll be interesting to kind of see how this pans out in the long term. Right now, I feel like almost every month I'm seeing a new study that's doing the head-to-head, what's better, program cycle or natural cycle. And really what I'm seeing is pretty equivalent. Pregnancy and live birth rates, but my caveat to that is. A lot of times when the studies I'm seeing recently when they're comparing a program cycle to a natural cycle, they are actually comparing a program cycle in Europe. Mm-hmm. Which is different from a program cycle in the us. Yeah. And so I do feel like that's some definitely a factor to look at. And maybe this is also a little bit of a side rant too, about studies that are comparing pregnancy rates in LIBOR overall. Right. So you'll always see like. Patients who did this intervention had twice the pregnancy rate of this other intervention, right? So a couple things for us to think about. Pregnancy rate does not equal live birth rate, right? Mm-hmm. So that's really important. Um. But the second thing is look at what the pregnancy rate was in each group. Mm-hmm. Okay. I'll see these studies. Our pregnancy rate was twice, and then I look at their pregnancy rate, and the pregnancy rate was like 40%. And I'm like, oh gosh. Yeah. Like your pregnancy rate is really low in both groups. Yeah. Like you shouldn't be giving anybody advice, right? Yeah. Right. Because then we have to compare our own pregnancy rates. If there's a study that has way lower pregnancy rates than what we're getting right now. Ignore. Yeah. Right. Absolutely. It's a really good point. Yeah. Mm-hmm. And a lot of times too, when patients are considering doing a natural cycle or modified natural cycle, they might have failed a traditional program cycle first. Yeah. Um, so there's also a concept in statistics called regression to the mean. So if you have a bad outcome to begin with and you do another cycle, you're more likely to have a good outcome the next time you do it right? Yes. So we have to be careful too about making interventions in those um, populations. But yeah, you made me laugh because guys, Dr. Reed helped me with my IVF and I do feel like you're the progesterone queen. I do. She dosed me up so high on progesterone. I thought I was gonna die. I love progesterone. It's the best tor. Well, I love it. Unless somebody's injecting it into me. Oh yeah. My progesterone level was so high. It was like not even a number on our. Assay on our blood work. It just said over 60. Yeah. I, it's so high. We can't even tell you how high it is. I know. Well, that's how it usually comes back and I'm like, okay, we're good. Right. Um, but then I had a patient the other day where her pro came back as 15 and I'm like, what? That sounds great. No, not high enough. And I already give a high dose. I had to give her even higher dose. But yes, I, I am a fan of progesterone for sure. Um, okay. One more thing about needles, and I wanted to get your opinion about this too. So a lot of times we hear about acupuncture and how it may be helpful during your fertility journey. And I'm always surprised because I just see such different experiences amongst my patients. Mm-hmm. I've never had acupuncture before, but to me. I mean, that does not sound relaxing to have somebody say, I'm gonna come insert giant needles into your body. Yeah. So I, well, first of all, agree, they're not, they're not giant. They're not Okay. How big are they? They're small and they have this little like cup like device that goes around them when they put them in. And I think this is another sensory trick. I haven't actually asked an acupuncturist about this. Yeah. But maybe someone can write to us and tell if this is true. Yeah. When you place the cup around it and then the needle gets pressed in Uhhuh, I think you first feel the cup and they're distracted before the needle goes in. Okay, so you don't, it feels like a little flick almost. Okay. It's not a needle, like you're thinking of a shot or a blood draw. Okay. Yeah. Okay. Mm-hmm. Did they, okay. Have you ever seen where they put a needle in the head? Yes, I've had that before. Does that hurt? I heard that one hurts. More. For some reason I, there are certain spots that hurt more and I had one that bled one time. Oh God, that was probably so creepy onto your face. Like you're just like, hi. It wasn't like a lot, but afterwards I was like, oh wow, I have some blood on my head. Um, okay. So I dunno, maybe that one wasn't put in quite right. Okay. But did you, okay. When you left. Did you feel amazing? Did you feel good? Relaxed? I like, so there was a word for this again, acupuncturists. Tell me you're totally wrong if I say, but I think it's called like Q or something. Okay. So there's this concept that when all of them are in you, you feel like this flow. Yeah. You like this chi flow or something. Did you feel the chi? I feel it. Like I definitely feel like something happening almost like a vibratory like sensation or something. Okay, cool. Um, and I'm sure it's like your body reacting to, hey, just like. Stab me in a bunch of places. Um, so I mean, I think there is a real phenomenon that's going on. Yeah. But it takes you a minute. Yeah. You know, it takes a minute and then you kind of feel it and then feel more relaxed. Yeah. Um, but also, I mean, I just think it's so healthy in this day and age to just like sit in a quiet room and have no one talk to me and not play on my phone. Yeah. Yeah. It was the only time in my life that I've ever really done that. Yes. You probably never do that. Well, no. Do you ever sit in a quiet room by yourself with no phone? Well, actually well no, but I should because I heard that's how you're supposed to fall asleep at night. Yeah, I think it would be really good. Yeah. Yeah, yeah. No, I think that's good. Okay. But I love something that you brought here to peak fertility, um, which is instead of needle acupuncture. Let's get rid of the needles. Let's do laser acupuncture. So can you tell the audience a little bit more about how you thought of this great idea to bring its peak? Yeah. So I'll give tribute to where I was before. Mm-hmm. Um, up at RMA in New Jersey, they do laser acupuncture before and after their embryo transfers. And they published a study based off of this that did show higher implantation rates after embryo transfers with laser acupuncture. Laser acupuncture is really nice. It's a cold laser. It's a low level light laser, um, that hits. The little acupressure points in your body to the same level that a needle would. Um, it's not painful at all. It's actually quicker because I would say a traditional acupuncture session takes about 45 minutes. This only takes maybe 10 to 15 minutes. It's extremely relaxing. Um, you can feel something, but it's not painful. Okay. Yeah. And so, and you did that too right then? Mm-hmm. You did laser and needle? Mm-hmm. So did you like one better than the other? I like laser much better. Okay. Again, but I think our vibe is like really relaxing with the laser. Yeah. Um, I thought it was so relaxing. I'm just almost like getting myself talking about, I'm like, I wanna go get something. You should have nurse Megan do it. Laser. I know. Why am I not taking advantage of this? There's so many uses for this laser that we have. I, yeah. Lots of stuff we could do with it. I remember when we did the training on it in the beginning, we, you know, lasered ourselves on some different points. And it was really interesting too. I did feel a little scared in the beginning. I'm like, laser, you know, but, um, but yeah, I did like it and I remember, um, there's different points you can do even aside from fertility. Mm-hmm. You know, if you're feeling sick, if you have allergies, you know mm-hmm. If you're pregnant mm-hmm. You're feeling nauseous or different things like that. So it's kind of a good reminder. I need to get back to that and maybe laser myself a little bit here and there. Have. One of the nurses help me out, so. Okay. Good. Well, I think we talked about all the needles that we can. Yeah. Hopefully. I know. Do, did it stress you out at all to be talking about the needle? No. Okay. Good. Good. Okay. I feel, I feel alone. Um, but alright. Well thank you guys for listening. If you would be so kind to leave us a positive review for our podcast or on our YouTube channel, or even on our practice page, we would greatly appreciate it and tune in for our next episode. Bye. Have a good week.