Pushing Fertility Limits: Erin Andrews’ Story and the Age Cutoffs for IVF

Dr. Amber Klimczak and Dr. Beverly Reed discuss how Erin Andrews has shared her difficult IVF journey. They discuss the impact of age on fertility as well as difficult conversations and thoughts on when the age cutoff for IVF should be.

Watch this (Season 3, Episode 17) 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.

Transcript

Speaker 0:06

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber Klimczak. And we are two peas in a pod. Well, hello, everybody. Okay, we might look a little different today because Dr. K. and I are in different locations. I think you've been out and about today, right? Yes. Yeah, I'm virtual. I'm virtual podcasting today. Amazing.

Speaker 3 0:26

How's your week been going for you? It's been good. It's been a nice week, actually. I had a patient that has been trying for 10 years have a pregnancy yesterday, which is so exciting. Amazing. Oh. But here's the sad thing. I got the results back at 7:30 at night, and I was so excited, called. She doesn't answer her phone. I call her husband. I feel like he... I had to, like, be more excited than he was. I was like, "Come on, man." "I'm jumping up and down in the kitchen." And he was just like, "Okay, what are next steps?"

Speaker 1:00

That was a little anticlimactic for me. I was like, "Oh, man." That, um, definitely happened to me recently too, um, where I had called a patient. She had tried several IVF cycles and, um, actually, it's very applicable to what we'll be talking about today 'cause she's in her 40s. Uh, we had tried several IVF cycles. We kept getting abnormal embryos, and we finally got a normal embryo. Mm-hmm. And so I, of course, call them, you know, over the moon, jumping up and down, like, you know. And she was just very stoic, like Wonderful. Thank you. What are next steps? I'm like, "No, no, no. I need you to be more excited." I- This is what we live for. Yeah, so

Speaker 3 1:43

I definitely get it. Definitely get it. Yeah. No, we need those ups and downs. What we do has a lot of downs,

Speaker 1:49

so the good- Yeah points, we need to really celebrate. That's right. That's right. Um, okay, so I hear you have a celebrity t- that has kind of opened up about her more recent IVF journey. You wanna tell us about that? Yeah. Yeah, so

Speaker 3 2:04

this is, like, really trending apparently. I don't know, I'm not very trendy. But, um- I think probably everyone has heard of Erin Andrews. I think she's such a pioneer, right, in her field. She's a female sportscaster, which I think w- especially when she started doing it, was more rare. Um, and she has opened up about being on a fertility journey. Um, and I think she had had even maybe some health complications before that, that led her into exploring infertility. Um, and she had an ins- interesting conversation. I think she was either being interviewed or maybe she was on, um, a podcast, right, and talking about this. And she was talking about how she's been going through IVF. I think she's gone through a few times. And because she is older, hasn't been having success. And ultimately, she's had a conversation with her doctor, and I think her quote is kind of funny. And she, she says, "Here's my whole thing. I'm crazy," she says. And "And I'm with a doctor that says, 'Listen, we'll call it when it's time.'" And she says, "But I'm psychotic right now." She's 47. And she says, "I feel like I believe my body can do it, even though I know my age is not what history says is great at producing eggs and the viability of your eggs." And she says, "There's just some," I can't curse, "S-H-I-T in me that I'm like, 'Wait, watch me do it.'" You know, I think she is just probably very motivated, right? She's very successful and, um, really believes in herself that she can do it. And so she's continuing on her IVF journey, despite being what we would classify as advanced reproductive age.

Speaker 3:39

Wow. Wow. Okay Now this is interesting, and her name... Uh, so I'm not really into sports, shocker. Ah. But her name had sounded familiar because I do remember years back, I think she had maybe reported she'd done, like, a ton of IVF cycles or something- Mm-hmm to have her baby that she, um, had. So, uh, that's interesting 'cause I would have hoped maybe she would have some leftover embryos from her prior cycles, but it sounds like she doesn't. Um- She does have a son from- Yeah

Speaker 3 4:07

I guess delivered in 2023 via surrogate. So- Yeah certainly she's been through IVF previously and had success. Um, but that was some time ago, I think, that she delivered. At least three years ago that that baby was born.

Speaker 2 4:20

Yeah.

Speaker 4:20

Mm-hmm. I mean, one thing I'd be interested to know, um, is sometimes people use the term IVF and embryo transfer interchangeably. Mm-hmm.

Speaker 2 4:29

And you

Speaker 4:29

and I, I think when we talk about IVF, we're usually talking about the egg retrieval part- Mm-hmm and then we talk about the transfer part separately. So sometimes I'll notice people say, "Oh, I'm doing IVF," and really they are just doing an embryo transfer. Um, and so I'll, I'll be curious to kind of know those details, I think, over time. Yeah. Well, lucky for us, Erin

Speaker 3 4:50

Andrews has been very forthcoming. She said- Oh, good. Finally that she started another round of IVF injections. Okay. They have not worked. She said they did not work, but she's undeterred.

Speaker 5:01

Oh, wow. Okay. Yeah. So

Speaker 3 5:02

she's actually attempting IVF stimulation- Mm-hmm at the age of 47, and of course is saying, you know, "I know my eggs are probably not the age of eggs that you'd expect to cooperate."

Speaker 5:13

Mm-hmm. Mm-hmm. Well, I find this especially fascinating because it sounds like she's my age range. You know, usually when- we talk about these, they're your age range, but- Yeah. Yeah she's 46, about to turn 47, and it's just so interesting that she is like, "This can happen," but I'm like, "Oh, my gosh, my eggs are definitely too old." Like, you know? I know. Yeah. Like, I wasn't gonna try, you know? I know. Um, so that is fascinating to me, but I have to say, when I see women who have this confidence in, in their fertility that defies the statistics, I do always have to pause and have some admiration for it because- Mm-hmm you and I have done the same thing, maybe not with fertility, but with overcoming stats, right? Mm-hmm. So we, I think, at the time, in Texas, I, I... Aren't we the only female-owned s- you know- Yeah started clinic and combined embryology lab and everything. Um, and people told me at the time, "Your chances of making it are less than 5%," right? Yeah. People told us that, and what did we say? "Well, we're the 5%," like, of course. Yeah. We said, "Watch us," right? Yeah. Just like Erin Andrews. Yeah. So when I see that determination and grit in a woman- Mm-hmm I kind of love it, actually. Yeah. Yeah. You know? And

Speaker 3 6:36

I think it's hard because- It's the same yeah, I mean, we are not the gatekeepers, right? But we're the people sitting here seeing the other 95%, right, that don't have success, um, doing an IVF stimulation, um, you know, in their mid to late 40s. So it's, it's hard that, you know, we can never recognize in advance really who is gonna be that 4% or 5%, so it's certainly- Yeah a rare person. But it cer- I think it definitely starts with someone who believes in themselves and their- Yeah their body.

Speaker 7:09

Yeah. Yeah. Well, it's interesting because I think there is such a discrepancy between what we see on social media and on TV and what kind of just patient awareness is about how much age affects fertility versus in the fertility world what we actually see. And I think if you ask any fertility doctor, we would... And, and if you ask any fertility doctor, "Would you recommend you try IVF at age 47?" I, I think you would be hard-pressed to find anybody who would. Mm-hmm. Um, but I think what's so hard is when patients are, I guess I would say, out in the wild, Yeah you run into all these people who always have their stories. My aunt had a baby when she was 50. Mm-hmm. My sister got pregnant accidentally when she was 48, and all the rest of it. And, uh, it, on social media, the comment- I'll see 100 comments, and I'm like, I am just fascinated by this. Because I'm like, "No, we're not seeing that."

Speaker 3 8:13

Yeah. We don't see it, certainly. Yeah. Yeah. There's a selection bias, a huge selection bias- Yes. Mm-hmm I guess. And sometimes people, um, don't talk about their failures, right? Those stories tend to be kept quiet, and successes can be broadcasted loud even though maybe it is a very rare occurrence. And those are the ones that make waves and get passed on. Um, so I think there's certainly a- an information bias out there- Mm-hmm towards patients who maybe have good and positive things, you know, and sharing. But I think realistically part of our role as a fertility doctor is also to guide you into treatment options that we believe to be Have a good chance of success, right? Not put you at undue risk, and also not spend a lot of money on a futile treatment. You know, what we do is very expensive, and it is tough on your body. So I think that those conversations are important to have.

Speaker 9:10

Yeah. Yeah. And I think what's really interesting as we get older, um, one of my favorite graphs is when you're graphing the success rate of trying on your own versus doing an insemination cycle- Mm-hmm versus doing IVF. And when we're young, there is a huge difference between your chances of trying on your own or doing insemination versus IVF. But all of those treatments go down with age, but what you'll see is the difference between trying on your own and IVF at some point really converges to say- Mm-hmm surprisingly, that our most aggressive treatment is oftentimes unlikely to help. And I think sometimes that gets confused because somebody may hear that and think, "Oh, you're saying I can't get pregnant," for example, at 45. And I would say, "No, it's not that you can't get pregnant. It's just that IVF doesn't really help you get pregnant above and beyond what your- Mm-hmm natural conception or fertility rate would be," you know? Now, there are exceptions to that. If somebody has blocked tubes or their partner's sperm is really low or something. Mm-hmm. Um, but assuming all those things are, are normal, you really don't have much benefit to IVF. But I will say the advantage to IVF is genetic testing, right? Even though it wouldn't change the overall success rate of IVF- Mm-hmm you could prevent, um, putting an abnormal embryo in, which could lead to, for example, miscarriage or, or something of that nature. So, um, when people are trying to decide what treatment option, yes, there can be some pros to doing IVF, but it's important to understand that at some point, even IVF can't overcome the age factor.

Speaker 3 10:55

Right. Right. Yeah. And I think what you're talking about with mentioning the anecdotal stories and success rates as we get into our 40s, it is interesting to see too. I think there is a huge difference between patients who haven't struggled with infertility- Mm-hmm haven't done fertility treatment, right? And they have had multiple children throughout their 20s and 30s, and then perhaps conceive on their own, what we kind of call a spontaneous pregnancy, in their 40s. Those pregnancies are happening. Absolutely, those pregnancies are happening. Um, but I think it's unfair to lump our patient population into that group, right? Because if you've been struggling and haven't had a prior pregnancy, and then are trying to get pregnant for the first time in your 40s, I think the statistics really are totally different and cannot be applied. Yeah. Um, and so, you know, just so you have some concept, I mean, we often see patients, we break down our patients by SART age categories, right? Our oldest category over 42. If you're gonna go through IVF, across the whole US, no matter, like, which clinic and which lab you're at, success rates for IVF are really low, 4% or less. Probably some places are putting forward 3%. And even those pregnancies, I mean, Dr. Reed and I will, will tell our listeners, I have some concerns about maybe even errors in data reporting with IVF success at those ages. So- Yeah um, you just never know really how accurate that is, but we know it's very low. Um, and I think that it's probably slightly higher for spontaneous pregnancies for patients that are not going through fertility, right? But it's still low. It's hard to get pregnant in your 40s regardless of who you are and what your history is.

Speaker 12:36

Yes. Yeah. And this was interest- I, 'cause I, I remember one day I was going through the rabbit hole. I wanted to know all the, who's the oldest woman to have had a baby and, and things like that. And that's what I saw as probably the biggest predictor of somebody who was able to spontaneously conceive in their mid to late 40s, is that they had babies before. Mm-hmm. And so it's just almost like you have kids, and it makes you more fertile or, or something. Mm-hmm. And your fertility window is extended when compared, uh, to somebody who's never had a pregnancy or, or a baby before. Um, so I thought that was interesting that that was such an important, um, factor. But, but that's more so spontaneous pregnancies. I think it's, would likely, um, it could be applied to IVF pregnancies too. Um, but here was the oth- other interesting thing that I looked at is what is the age of the oldest woman in the United States who had a baby from IVF? And what I found published is 47 With her own eggs Yes, with her own eggs. Yeah. Yes. Okay. So that's a good point, and we should touch on donor eggs later. Yeah. Mm-hmm. Um, but to me, I was like, "That's it? Nobody else in the US has been able to help a woman who's 48, 49, y- you know, older than that, use her own eggs?" And the answer is no, and that's really important for patients to hear, including Erin, right? Mm-hmm. Now, Erin may say, "Well, it's possible, right?" Yeah. We have this case report. Mm-hmm. It's possible. It can be done. Um, but, but I think y- really it just kind of points out how rare it is for that- Mm um, to actually, actually occur. Um, and so I, I follow these cases with special interest because, of course, when you say, "Oh my gosh, somebody did it," I wanna know, well, how did they do it, right? Right. I wanna know all their tips and tricks. And, um, I know you and I pay a special attention to those things and really try to apply that to our patients who are in their 40s, uh, who are cycling, uh, with us. Now, interestingly, every doctor has to sort of determine what they're comfortable with. Um, we get plenty of patients who would love to do IVF at a certain age, but also the doctor has some say in that too, right? The patient can say, "It's my right to do what I want," but it's also the doctor can say, "You know what? I don't feel that the benefits of this cycle are higher than what the risk could be," right? Mm-hmm. And so for me, at this time, I have used an... I'm using an IVF cutoff now of 45 because when I look at the data, I do have concerns that the risk of IVF is just higher than the potential benefit. It's not to say it's impossible, but that's just been my personal decision. But I hope to change it over time And over time, we may be increasing that. But with our current science and technology, I think that's kind of a reasonable cutoff to use. Now, certainly if I have somebody who wants to use donor eggs, then we go... We can let them go, um, older. But with donor eggs, you have such a better chance that it's actually gonna work- Mm-hmm at that point.

Speaker 3 15:39

So. Yeah. Yeah. Um, and I think it's such an important point. I think that this sometimes can be a hard area in medicine, where we do want our patients to have so much autonomy- Yeah but we also, we respect our patients enough that we also want to guide them, right? Yeah. That is so important for us as a physician. Sure. And if you don't have a physician that is giving you reasonable guidelines, then I, you know, I have some questions, right? I don't want a physician that's just always telling me, "You can do whatever you wanna do," right? That's personally not what I look for in my physician. I look to them for guidance. "You're the expert. What do you think is a reasonable choice here?" Um, and so I think for you to say, "Okay, I've examined all this. I've seen my success rates and my history with this, and I don't think it's worth it past this age," I think that's really something to be respected by- Yeah a patient that's listening. Yeah.

Speaker 16:33

Yeah. I think it has been something I've struggled with personally, because in the beginning, um, when I, when I was a baby fertility doctor- Mm-hmm um, I would really just present the statistics to my patient- Mm-hmm with the expectation that if they saw the statistics, they would not wanna try, right? Mm-hmm. So, um, and this is real life. I mean, I showed a patient, I said, "Okay, with your age and your egg count level and what I'm seeing, the calculator says your chances of having a baby are 4%." And I thought she would hear 4% and say, "Oh, well I'm definitely not gonna do this," right? But she heard 4% and she said, "So you're saying there's a chance." Yeah. Yeah. Wow, okay. Right? Um, and, um, and so I said, "Wow," like it's just so interesting because, um, if I were her, in her shoes, I, I thought that I would say, "Gosh, I, I just wouldn't wanna do this." But, you know, I did let her do it, um, and unfortunately it didn't work. And that's so heartbreaking for me. Even if I know the chances aren't good, it's heartbreaking for me, it's heartbreaking for her and everything. And I did ask her after we tried, I said, "Do you regret now that we tried?" And she said, "No." She said, "Look, here's the thing. I needed to know." Mm. "If I didn't try, I was gonna spend the rest of my life wondering, what if I would've tried? What if I was that 4%," right? Yeah. Um, and so I, I do have respect for that too, but then again, I just, you know, felt like I had to have some sort of- Um, cut off there. And, um, ultimately, she ended up doing, um, what's called embryo donation or some people call it embryo adoption, and she got pregnant really easily on her first cycle with that, which is amazing. She's super happy and, and all the rest of it. But she did feel like that was an important part of- Mm-hmm closure for her journey, too. Yeah,

Speaker 3 18:21

which is not unusual. I mean, I think that there's even been studies published on that, that many women need to go through that process of having a cycle not work in order to- Yeah move forward with other, um, treatment options.

Speaker 18:34

Yeah, yeah. I always, uh, talk to patients, too, in the beginning, and I say, "Look, you know, if, if we're trying and we know it may be a difficult journey, sometimes it's helpful to psychologically just kind of come up with a road map in your head. You don't have to stick with this road map, but sometimes it helps you feel like you have more of a plan," because it's really easy s- to start feeling lost in this journey, um, as you go along. And so what I usually will tell them, I say, you know, "In the beginning, just first kind of talk about how you feel about using an egg donor," right? Now, I will say nobody wants to use an egg donor on their first appointment. Never- ever, ever, right? Yeah. Um, and but so, so really I would say the assumption is you're not gonna use an egg donor, but would you ever be open to it if you tried- Mm-hmm with your own eggs and it didn't work, right? And so if that's the case, if it's something you would be open to, you just don't wanna get to the point where you've exhausted yourself from trying with your own eggs that by the time you're ready for a donor, you're just not okay at that point, right? Yeah. And it's not- Mentally

Speaker 3 19:39

or monetarily. Like some- Right, right I mean, sometimes definitely, uh, that's again, you have to kind of protect our patients. If you expend all of your funds on trying IVF with your own eggs, then ultimately you might miss your chance at building your family through a much more successful route, such as donor egg or embryo adoption.

Speaker 19:58

Yeah. Yeah. So sometimes I'll say, "Look, you know, you could try one IVF cycle and if it doesn't work, then move on to donor egg. Or maybe try three IVF cycles." Mm-hmm. "If it doesn't work, move on to donor egg. Or maybe you don't even wanna try VF- IVF. Maybe we try fertility pills and an insemination," you know? And you maybe try three of those and if it... Right? So you could have your backup plan. But I think it does help direct you sometimes just to kind of know what would your stopping point be. Now, of course, you never have to stick to your plan, right? Mm-hmm. But I think it just helps you mentally organize as an escape route if you end up not being happy with the results that you're seeing as well. Yeah,

Speaker 3 20:35

yeah.

Speaker 20:35

Absolutely. Um, okay. I wanted to talk a little bit about why this happens to us, right? And one of the examples I like to think about is the Duggar family. Okay, so do you know about the Duggar family? Does that sound familiar?

Speaker 3 20:52

Only, only from you really- Okay 'cause you know I don't watch these shows. Yeah, me neither. And it kind of,

Speaker 20:55

like, freaks me out a little bit when I think about...

Speaker 3 20:57

Isn't

Speaker 20:58

this the family where, like, the kids raise each other? Oh, well, yeah, I think so. And they've got some dicey things going on with Ricki Lake's case. Yeah. But anyways, n- but really, the overall concept is this is a reality TV show of this family where Mrs. Duggar is very fertile. Okay? So basically, their whole marriage, she's pregnant and having a baby all the time. Okay. Crazy. So I believe she had somewhere around 20 kids. I mean, can you imagine 20? No. I c- I, I just, your body is wrecked. Like, I just can't even- No. I can't imagine I'm like, "Wow." But to me, as a fertility doctor, I'm fascinated by this, right? Yeah. Because I would say this woman is the most fertile woman alive, right? Yeah, yeah. The proof is in the pudding. Yeah. She's got 20 kids, right? Yeah. And so I see that, and I say, "Okay, well, I'm curious, for the most fertile woman alive, how old was she with her last kiddo?" Okay. Mm-hmm. And she stopped having kids somewhere around 43. Okay? And that was not 'cause she chose to, like it just stopped. Right. Yeah. Yeah. 'Cause I was like, "Oh, sh- maybe she was finally like, 'Okay, 20 is enough,'" right? Yeah. But no. Needs an IUD. They Yeah still wanted to have more kids, okay? So she abruptly stopped having kids, but it's not because they wanted to stop having kids. Mm. They actually did keep trying, but it never happened at that point. And I do think even, too, one of their latter kids, sadly, I think maybe delivered preterm and lost or something like that too. Oh, gosh. Yeah. Which, of course, is so heartbreaking. Yeah. And I'm sure that's, maybe that's why they wanted another one too. Yeah. That's like such an awful way to kind of end things, right? Yeah. Um, but, but no, they, they continued to try after that and did not have any more babies. Now, I will say, and she sounds like one that could still be in the possibility, right? 'Cause we said- Yeah if you've had a baby before, you're more likely to have one. So I don't know. Yeah. Maybe next year she'll be pregnant. Yeah. But to me, that really stood out, is that our patients should not be feeling bad if they're struggling to get pregnant at 43, when the most fertile woman alive- Mm-hmm is even struggling to get pregnant at that point. Um, but I thought we should maybe break down what are the things that happen to our body as we age. What... 'Cause why is this happening?

Speaker 3 23:25

Right. Yeah, and I think it's, um, it's easy for women to understand, 'cause we're kind of told even from a young age that you have a biological clock, so everyone pretty much understands that your fertility window is limited, right? And there's a point where you're not gonna be able to have any more children. But I think most people think about that in terms of I'm gonna run out of eggs one day, right? And so the big, big misconception is actually at 43 you didn't run out of eggs you know, she still has probably a sufficient egg supply. I think she's probably still ovulating every month. Yeah. The bigger issue is that the egg that you're ovulating is not capable of being fertilized, growing to an early embryo, implanting, and having a normal set of genetics to make a live, healthy baby.

Speaker 2 24:10

Mm-hmm. You know, those

Speaker 3 24:11

are the bigger issues. That really is what egg quality is, and quality absolutely is the biggest issue, right? That's what we can't overcome, even in our early 40s. It's not so much a quantity issue. Yes, of course, ultimately we're all gonna run out of eggs, but it's the quality that really is the biggest barrier. Your eggs are just not as capable of making it. Right. Absolutely.

Speaker 24:39

And I think that can be actually really hard, though, on a level of women who have maintained amazing egg counts, right? Mm-hmm. We'll check an ovarian reserve test. Let's say her AMH comes back as three. Mm-hmm. And she's like, "Oh, my gosh, I have the ovaries of a 30-year-old," you know? Mm-hmm. And unfortunately, it does not matter how high your number is. Yes, you may have a great response, meaning your follicles grow and we can get eggs, but if your eggs are not working properly, um, which most of the time they aren't, um, when we're in that age range, then we'll never get to a normal embryo, and I think that's so frustrating. Mm-hmm. Um, but what is amazing about our body is our uterus doesn't really age like the ovaries do. And I think that's so cool that even our menopausal patients, we can have a patient who's been in menopause for five years. All we have to do is give a little estrogen and progesterone. We can wake that uterus right back up, implant an embryo, and she can get pregnant. But the key is it has to be a genetically normal embryo, and, and that's, can, can patients in this circumstance make a genetically normal embryo? That is really the struggle that, that we're seeing. And I think we're really excited about a lot of the newer treatments that are available. Um, some of my favorite things right now to do for patients in their 40s is, uh, a month of testosterone priming. I'm loving adding on growth hormone. Um, you are my PRP queen of the clinic- that I love to send patients to. I actually saw another patient today. I mean, her poor ovaries, they had looked so sad before. And you did some PRP on her. I just scanned her, and I'm like, "Oh, my gosh." I see follicles. That's great. We're starting. Yeah. We're starting this, and we're gonna do a quick start. So I'll keep you updated on that. So I think we're really excited about some of these adjuncts, but in all, you know, fairness and honesty, it's just not enough to significantly increase the success rates like we'd wanna see.

Speaker 3 26:45

Yeah. I think the hope is there, though. Yeah. And I, I really do. I think our field is so interesting, and I am just so glad that people are looking into this now more and more. Yeah. I think the treatment options are coming. Like, this is the holy grail of fertility, right? If we can get some sort of answer, some sort of treatment to help improve that quality- Mm-hmm I mean, it's gonna just break open the field, you know? So I'm really excited that we are- Yeah looking into these other treatments. And

Speaker 27:16

I think we'll see it in our lifetime. Oh, for sure. You know? Yeah. Yeah, yeah. Mm-hmm. The things we think we, that may be helpful are stem cell treatments. We don't get to do those in the United States, unfortunately. Um, but we think there's some potential for that. Exosomes is something people are talking about. We've kind of looked into that a little bit, too. Um, I love the thought of making eggs out of skin cells. Mm. I mean, that would be amazing for patients. They've, they've talked about this because how awesome would that be for a patient to not even have to do an egg retrieval, right? Just take some skin cells and turn 'em into eggs. I mean, easier said than done, right? But- Yeah, yeah um, I d- I'm definitely excited about all the possibilities for the future as well. Yeah. Absolutely. Perfect. Okay, should we wrap it up for the week? Yeah. Thanks for listening. Yes, thank you, guys. Um, if you would be so kind to leave us a positive review on either our podcast page or YouTube channel or even on our Peak Fertility practice page, we would definitely appreciate it, and we will see you next time. Bye.