Parenting in Medicine, Part 1 – A Conversation with Dr. Brindha Bhavan

Join us as we learn from Dr. Brindha Bhavan, an OB/GYN and Reproductive Endocrinology and Infertility specialist. about some of the unique challenges that healthcare providers face in becoming parents, and different pathways of fertility preservation and infertility treatments that are available.

Learning Objectives

1. Understand differences in fertility and family planning between physicians and non-physicians outside of the medical field.
2. Understand different methods of fertility planning and preservation.
3. List the benefits and limitations of egg/embryo freezing.
4. Know the time and financial considerations of fertility preservation.

Credits

• Guest: Dr. Brindha Bhavan                                                                     
• Host/Co-Executive Producer: Dr. Pooja Jaeel                                      
• Executive Producer: Dr. Tammy Lin                                                               
• Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman                    
• Senior Producer: Dr. DJ Gaines                                                            
• Managing Producer: Joanna Jain                                                             
• Production Assistants: Clara Baek, Ann Truong                            
• Website/Art Design: Ann Truong                                                                
• Music: Chris Dingman https://www.chrisdingman.com

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[00:00:00] Pooja: Welcome to The DEI Shift, a podcast focusing on shifting the way we think and talk about diversity, equity, and inclusion in the medical field. I'm Dr. Pooja Jaeel, a Medicine hospitalist and primary care Pediatrician. We have an exciting set of episodes for you today, focusing on parenting while in the medical field.

 Our first episode, this one, will be focused on the pathways to become a parent. I'm excited to introduce our guest, Dr. Brindha Bhavan to the show. Dr. Brindha Bhavan is a clinical assistant professor in the Division of Reproductive Endocrinology and Infertility within the Department of Obstetrics and Gynecology at Stanford University.

 While an L.A. native, she's lived in the Bay Area since 2006 and completed her undergraduate studies in all medical training, including an MS in epidemiology and clinical research at Stanford. Her research interests include cost effectiveness analyses of assisted reproductive technologies, clinical outcomes of frozen embryo transfers, and patients’ experiences with recurrent pregnancy loss.

 She's passionate about medical education and increasing awareness of and access to fertility preservation and infertility treatments for medical providers. Welcome. 

[00:01:20] Dr. Bhavan: Thank you so much for having me. I'm thrilled to be here. 

[00:01:23] Pooja: So we'd like to keep things casual here on our podcast, and we generally ask our guests to call us by our first names. Is it okay if we call you by your first name as well? 

[00:01:31] Dr. Bhavan: Yes, absolutely. 

[00:01:32] Pooja: Great. Thank you so much. So before we get started, we'd like to ask each of our guests on this day shift to share something with our listeners about themselves. This can be something like a hobby, a favorite food, or a meaningful experience of yours that helps us to get to know you and your background a little bit better, and then help us flex our cultural humility muscles. We call this our step in your shoes segment.

So Brindha, what would you like to share with our audience today? 

[00:02:08] Dr. Bhavan: So I love that you do this. And I was thinking that I would share a little bit more about my childhood and upbringing in LA that kind of frames my perspective today. My parents are from Sri Lanka. They were born and raised there and came to the States for their graduate studies.

And my sister and I were born and raised in a very multicultural community in Los Angeles. And I'm so proud of that. And I think because in Sri Lanka, there's a lot of beautiful communities of Buddhist, Hindu, Christian, Islamic cultures. My parents were very open to honoring and celebrating all different religions and all different holidays.  

A good local school was a Greek Orthodox school. And I went to this small church school. And at first was the only brown student. And with time we had more students of [00:03:00] color and diversity, uh, but they were so accepting and interested in my different background and I appreciated so much that I was teased a lot more for being nerdy rather than looking different. 

[00:03:13] Pooja: That's very unique, but also true. 

[00:03:16] Dr. Bhavan: And so kids, I guess we'll just be kids in that regard, but I appreciate that really, I was so accepted. Um, While we had to draw art of our cultures and people would drop beautiful pictures of icons, I would draw a coconut full of flowers and they wanted to learn more.

[00:03:30] Dr. Bhavan: And I'm very, very grateful for that. Um, yeah, so that really lent us to having our best family friends growing up were Greek and we celebrated all the holidays with them. Our neighbors growing up were Jewish and we also celebrated holidays with them and they celebrated ours with us. And I loved that.

And then I went on to go to a very large public high school, which was a shock to the system from like a small church community school to a 4, 000 plus public high school. It was amazing. And my best friend group there. Envelop, you know, it's a group of us and our backgrounds were Sri Lankan for myself, but then Mexican, Persian, Russian, and spent time in each other's homes and just living with each other's families and seeing everyone just working hard to create a better life for themselves and their children.

It was beautiful. Um, and so that really makes me grateful for all of that diversity. I was exposed to when it came. you know, to starting medicine and then really taking care of patients of all different backgrounds today. 

[00:04:28] Pooja: Oh, that's so beautiful. Thank you so much for sharing. And it's such a great example of being really curious and open to learning.

And then, um, like a very good example of actually how to step in other people's shoes and learn about how they live and their families and their cultural traditions. Thank you so much for sharing. 

[00:04:45] Dr. Bhavan: Oh, you're so welcome. Thanks for asking such a thoughtful question. You know, question that prompts good self reflection.

[00:04:51] Pooja: Absolutely.

So we'll just jump into the topic. So I just wanted to start with asking you if you can tell us, you know, what do you see as kind of major differences in family planning between folks in medicine, in different parts of the medical field, and between those folks and people outside of the medical field?

[00:05:20] Dr. Bhavan: Yes, I mean, I have to acknowledge I have a bias in that the majority of people I take care of are people that have Difficulty getting pregnant so that you know might be infertility or recurrent miscarriage. I also help people who are trying to preserve fertility for social reasons because they anticipate delayed family building or they're pausing attempts or going to have delayed attempts because of anticipated cancer treatments that might impact their egg or sperm reserve and then also take care of individuals who are part of the LGBTQ plus community or single parents that are trying to build their families.

[00:06:00] Dr. Bhavan: And so I love this diverse background of who I'm helping, but I have to also remember to put in perspective that infertility affects about 12 to 15 percent of the population. So after about a year of trying, about 85 percent of couples will be pregnant, but we do know that, for medical professionals or people that are really focusing on intense training paths and possibly having limits to the time that they could meet the partner they might want to build their family with or financial stability given the loan burden of medical training, and not feeling ready to bring a child into the world that they can support for people having to uproot their lives every few years from medical school to residency to fellowship, and then just maybe feeling ready at a later age, and we know age is so linked to ovarian reserve and the quantity and quality of our eggs, and so for those numerous reasons we see that infertility rates are actually higher within the medical provider population.

[00:07:04] Dr. Bhavan: And there's pretty robust replicated data that it might be twice as high as about 12%, 24 percent of this data was looking at physicians having infertility. And so not only the socioeconomic factors that I highlighted, but it might also be linked to just the demands of our jobs. So day shift, night shifts, circadian rhythm switches.

[00:07:27] Dr. Bhavan: Major stressors that we're facing, limited sleep. You know, we say doctors are the worst patients cause we just don't have time to take care of ourselves or focus on ourselves. So I love that you asked me to speak today cause we're just trying to highlight that people can be aware about this and mindful about this and know that they're not alone in their struggles and can reach out early for help if needed.

[00:07:49] Pooja: Oh, thank you. And thank you for touching on some of those reasons that this happens too, because it's usually the first question, why, why this field and what are some of these barriers? So knowing all of this exists, you know, what are ways that folks in the medical fields can kind of know this and kind of take control of their family planning journeys?

[00:08:06] Dr. Bhavan: Yeah, you know, there's been a lot of calls to action. The American Medical Women's Association had put out that we need to increase awareness with initiatives such as your podcast, and that we should really be talking at the medical training level about the potential risks, not to scare people, not to like, fear induce them that everyone has to freeze eggs, but to just let them know that these risk factors are there.

[00:08:32] Dr. Bhavan: And to have fertility awareness, if building a family through an assisted conception or assisted reproductive technologies, because someone wants a genetically related child is on their mind, you know, very, many beautiful families are built through adoption or fostering or blended families. So I'm not just saying there's this one way to build a family but a lot of people share a feeling that they'd like to have a genetically related child and we know that there's such a disparity just in terms of biological sex because men can, or I should say 46 XY individuals, can make sperm through the lifetime. About every three months we have turnover. We know there's advanced paternal age after age 45 to 50 where we can see impacts with increased rates of autism or bipolar disorder, achondroplasia, but we do hear those stories right as someone in their 70s fathering a child. 

[00:09:33] Dr. Bhavan: And in juxtaposition for 46XX individuals were born with our set of eggs, and those are declining over the lifetime with regard to counts and to quality, and that rate of decline hastens after age, you know, a little bit in our early thirties, but really, you know, starts a trend downward and our 37, 38 and onward and markedly so after our forties.

[00:09:59] Dr. Bhavan: So that becomes particularly harder to get pregnant. And that's because we have less eggs and the quality of the eggs. It's more prone to making mistakes, so we don't get the right chromosomal content of embryos and that can lead to no pregnancy or miscarriages. So, just sharing a little bit more with people as to the physiology and there's a lot of mixed feelings about terms like reproductive window or biological clock because I don't want people to feel pressure, but I do want them to be aware that there might be a, you know, you're in a long surgical training and might only be able to start to have children in your later thirties, early forties, then you might want to have a conversation about egg freezing or embryo freezing because we can really preserve the quality and quantity when we're freezing at a younger age than if we're coming later to get treatment. My treatments can only work with what's there, not maybe increase it. 

[00:11:00] Pooja: That makes sense. Yeah. I think that's a great idea. I, because I, you know, I, I see that as a, you know, in medical training, we used to have these financial planning talks, uh, all throughout knowing that, I mean, that the loans, the large costs, and then the differences that we, uh, have in terms of lifestyle and what we get paid during training, I it's really, it's the realities of what training looks like today. So I like that this is kind of taking into account the realities of age and training and, um, what that might mean for future families. I, that would, that would have been great. Cause I think that was in the back of my mind too, when I was entering medical training and kind of throughout my time of, uh, residency and everything of, uh, you know, what is that going to look like for me?

[00:11:40] Pooja: What are the realities going to be like for me? We started talking a little bit about all these methods you started to touch on, but I wanted to ask you if we can kind of dive a little deeper into what are these different methods of fertility preservation. 

[00:11:52] Dr. Bhavan: Yes. Okay. So when we're focusing on fertility preservation, the main ones, so are egg freezing and embryo freezing.

[00:12:01] Dr. Bhavan: Okay. Now some individuals will ask me, should I freeze because sperm is regenerating every three months, we don't really see an aging impact till after age 45, 50, unless someone's anticipating some type of pelvic or testicular surgery or again, some type of cancer treatment or some starting of a medicine that their doctors have warned them this could impact their fertility.

[00:12:24] Dr. Bhavan: Those are the individuals who you might want to talk about are going to, um, you know, cryopreserve sperm. Um, but mostly we are focusing on eggs and embryo freezing because of that limited time window we have for good egg counts and quality. So a very common consult question that I get is, um, should I freeze eggs or should I freeze embryos?

 [00:12:46] Dr. Bhavan: And they are both really great options. And now with our newer technologies of vitrification, freezing, and thawing, we have comparable success rates for freezing eggs and freezing embryos and them surviving the thaw. It used to be that Embryos did better. And we would say if you have a partner or you'd be open to donor sperm, let's make embryos because the surface to volume ratio of eggs was really tricky.

 [00:13:14] Dr. Bhavan: And now that it's comparable, I really think both are good options for patients. 

 [00:13:18] Dr. Bhavan: And so when I have this discussion about eggs versus embryos, for eggs, I'll say if someone's single or someone's in an early partnership, they're not really sure about the future status, it might be dating or just kind of, you know, figuring out things, then eggs is a good option because you could have the opportunity in the future to confirm your sperm choice.

 [00:13:39] Dr. Bhavan: And I've had some people say, I'm with someone now, we've tried, we've faced difficulties, we're ready to use these eggs. I've had some patients come back and say, I still haven't met the right person, but I'm ready to be a parent on my own and I'd like to choose donor sperm. Um, so it creates some flexibility for the future.

 [00:13:56] Dr. Bhavan: So that is one, one kind of figuring out partnership status or sperm choice. Um, because I, I know it sounds so obvious, I tell my patients, but once I put sperm and egg together, I can't undo that. And so then the embryos are embryos. So that's one point. The other is cost. So egg freezing is cheaper than embryo freezing because we're just doing less with the eggs.

 [00:14:19] Dr. Bhavan: So we are, once the eggs are retrieved, the mature eggs are frozen as those are options for the future because mature eggs can be fertilized. For, um, embryos, we are fertilizing them, growing them in culture, checking how they survive to the blastocyst stage, possibly doing a biopsy of what will become the placenta to run genetic testing of the chromosomal makeup of the embryo, and then freezing them.

 [00:14:47] Dr. Bhavan: And so for those extra steps, embryo freezing cycles can be More expensive. These are ballpark numbers that can really vary depending on, you know, where you live and what benefits you have. But egg freezing can be 10 to 15, 000 a cycle. And embryo free can be 25 thousand plus, depending if you do some of that genetic testing, you can opt into, which has a lot of pros and cons.

 [00:15:13] Dr. Bhavan: So benefits and limitations to chat with your doctor about if exploring that. Yeah. So that's another element I talk about. For embryos I say, what's nice is that you kind of see how the eggs perform over those extra hurdles of fertilization, of surviving to the blastocyst stage of seeing are they good quality or you know, normal chromosomal makeup of doing the pre implantation genetic testing of opting into that.

 [00:15:40] Dr. Bhavan: And so you might get a little bit of earlier knowledge on the performance markers. So you could see if you did better than average and you might need less cycles than you thought, or you did worse than average and you might need more cycles than you thought. And you could take action when you're younger versus coming back in five years and finding out, Oh man, had I known I would have done more cycles earlier on.

 [00:16:00] Dr. Bhavan: So that's another. And then lastly, it's just the political landscape. So after the Dobbs decision changes impacted our field and embryos in certain areas of the United States are being assigned personhood and then having concerns if someone there is a human error and an embryo is dropped or someone's done building their family and they'd like to discard embryos then you know will that be equated with homicide for instance and people really are fearful and fear that they have limited choices and so they might be preferring eggs.

 [00:16:34] Dr. Bhavan: So that that's really I feel very grateful to be in our bubble in California, really supporting reproductive autonomy, but it really is impacting the day to day of a lot of people throughout our country. And so if people are planning to move or people anticipate that their social situations or job opportunities will, you know, take them elsewhere.

 [00:16:56] Dr. Bhavan: That's something I do talk to them about just to be aware of. 

 [00:16:59] Pooja: Yeah. 

 [00:17:00] Dr. Bhavan: So yeah, that's a little bit of egg and embryo that I, that I share with people. 

 [00:17:03] Pooja: Thank you so much. So I have a couple of follow up questions. I think the first one is you talk about, you know, age and early and early enough, you know, what age would you recommend folks to start considering the egg or embryo freezing?

 [00:17:17] Dr. Bhavan: So yes, in regards to your question, you know, is there an ideal age? There really isn't. I think it's a multifactorial conversation with your OB GYN, your REI to figure out socially, economically, personally, is it the right move for you? And we support you. And so if someone's pretty early on and wants to take more time, just learn more, but maybe revisit in a couple of years versus someone's, you know, in their 30s and assured they want to do this, you know, we can, we can move forward. And, you know, I will always take eggs now than eggs in the future, because those will relatively be older with maybe less quality potential, but there's not as big of a difference between 31 and 33, while there is a more notable difference between 38 and 41.

 [00:18:06] Dr. Bhavan: And so that's why we encourage people to consider it early, but they don't have to feel pressured that they have to do it or do it too early if it's, if it's not the right time for them. So definitely important to have good conversations and talk through the pros and cons with your provider. 

 [00:18:21] Pooja: I wanted to ask you, you know, as we're talking about medical professionals and as folks are going through different stages of their training, knowing that as we get later into training, into residency and fellowship, we've got so many constraints in terms of schedules, how intensive our schedules can be. the flexibility we may have and the realities of going through this types of procedures and kind of recovering from the physical load that it can put on you. What do you advise for somebody who say like earlier in medical school coming to talk to you about this? 

 [00:18:51] Dr. Bhavan: It's such a thoughtful question and a difficult one because it's one thing to be aware and then we're facing access not only from a cost perspective or insurance benefits. Uh, but also from feasibility standpoint, right? So we know this is an at risk population, but it's such a demanding schedule. It's hard to even get in to have the process and procedure completed. So I hear you. I really, you know, I try to talk with people to learn more about their schedules and find out, is there a time that they might be having more flexibility, a break between rotations or a research block and residency?

 [00:19:29] Dr. Bhavan: And also I think there's more awareness about this. So I've had people in very demanding subspecialties and they've talked to their program leadership and with more focus on wellness and empowering people for building families in the way that they hope to. Um, some people have had to pioneer, but, uh, and still do and still don't get as much support as they deserve, but really advocating to say that this is, you know, medical treatment, medical procedures and, you know, working with their co residents or co fellows or, you know, fellow attendings to be covered or, you know, have a backup plan so that you can make the ultrasound appointments and take the day of the procedure off.

 [00:20:10] Dr. Bhavan: I think actually your question lends itself nicely to share a little bit more about the process. So, there's different protocols in different ways, but generally what I tell my patients is those who are, are cycling, we have, our gonadotropin releasing hormones speaking to our from our hypothalamus speaking to our pituitary to release FSH which will grow a dominant egg for the month and then LH surge you'll get ovulation and then, if not pregnant, two weeks later we have withdrawal of hormones and have bleeding.

 [00:20:42] Dr. Bhavan: So that's kind of a quick and dirty of the menstrual cycle. 

 [00:20:46] Dr. Bhavan: And so how we manipulate it is that, you know, of those chocolate chips or antral follicles, one is chosen and the rest will die off. And then we, you know, keep cycling and keep having these waves of recruitment. And I know earlier I said it happens about once a month, but it's kind of happening continuously.

 [00:21:01] Dr. Bhavan: And that's why we can sometimes do a cycle right before someone's ovulated and right after someone's ovulated for like our cancer patients who don't have time to wait and need to try to get repeat cycles in. And so typically, with our 9 to 12 days of subcutaneous or lower abdomen and the fatty tissue we all have there, we administer, depending on the protocol, 2 to 4 injections a day, and those are FSH and then the other is a mix of FSH and LH.

 [00:21:31] Dr. Bhavan: And by giving super physiologic levels of these hormones, we're actually optimizing our body's system. So instead of just one to grow and the rest die off, let's try to get as many to grow as safely as possible. And so, sometimes before you go into the injection period, you'll do a short course of birth control pills or estrogen pills or no pills.

 [00:21:52] Dr. Bhavan: It's just kind of decided by your doctor, your history, your counts, but you know, you'll maybe do some prep work and then move into the injection period. During the injection period, people can come for about four to six ultrasounds to check on the rate of growth. And those are quick appointments, 10 to 15 minutes, maybe a blood draw, but you are having to come and go from work.

 [00:22:13] Dr. Bhavan: Depending how far you are from the clinic you're being seen at, you have to account for commute time. For that, you know, two week window, it can be quite busy. I just warn patients, but most patients continue to work and carry on during this time. And the most symptomatic people get is, you know, some people feel fine. Some people have nausea and headaches, but the most common symptoms are bloating and fatigue, and it will get more intense as the eggs grow more and you got more eggs and higher estrogen levels and when we decide and are monitoring that the egg cohort has grown as optimally as possible We'll take a special set of trigger injections that get the eggs ready for the maturation process and before they release about 36 hours later we do an egg retreat ball and that day, you know, we provide, you know full procedural sedation for our patients and they need to be to take the day off, have a ride to and from the clinic.

 [00:23:11] Dr. Bhavan: And yeah, so they will not feel the pain or have memory of the procedure. And we're able to use an ultrasound, vaginal ultrasound with a guide for a very thin needle that will go through the top of the vagina into the peritoneum and right into the ovary to drain the follicular fluid. And then in that Um, it's collected in test tubes and handed to our embryologists who start looking under the microscope to identify the eggs. And then the eggs can be identified which ones are mature and frozen or they go through the fertilization blastocyst formation and optional genetic testing before they're frozen. Um, so that's kind of a an overview of what the process entails. And for after the procedure, even though the eggs are retrieved the hormone levels are still the same still going to peak and come down over the following week.

 [00:24:00] Dr. Bhavan: So people find that they could have their worst symptoms of bloating and fatigue following and that they have to take some, take it easy, use supportive medicines, ibuprofen, Tylenol, nausea regimen, bowel regimen for constipation to keep comfortable until they really will turn the corner and hormone levels are resetting.

[00:24:21] Dr. Bhavan: Uh, and about 10 to 14 days after the egg retrieval, a period will come and people should really, their ovaries should be pretty much back to normal size and feeling better. Uh, but I, I shared this because some people, especially younger people who have good counts can get ovarian hyperstimulation syndrome where they have a very robust response and it usually means you've gotten a good number of eggs, but you are quite symptomatic with bloating, maybe abdominal ascites or fluid in the belly.

 [00:24:48] Dr. Bhavan: More extreme cases, you're not really perfusing the kidneys well, so you have less urine output and maybe some chemo concentration, putting you at risk for blood clots. So those, those are the more extreme cases. So, you know, it really depends. I have just like pain is so subjective. I have some people come through and be like, that wasn't bad at all.

 [00:25:07] Dr. Bhavan: And I have other people went, wow, the bloating and the cramping and fatigue, it really got me. So I tell people experiences can be variable and just preparing. And some people were not anticipating needing to take a few more days off work than they needed to, because they did get OHSS and feel unwell and need more time to recover.

 [00:25:26] Dr. Bhavan: And that's always hard because it's never convenient to have to leave work. Especially when you're within a team practice in medicine, but yeah, depending some people say I'm going to make it work. Some people say I'll wait till a period, maybe, you know, end of, you know, uh, medical school, like in the end of fourth year after interviews and lighter rotations, maybe is a good time or in residency, a research block, as I mentioned, same with fellowship or just working to find, lighter rotations or maybe coverage is more possible.

 [00:25:55] Dr. Bhavan: So those are some of my, my tips and, and just empowering people what they can do in terms of medication support so that they're not miserable and, and really we can temper some of their symptoms.

 [00:26:06] Pooja: That's great. Have you seen more and more support from program leadership kind of across the country as this is becoming just more of a frequent occurrence?

 [00:26:15] Dr. Bhavan: I have, I definitely think there's like room to grow and even get better, but I really have. And I've, I've been touched. I've been asked to give a number of talks, you know, at Stanford to the different departments. And it's just so nice to have awareness of the process and have a contact and someone who's could be an advocate.

 [00:26:33] Dr. Bhavan: So I do still hear anecdotally from some of the people I take care of that they don't have the support they wish they had, which is why I said that there's room to grow. And I think seeing this, As yes, it is elective, but it is also really still doesn't mean it's not important and worthwhile and that we should support people wanting to invest that time as they go through.

 [00:26:54] Pooja: Yeah. Yeah. And I'm hoping as we kind of, uh, move forward in the future that this can be, uh, something that we start incorporating into say ACGME guidelines or common requirement guidelines. So it is something that can be standardized across the board at other programs. That would be so powerful, yes. And I wanted to come back to a point that you had made earlier, which is the political landscape of a lot of this.

 [00:27:16] Pooja: As, you know, we go through like the match process and have little power about where we may end up for our training programs, if we do have to go to a state that isn't as accepting or politically friendly of these processes, what do you advise for students or residents in that case? 

 [00:27:37] Dr. Bhavan: Yes, this has been just saddening that this is the reality so many people are facing.

 [00:27:43] Dr. Bhavan: And when, yeah, you're considering making your rank list for match or for our OB GYN, um, residents just figure out where they want to train and have exposure to be able to help people. Uh, it's, it's really had so many far reaching impacts. I think, you know, there are, are still options to reach out, have a consultation, learn more.

 [00:28:07] Dr. Bhavan: Maybe someone will be more likely to choose egg over embryo freezing. That might be one option. Some individuals whose insurance allows, if there may be from somewhere that is more friendly towards supporting just the rights about using eggs or embryos, then, you know, you might embryo a vacation week or some flexible research block, go back to where your, you know, hometown is and proceed there because eggs and embryos can be moved.

 [00:28:39] Dr. Bhavan: That is actually a common question I get. It's like, well, what if I'm in residency here, but I go to fellowship or get an attending position somewhere else. And so you can. Yeah. you know, in an ideal world, we love people to come back to where they froze because then you don't have any risks with transport.

 [00:28:53] Dr. Bhavan: But cryo transport can be done successfully and safely. And many people just can't come back for an extended period of time to use their eggs or embryos and prepare the uterus for implantation. And so what they'll do is, you know, established with a local fertility clinic and move their eggs or embryos there.

 [00:29:13] Dr. Bhavan: And so that's available. For individuals who maybe feel the environment in which their training is more politically volatile than they might decide to go back to somewhere that they feel more supported in. So that's why I think it's so important that we continue partnership with all of our legal advocates as well, that we can make legislative changes and have more support for, you know, it's really scary to hear that IVF is being attacked, contraception's being attacked, and that we can still have choices as, as patients so wholeheartedly deserve. 

 [00:29:50] Pooja: Thank you so much for bringing that up. I think that's an important point and ways that we all as listeners can, can absolutely get involved. If you're looking for an advocacy home, acponline.org/advocacy has a lot of great resources that are constantly being updated, both about what's happening at your state level and at the national level. Um, so go ahead and check out that website and see how you can get involved and always encourage listeners to participate in their local and national advocacy days.

 [00:30:18] Pooja: So you can actually go and meet with your state legislatures and national legislators. To voice your opinions on behalf of your patients and on behalf of ourselves and as medical professionals. So Brindha, thank you so much for being here with us today. We are unfortunately at time, but there's so much that we've already covered and so much to talk about in the future for potentially another show.

 [00:30:38] Pooja: But I wanted to just give you the opportunity to share any final words of wisdom or last pearls of advice for our audience. 

 [00:30:44] Dr. Bhavan: So I want to thank you so much, Pooja, for having me. I really appreciated the chance to share some of my perspective with the listeners today, and in terms of, you know, final pearls, just want to let people know that if they're having thoughts about this, concerns about this, difficulties with this, if they're actually facing infertility as they're, you know, trying to build their families now, you're not alone.

 [00:31:05] Dr. Bhavan: And your local OB GYN, REI, we would love to talk more with you and find the best way to support you and help you reach, you know, the family planning that's ideal for you. Um, so thank you to everyone for your time and attention today. 

 [00:31:19] Pooja: Oh, thank you so much. That's a really sweet message of solidarity. And we appreciate, you know, giving us an insight into where we go next with this.

 [00:31:27] Pooja: So, well, that's all the time we have for today. We have part two of this series, which will focus on the challenges of parenting while doing clinical medicine and medicine in general coming up next but for now, we'd love to invite our listeners to join the discussion online and share your stories and experiences with us. You can send us your experiences over email at theDEIshift@gmail.com or on Instagram and X with the handle @thedeishift. We'll also have a transcript of this conversation along with show notes that include the resources discussed today. Thanks again to our guest Charlie for joining us and to our listeners for tuning into this conversation. Don't forget to claim your CME and MOOC at ACP Online. Thanks and see you next time.

Disclaimer: The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.