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Fertility (transcript)
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(Announcer) 
Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association; an Association of independent Blue Plans committed to better knowledge leading to better, more affordable health care for consumers.

[clock ticking]

[music]

(Dr. Peter Salgo) 
Welcome to Second Opinion where each week our health care team solves a real medical mystery. When we close this file in a half an hour from now, you'll not only know the outcome of this week's case, but you'll be able to better take charge of your own health care. I'm your host Dr. Peter Salgo and our story today concerns a couple named Brad and Diane. Now you've already met this week's special guests who are joining our cast of regulars, Primary Care Physician Dr. Lisa Harris and Health Reporter Kat Carney. No one on the team knows the case so it's about time to get to work. Brad and Diane; a 40 year old couple, they've been happily married for 12 years, they both have high pressure jobs; Brad owns a business, Diane is a book editor and 1 year ago they decided they wanted to start a family and they have been trying to do so ever since. Now Lisa you're Diane's doctor and she comes to your office frustrated that she is not pregnant and she says help me. It's been a year. Is that too long? Should I be worried about this? Should I be pregnant by now?

(Dr. Lisa Harris) 
I think people, particularly women in this day and age put a lot of pressure on themselves and think that pregnancy and delivery and things like that fit into a time schedule like your career; you go to college for 4 years and therefore you should be pregnant within a certain amount of time. She's feeling her clock ticking and she's worried.

(Peter) 
But is that reasonable? Is it fair?

(Michael Tucker)  
I think that's total red flag is, is the wife's, Diane's age. At 40 I think that's definitely a reason to jump into more in-depth investigation.

(Peter) 
If she were 25 would it be a red flag?

(Michael)  
Less so, less so.

(Peter) 
Is it fair to say that if we make the assumption they have been trying in the usual manner as they say in medical school for a year that they're infertile? Is this an infertile couple?

(Dr. Kathleen Hoeger) 
It is by the definition that we use because...

(Peter) 
What's your definition?

(Kathleen) 
It is a year of unprotected intercourse and most couples if you look at the availability of the data we have, will conceive, 85% of them within that year's time.

(Kat Carney)  
Well I'm curious; is she the only one who went to her doctor or did they go as a couple?

(Peter) 
No it looks like, and I can read what the doctor's note says. Diane goes to see her doctor. Brad apparently is not part of this concerned picture, at least not right now. Does that concern you Kat? 

(Kat)  
It doesn't concern me. I find it curious because so often we talk about, you know, infertility, it's always got to be the woman. The woman is the one who's the most proactive so I'm just wondering, you know how proactive is the husband as well in looking in to what might possibly be the problem if there is one.

(Dr. Peter Salgo) 
Kathy, tell me a little bit about what it was like for you to have wanted a child, had been trying and then to have sought help. What were you going through?

(Kathy Natoli)  
It's very frustrating. You get to that point where you think you're doing everything right. You go to college and you start your career. We wanted to get to a financial spot so it's like okay we've got both of our careers where we wanted them to be, we had a home so we could provide for the child and then, oh I'm sorry you can't conceive.

(Peter) 
How old were you at that time?

(Kathy)  
I was 29 when we started.

(Peter) 
Okay so you were 29. Diane here is 40. Does that make a big difference?

(Kathleen) 
It's a huge difference.

(Peter) Why?

(Kathleen) 
Fertility rates decline, we believe continuously from the late 20's really through the 30's. After age 35 they take even a more dramatic decline and by 40 there are a good substantial proportion of women who will not be able to conceive.

(Peter) 
If what you're saying is true, she's 40 now, they've been trying; by your definition she's infertile. Should they just say the heck with it, we're not going to get this done?

(Kathleen) 
No not by any stretch. There are still treatable causes at 40. The success rates will be lower and it's important to be upfront and honest with them as they start.

(Peter) 
What are the ethics about all of this?

(Glenn McGee) 
It's spaghetti, a kind of crazy mess because on the one hand we're looking for who's at fault, which creates an enormous amount of stress. Then there is the money piece and as together as they are, this can be very, very expensive and maybe more so because of their age.

(Dr. Peter Salgo) 
Why does fault come into this at all and apparently it does.

(Lisa) 
People start blaming themselves, and I don't, I don't want to interrupt you too much, but you know I was just thinking about you and about how you put your career and everything together and things look like they're perfect and all of a sudden you can't do this and you start blaming yourself. What's wrong with me?

(Kat)  
What point is the husband brought into it to say well let's try to eliminate or identify the problem in one or both of you at the same time.

(Kathleen) 
Yeah and we like to bring them in right away, in fact all of our appointment it's strongly encouraged that the partner be there.

(Peter) 
I've got some information. I can tell you that she was on birth control pills and stopped about a year ago, prior to that she had tried some other forms of contraception. There is no history of gynecologic infection. The pelvic exam was normal. Anything else you'd like to know about her?

(Lisa) 
How are her menstrual cycles?

(Peter) 
Her menstrual cycles are regular; they're about every 28 days, she has 5 days of flow. Why would you ask?

(Lisa) 
Because if she's having abnormal menstrual cycles I'm kind of wondering if she's in premature menopause and then...

(Peter)
Would there be any other reason to look for abnormal lengths of cycle?

(Dr. Kathleen Hoeger) 
Ovulatory Dysfunction is one of the major causes of infertility and although it does vary across age groups, it's often women on birth control pills who wouldn't realize it because their cycles are being managed hormonally so when they come off of it it's not infrequent that they had an Ovulatory Disorder.
 
(Michael) 
Do we know anything about her BMI or her weight, height?

(Peter) 
Yes she weighs 160 pounds; she's 5' 5" tall. I could also tell you she drinks a glass of wine with dinner every night, she doesn't smoke and quote, I'm way too busy at work to exercise. How does that affect everything?

(Michael)  
Issues of weight can sometimes relate to the status of the hormonal, the hormones in the woman. Polycystic Ovarian Disease for example is often associated with increased weight and so that may have some impact on the case.

(Peter) 
I have some labs for you. I'll give you them if I have them. What would you like to know, anybody?

(Kathleen) 
Well one of the things that we look at because age is such an important part is we immediately look for Follicle Stimulating Hormone or FSH.

(Dr. Peter Salgo) 
That was normal. Her Follicle Stimulating Hormone, her LSH, her Thyroid test, they were all normal. Her Glucose Tolerance Test which is to look for Pre-Diabetes and Diabetes; mild Glucose intolerance is what's written here in the chart. She has had a Trans-abdominal Ultrasound Exam to go look for masses; that was normal. Basically all of the laboratory tests that I have here so far look like nothing, nothing out of the ordinary. What's wrong with Diane; she can't conceive; she's infertile. All of her tests are normal.

(Kathleen) 
Well she hasn't had all of her tests. You still need to look at her Fallopian Tubes through a Hysterosalpingogram. That's an x-ray that injects dye through the uterus to see the latency of the Fallopian Tubes. Still you need to be assessing her for ovulation. Even though you can get a pattern of hormones that is normal, there's a, there's a dynamic process to each cycle and it can vary so having an assessment over a cycle, either with temperature charting or some measurement of progesterone would be helpful.

(Peter) 
With regard to all of these tests, there's nothing here specifically that says what the problem is?

(Kathleen) 
That's correct.

(Peter) 
But what about that stressful job thing that they were talking about? Is that a problem?

(Lisa) 
It absolutely contributes to infertility.

(Glenn) 
Yes.

(Peter) 
How so?

(Dr. Lisa Harris) 
I think people are pressured into thinking that, you know you can take a 5-minute vacation and boom, you should be pregnant and we know that stress and stress hormones will affect your ability to conceive.

(Peter) 
Diane's sitting there, she's 40 years old, we've got all these lab tests, we've got all these lab tests, you've got the history, you've done the physical exam, now what?

(Kathleen) 
A semen analysis, which is of course, is really part of the beginning analysis.

(Peter) 
Not done. So, I mean I am catching a big miss here in this chart where they're looking at Diane, they're looking at Diane and nobody is talking about Brad.

(Kathleen) 
Oh yes absolutely, absolutely.

(Glenn) 
But Diane's the patient and that's the critical pieces. We haven't designed our medical system around for genetic testing or for infertility around the idea of bringing in others and often, often increasingly often; Diane wouldn't be part of an ordinary partnership.

(Dr. Peter Salgo) 
The fertility specialist said this according to the chart; I want to see you again. I want you to diminish the frequency of intercourse and try to have intercourse just around the time you're ovulating. I want you to start exercising regularly, lose weight, stop drinking and decrease the stress in your life. Does this have any chance of working and why is this decrease the intercourse thing going to help if in fact what they want is to have a baby?

(Dr. Kathleen Hoeger) 
The process of fertilization occurs only at a single point in a cycle so the frequency of intercourse is not going to improve the odds if it's not timed appropriately. There's very little information though that frequent intercourse in the face of a normal sperm count will actually do any harm. So in the absence of knowledge of what's going on with Brad, we really don't know if that is good advice or not. Certainly the things that are mentioned about stress reduction and all of those things are very important, but I think acknowledging stress as a component is important, but delaying her beyond the point of where you're going to be able to help her would not be a good idea.

(Peter) 
Well Kathy what did your Gynecologist tell you as you left the office that first time after asking for help? What was the advice you got?

(Kathy)  
She said I'm going to send you for a Laparoscopy.

(Peter) 
That was it?

(Kathy)  
But then after the Laparoscopy was all said and done, then they said oh well we'll send you to, we'll send you to a specialist.

(Peter) 
Any behavior change or behavior change for your husband or any medication they recommended nothing?

(Kathy)  
No.

(Peter) 
That was it?

(Kathy)  
Yeah.

(Peter) 
Were you happy with this by the way?

(Kathy Natoli)  
She tried me on Clomid for awhile. 

(Dr. Peter Salgo) 
They did put you on Clomid?

(Kathy)  
She did try me on Clomid for awhile.

(Peter) 
What's Clomid?

(Kathy)  I...

(Peter) What's Clomid?

(Kathleen) 
Clomid is an anti-Estrogen. It's in the same group of drugs like Tamoxifen so it's a drug that's designed to really induce ovulation; that's what it's made to do.

(Peter) 
If you'll forgive me, that's what people hear about in the press, the fertility drugs. Clomid is one of those.

(Kathleen) 
Clomid is an oral form, a pill that you take for fertility.

(Peter) 
Any other advice that they gave you at that time? In that case let's pause for just a moment and review where we are and where we're going to be going. Having difficulty getting pregnant can have many causes. Now some of them you cannot change, such as your age. Some of them you can change and if you're having difficulty getting pregnant, the first step is to work with your doctor to find out what these fertility issues really are. If I take anything away from our discussion at the beginning here, it's that it can be complicated, or as you said, a bowl of spaghetti. Let me tell you a little bit more about Diane because Diane comes back to her doctor's office 3 months later and she is still not pregnant. Now this time her doctor refers her and Brad; it's the first time Brad's name appears in the chart, to a fertility specialist. What should they expect?

(Kathleen) 
Well the doctor that sees them in the specialist clinic is going to really review in great detail all the work up that they've had to that point.

(Peter) 
Any additional tests for either, either Diane or for Brad?

(Kathleen) 
Well we still need the semen analysis on Brad so that would be probably right up there number 1 and then based on her age we may do an assessment by ultrasound to look at the number of follicles that are contained in the ovaries. The follicles are the early eggs that will develop each month and so we like to know if there's a good cohort of them or a good amount left.

(Dr. Peter Salgo) 
I can give you the results of what the fertility expert got.

(Kathleen) 
Okay.

(Peter) 
Diane got Ovarian Reserve Testing and that showed more than 7 mature follicles. It turned out to be normal essentially. Brad got the semen analysis.

(Dr. Kathleen Hoeger) 
Yeah!

(Peter) 
I can hear somebody saying it's about time. And his sperm had normal motility, they looked normal under the microscope, they were swimming okay, the number of sperm was 20 million per ejaculation. Is that good or bad? Is that normal, not normal?

(Michael)  
Is that total count or per...

(Peter) 
Total count is what I've got here; 20 million. You look disturbed by this.

(Michael)  
Well I mean that may be an issue of frequency of intercourse; when did he last ejaculate? If it was the night before that may not be so surprising. The count varies enormously, but its right there on the borderline.

(Peter) 
But this is on the low side in any event is it not? I mean if it makes normal, it makes it, but just.

(Michael Tucker)  
But there are other factors involved. You need to know the volume.

(Peter) 
Well I can give it to you actually because it's in the chart. The total volume of the ejaculate, which is two and half cc's.

(Michael)  
Okay.

(Dr. Peter Salgo) 
And the total count was 20 million.

(Michael)  
Okay so the count was actually in the 7 and a half million per milliliter range which is low; it's sub-fertile.

(Kathleen) 
Yes.

(Peter) 
Kathy you've got a smile on your face. You know this story. The issue was with your husband.

(Kathy)  
Yes.

(Peter) 
Was it a low sperm count, was that the problem?

(Kathy)  
Yes, almost none. There was a little tiny bit of me that said mm hmm why didn't we just have him do that first because it was so easy.

[laughing]

(Kathy)  
It was easy for him to go and do that and I think that's a, you know that is a little bit frustrating, but I; we didn't let it invade in our relationship.

(Peter) 
How does a sperm count get low?

(Kathleen) 
It can be from many numbers of reasons. Mostly we never find out. It can be from genetic causes; very low sperm counts often are. It can be from previous surgery, trauma, and obstruction.

(Peter) 
Let me; let me run through some common...

(Lisa) 
And grandma's thing; don't wear tight underwear.

[laughing]

(Peter)  
I was going to say that. Let me go through some of these popular myths or not myths. The tidy whitey versus the boxers' myth, does it matter?

(Kathleen) 
I don't believe so.

(Michael)  
It's not as firm a rule as you would imagine but there is some element that the testicles need to be kept cooler than the rest of the body at about 34 degrees Celsius as opposed to 37-body temperature.

(Dr. Peter Salgo) 
So boxers are better than...

(Kathleen) 
But whether the boxers do that versus the other ones...

(Glenn) 
The tidy whitey study has yet to be done.

(Peter) 
Smoking or alcohol affect your sperm count?

(Dr. Kathleen Hoeger) 
Yes they do. Lifestyle factors are important in sperm. We don't have as much information, but they clearly are.

(Michael)  
And that includes stress as well, back to the lifestyle of Brad and Diane here. It could have a significant impact on him.

(Peter) 
How often does that occur? How often is it more the men than the women?

(Kathleen) 
It's close to 40% of the time where it's primarily an issue related to sperm, but it's often the case that it's multiple things.

(Peter) 
Alright now you know all the results. What are you going to do? What are there options?

(Kathleen) 
Well the options you're going to discuss with them are ways to improve the sperm function in the reproductive tract and usually the 2 options that we'll talk about are Intrauterine Insemination or In Vitro Fertilization. Sperm function if you can find a reason for the sperm to be abnormal that you can correct, remembering her age of 40, and we don't have a lot of time, so most people would be given the choices of using Intrauterine Insemination combined with some fertility enhancing agent for the woman or using In Vitro Fertilization.

(Peter) 
All right let's run through some of these. How do you do it?

(Kathleen) 
Well one is Clomid. We talked about that. That's a pill that you take during the early part of the follicular menstrual cycles so that you can induce egg development to occur in more, usually 2 to 3 of them whereas a normal cycle your just going to make 1 egg. The other options you have are injectable FSH or Follicle Stimulating Hormone preparations and there are a number of them.

(Kat)  
Are there any down sides to these types of treatments?

(Kathleen) 
Absolutely. Any fertility agent that you use is going to increase the risk of multiple gestations, maybe less so in a woman at 40, but still a very relevant conversation.

(Peter) 
So what you're talking about is Assisted Reproductive Technology?

(Kathleen) 
Yes.

(Peter) 
This is a burgeoning field. How long has this field been around?

(Dr. Kathleen Hoeger) 
Well the first baby, 1978?

(Michael Tucker)  
1978.

(Dr. Peter Salgo) 
In the global, ethical issue, which is we're, we're encouraging couples to wait. The society seems to be doing that. We're encouraging women to have careers, we're encouraging women to become financially secure, we're encouraging them not to worry so much about the biological clock because you can fix that, and you can fix that. Should we be fixing that or should we simply say have your kids early. Is that the ethical thing to do?

(Glenn) 
Well I mean, to bite the bullet there are of course many, many people and organizations; the Catholic Church says it's wrong, wrong and it's become a more clearly articulated position everyday. American Catholics are the leading consumers of infertility technology so the question of whether it's just okay is one that individuals who are grounded in their moral and religious views. But the bigger picture is about how we find this technology. This, we're talking about billions and billions of dollars when there are, many will say, lots of kids who don't get adopted.

(Peter) 
Brad and Diane decided to go forward with In Vitro Fertilization. Tell me what that is and then tell me what they can expect and can they expect it to work?

(Kathleen) 
In Vitro Fertilization is the process by doing, taking the fertility drugs that we talked about a few minutes ago, allowing egg development. On an average, we aim for about 10 eggs and those eggs are extracted through a surgical procedure. We take the eggs and then we hand them off to the laboratory and the men collect a sample, or we have a sample already frozen, depending on the situation and then the fertilization occurs in the laboratory. Embryos are then cultured and placed back into the woman's uterus to allow for implantation.

(Peter) 
And how often does that result in a live birth?

(Kathleen) 
Well that's going to be very heavily dependent on many factors. The woman's age is probably the leading factor that will determine whether the cycle is successful.

(Peter) 
Diane's 40, what can she expect?

(Kathleen) 
In general, most clinics will report success rates for woman 40 or over are going to be in the 20% range or so.

(Peter) 
Let me flip that over so it's very clear. 80% of the time, no go.

(Kathleen) 
For a single cycle.

(Peter) 
That sounds like a very low success rate.

(Michael)  
To some extent many of these women or these couples have to come to terms with their infertility and by at least taking 1 shot at IVF, they get the whole thing explained.

(Kathleen) 
Mm hmm.

(Michael)  
And then there's donor egg or donor sperm.

(Dr. Kathleen Hoeger) 
Right.

(Dr. Peter Salgo) 
Kathy you had IVF.

(Kathy Natoli)  
Yes.

(Peter) 
What was that like? Tell me a little bit about it.

(Kathy)  
It's very trying. It's very emotional. It's very, it's just, it's a lengthy, can be a very lengthy process.

(Peter) 
There are a lot of drugs you have to take.

(Kathleen) 
There are a lot of drugs.

(Peter) 
There are shots that your husband had to give you.

(Kathy)  
There are a lot of shots. It's a lot of drugs. You line them up everyday and there's 7 or 9 different things you have to take and then oh my gosh I need to take my Prenatal Vitamins. It takes a lot of communication. It's a very hard process. It's, it's very emotional. There are definitely highs and lows. It takes a lot of family support, a lot of friend support if you're willing to let those people in to help you, which is a really good idea.

(Peter) 
Let me tell you a bit about Diane. They went to, they decided to go ahead and have In Vitro Fertilization. They had 7 eggs implanted. Let's be frank here; if all 7 eggs take, now we're talking septuplets, which is going to raise all kinds of issues. Which is selectively deselecting and let's be very clear what I'm saying here. Some of those developing embryos will be removed in a way.

(Kathleen) 
I think we should back up and maybe you would agree with me. Seven embryos transferred is really not the standard.

(Glenn McGee) 
But I think it's unethical, it's to fail to have the conversation, and in fact I'd go so far as to say I don't think a patient should be a candidate for this level of implantation unless they agree in advance to multiple reductions. There are of course lots of people in the field of Bioethics who disagree with that.

(Kat Carney)  
I'm sitting here listening and I'm not in any particular emotional state right now and it sounds complicated and it sounds scary and it sounds expensive and it sounds like that slippery slope.

(Glenn) 
It's nothing like sex either, nothing.

(Kathleen) 
Right.

[laughing]

(Glenn) 
There's nothing romantic about this at all.

(Kathleen) 
And I think one of the things you need to realize...

(Peter) 
We have from our ethicist that it's nothing like sex. Thank you.

(Kathleen) 
But these conversations are often happening with the embryos either on the video screen or in the laboratory next door and you can put a lot of theoretical in front of a couple, but like we know, any theoretical when you're sitting there ready to start, it means nothing.

(Dr. Peter Salgo) 
Let me just ask the bottom line. Did it work the first time?

(Kathy)  
No.

(Glenn) 
Uh oh.

[laughing]

(Peter) 
Okay so after all the shots, all the medicines, everything, no.

(Kathy)  
No.

(Peter) 
And guess what? It didn't work for Diane either. What's next? What do you do for Diane now? It didn't work.

(Dr. Kathleen Hoeger) 
Well I think you look, you sit down with the couple and you review the cycle in detail, that you want to know what her egg production was, what the quality of her embryos were and whether this is an appropriate thing to do again. Sometimes you come to the conclusion that it's not.

(Peter) 
Okay let's stop for a moment and sum up where we are. This has, this has gotten really complex. Assisted Reproductive Technology can be successful, but I think it's very clear from what we've discussed that it is not a cookie cutter approach. It is not a guarantee. Your best treatment option is going to depend on your specific fertility issue and your age and your overall health. This is; this is big stuff. Let me tell you a bit more about Diane. I want to get back there. She tried 6 times.

(Lisa) 
Whoa.

(Peter) 
Six cycles.

(Kathleen) 
Diane was rich.

(Peter) 
Meaning they had taken her eggs, taken them into the lab, fertilized them and they waited. She is now 41 years old. She is not yet pregnant. How many times are you supposed to try this before you say enough?

(Michael)  
I'm thinking the Reproductive Endo Specialist is very successful, at least from a financial standpoint.

[laughing]

(Michael)  
To put a couple through that many times is excessive.

(Kathleen) 
To get somebody to do it that many times. Yeah, yeah.

(Dr. Peter Salgo) 
Kathy how many times did you try?

(Kathy)  
3.

(Peter) 
And then you had wonderful babies?

(Kathy Natoli)  
Yes.

(Peter) 
At the end of the day what did all this cost?

(Kathy)  
I think in the end it ended up costing somewhere close to $28,000.

(Peter) 
$28,000; there was your nest egg I gather.

(Kathy)  
It's gone.

[laughing]

(Peter) 
Well with IVF not working I can tell you about Diane. She's decided that she still wants a baby. She wants to go further. They want, something called Assisted Hatching for 1 of Diane's cycles. Explain this.

(Kathleen) 
Assisted Hatching is something that's done to the embryo at the time before transfer to allow for some of the protein coat that goes over it to be removed.

(Peter) 
Let me tell you what happened. Can you guess what happened? Nothing; it didn't work. The Assisted Hatching did not work. All the testing, all the treatment, they're out of money. They still have eggs; some of these eggs and or embryos frozen in a tank somewhere. Can embryos or the eggs simply be destroyed? Can the companies that store them throw them away?

(Michael Tucker)  
Well yes, but only with the couple's consent.

(Dr. Peter Salgo) 
There's an electric bill, there are all sorts of Cryogenics going on here. Who's paying the bill to store all these eggs?

(Kathleen) 
The couple.

(Michael)  
The couple is.

(Peter) 
Out of their insurance or out of their pocket?

(Kathleen) 
Out of their pocket.

(Lisa) 
Out of their pocket.

(Peter) 
Forever?

(Kathy)  
Forever.

(Michael)  
Sometimes it can be free if you agree.

(Peter) 
You speak with the voice of experience here.

(Glenn) 
You can, there are clinics that if you donate eggs for embryos for research will, will pay for that as they will with sperm.

(Peter) 
Okay let me pause here for just a moment and point out that while Assisted Reproductive Technology gives hope to couples who otherwise could not conceive a child, there are lots of factors to consider. There are many ethical decisions that you may have to make, financial decisions you have to make, the time it may take to conceive is a real issue. It puts stress on your relationship too. All of this is really critical. I can tell you a little bit more about Diane and Brad before we leave. They finally decided at the age of 43 to adopt a child and 3 years later they are waiting to adopt another one. I'm just going to throw a loaded word out there; medically are they a failure? Anybody want to jump on this?

(Michael)  
No.

(Dr. Lisa Harris) 
No they're not a failure.

(Michael)  
From my standpoint or what I think is, is common in the infertility world; most clinics really counsel couples in terms of options and that includes adoption.

(Peter) 
How are you doing Kathy? Tell me a little bit about the birth.

(Kathy)  
I had 2 little girls.

(Dr. Peter Salgo) 
You had twins.

(Kathy)  
I had twin little girls at 38 weeks.

(Peter) 
Congratulations.

(Kathleen) 
That's great.

(Peter) 
What happened in your life after the twins?

(Kathy Natoli)  
Well...

[laughing]

(Peter) 
Fasten your seat belts.

(Kathy)  
Perhaps the tidy whitey theory might have worked for us because the Gynecologist did suggest that my husband stop wearing tidy whitey's; sorry. So he did and 3 years later I got pregnant on my own.

(Peter) 
And?

(Kathy)  
And I have another baby girl.

(Peter) 
Congratulations that's 3.

(Kathy)  
Thank you.

(Peter)
Well it's nice to end on a good note isn't it? That is just terrific. Let's just sum up a few of the things that we've, we've covered today. We've covered a lot of ground. First of all, having difficulty getting pregnant can have many causes; some of them that you cannot change such as age, some of them that you can change. Now if you're having difficulty getting pregnant, the first step is to work with your doctor to find out what your fertility issues are both yours and your partners. Assisted Reproductive Technology can be successful, however it's not a cookie cutter approach and it is not guaranteed. Your best treatment options may depend on your specific issue, your age and your overall health and while Assisted Reproductive Technology gives hope to couples who otherwise could not conceive a child, there are many factors to consider such as the ethical decisions that you may have to make, financial investments it's going to cost, the time it may take to conceive, the stress on your relationship. And before we go I just want to say on behalf I suspect of everybody here; congratulations. 

(Kathy)  
Thank you.

(Dr. Peter Salgo) 
And I want to leave everybody of course with our final message; taking charge of your health means being informed, having quality communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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[clock ticking]

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