All right. So I think while people are streaming in, I'll start doing some of the welcome talking and I'll repeat some of it based on how many attendees I see that might have missed it or not. But I want to welcome everybody. Thank you so much for coming to this webinar and caring. And I want to thank obviously ASPS and WPS staff and surgeons that are willing to participate in this webinar and tell their story. And for everybody that's listening right now, you know, I want to acknowledge that this is a really sensitive topic, but I want to establish that this is kind of a safe space. So I think everybody's coming from a good place. And so if we say anything that hurts or offend anybody, that's obviously not our intention. And in that vein, obviously, thank you to all the panelists for sharing their private lives and the willingness to be vulnerable. And so the format today is to start out with some education from our fertility specialists. And then we'll let the panelists briefly introduce their path to becoming parents. And then we're going to really try to get to as many questions as possible and kind of let the audience lead the content. So as things are going along, everybody can enter your questions into the chat. And I will kind of organize them and ask the panelists in an organized way. And I just want to say if we don't get to anybody's question or a particular topic, I think there was enough interest in this that we should definitely try to do this again. For the privacy of the families and the children, please don't take screenshots or record this because we will put out a recording that will be blurred and also a PDF so that you can have that information. Okay, I think we're about there. I don't think that the numbers are climbing too much higher now. Maybe give a couple more minutes. I think usually people give it five minutes for everybody to stream in. And so for those 25 people that have entered since the last time I said this, I just want to say thank you to everybody for being willing to share their stories on such a sensitive topic and to say that this is kind of a safe space and we're going to try to get to as many questions as possible. Okay, so I think we can maybe share the screen to Dr. Gerkowicz as the starting one. And go ahead and start whenever you're ready. Thank you, Dr. Oh, Dr. Oh, oh, introductions. First time hosting. Okay. So Dr. Gerkowicz I want to introduce is a reproductive endocrinologist who practices in South Florida. She has a special interest in LGBTQ family building and is well published as well. And her partner in crime here today is Dr. Ruhi Jilani. She's also a reproductive endocrinologist. She practices in Chicago. She's received multiple awards in fetal medicine and reproductive medicine and is also very well published. And so I'm going to have these ladies take it away. Awesome. Well, thank you so much. Thanks for the introduction. I am Sabrina Gerkowicz and I'm a reproductive endocrinologist practicing in South Florida, like you said. And I'm so happy to be part of this webinar and to be part of this conversation on physician infertility and as well to briefly walk everybody through what a fertility workup might look like and why it is so important. So I'm going to hope that I'm controlling things right. So troubleshooting. Let's see. I don't think it clicked. It's always the first person. That's how it goes. There we go. Okay. All right. So many of you might be wondering, what does a career in medicine or surgery have to do with fertility? So I'll start by taking us briefly to where most of us go when we are looking for evidence based answers. So this year, Anderson and Goldman found that studies comparing surgeons with the general population show increased rates of infertility and pregnancy complications. And while most of the attributed blame for these findings has focused on older age and demanding work conditions of pregnant surgeons, the authors note that there are reproductive hazards present in the operating room that might also be contributing. A 2017 study surveyed OB-GYN residents and found that 85% did not actively pursue fertility during residency, 29% considered fertility preservation, but only 2% sought consultation, 29% of those trying to conceive experienced infertility to some degree, 63% felt low or no support from their training program, and 35% reported stigma associated with infertility. In another survey with 300 female physician respondents, 24% who had attempted conception were diagnosed with infertility. When asked what they would do differently in retrospect, 29% would have attempted conception earlier, 17% would have gone into a different specialty, and 7% would have used cryopreservation to extend fertility. In a study of 113 thoracic surgeons, both men and women, of those who wanted to have children, 98% of these women and 50% of these men delayed pregnancy. 82% of women and 60% of men felt their careers would be adversely affected. 28% utilized assisted reproductive technology when the national average is somewhere around 12%, and this paper found that the total fertility rate in this cohort was lower than the national rate. Turner et al. found that while the number of women general surgeons becoming pregnant during training has increased in recent years, substantial negative bias continues to exist in both male and female colleagues. More than half of all women surgeons delay childbearing until they are in independent practice or until post-training. What about plastic surgery? Many of you might be familiar with this publication or with one of its authors, who happens to be leading our discussion today, but in a survey completed by PRS trainees, 67% of male and 76% of female respondents intentionally postponed having children because of their career. Females were significantly more likely than males to report negative stigma attached to pregnancy and thus plan to delay childbearing until after training. 56% of female trainees reported an obstetrical complication, and assisted reproductive technologies was used by 19.6% of trainees. These findings are very sobering, and they only represent a fraction of the available data that is now out there addressing the topic of physician family building and some of the barriers that exist. But as you can see, the answer to my opening question is, this has a lot more than any of us might think. So why does this matter? This information is not meant to scare you, and instead, the opposite effect is what is desired. Knowledge is power, and the sooner we learn this, the better. We are all so focused on our educations, our careers, and taking care of others, that we often do this at an expense or neglect of ourselves. Early awareness is critical and will help you make the right decisions for you. And today, we have more options than ever, but are they right for you? So I'll start by sharing a few points about fertility. So women are born with all the eggs that we will ever have, and this number declines at different rates over time. The slope sharpens most notably after age 37, and even more after age 40. And this is especially true if someone receives a cancer treatment, like chemo or radiation. And women also, unfortunately, are not able to make more eggs. So once this pool is low, there's nothing that we can do to increase that. So as a woman's age increases, so does the proportion of genetically abnormal eggs and the chance of miscarriage. So these graphs, I know it's a little busy, but they're from an amazing study by Steiner et al., and they reflect the fecundity rates of the general population. And the graph on the left, I don't know if I can use my little pointer, I don't know if you guys see that, but the graph on the left represents how a woman's fecundity decreases with increasing age. So each of these different lines represents a different age group. The younger age groups are here at the top, and the lower age groups are here at the bottom. And this is a cumulative over 12 months of trying to conceive. So if no infertility factors are present, approximately 85% of couples in their low 30s will conceive for their first time within 12 months of trying. And this number decreases with each advancing age group. So chances of conceiving a first and a second child are shown in this table here on the right, and the chances are lower per age group for conceiving a first child. A woman's best reproductive years are in her 20s. In our low 30s, the chance of conception per month is at best 20 to 25%. And by age 40, that chance is about 5% or less. So unlike women, most men are able to produce sperm throughout their lifetimes. And sperm production is very closely tied to overall health, however, and can be negatively affected by conditions like diabetes, hypertension, cholesterol, and alcohol consumption and stress, to name a few. There's also a slightly increased risk of the following outcomes in couples conceiving with a male partner over the age of 40. So infertility affects up to 10% to 15% of couples, and this incidence, however, can be even higher in women in medicine, affecting up to one in four women physicians. Infertility is defined as a failure to achieve pregnancy within 12 months of unprotected intercourse or donor inseminations in women younger than 35 years, or within six months in women older than 35 years. There are certain conditions that might put one at a higher risk of having difficulty conceiving, and those definitely warrant prompt or immediate evaluation. So a fertility evaluation should be recommended for any person who meets these criteria or who is at high risk of infertility. And it also applies to anyone who's interested in fertility preservation or interested in knowing their numbers. So as with everything, you first will have your visit, and we will go over and get a very thorough history. And I know that probably all of you, except for Dr. Jelani and I, are probably cringing at this slide right now. But this graph is so important, and our workup is done basically by performing tests that are done at very specific times so that we can better understand how the reproductive system and HPG access are functioning. So usually that means about one to three quick appointments over a span of about two weeks. And insurance coverage definitely varies here, but for a lot of people, you can have higher chances of getting fertility testing covered as opposed to treatment. So some of these things can be covered by insurance and might not be out of pocket. Brain reserve testing will basically help us learn about how the ovaries are responding to the different signaling mechanisms and then roughly how many eggs remain in the pool. And we'll do this by getting a pelvic ultrasound between days two and five of the cycle and counting an antral follicle count as well as doing some hormone level checks. AMH is a big one, and it reflects the size of the pools of eggs that remain in the body. But it's really important to know two things when interpreting that result. And one is AMH can be temporarily suppressed if one is taking birth control pills for a long time. So sometimes taking a break for a month or two just to do accurate testing or if the levels are low, that might be repeated after a couple months off of birth control pills. And the AMH data that we have to learn about these values tends to be in studies that are of patients with infertility. So we have found that it really better reflects how well people will respond to ovarian stimulation or fertility medications as opposed to it being reflective of your chance of getting pregnant either naturally or with treatment. So that's a really big difference. So the next step would then include evaluation of the uterine cavity and the fallopian tubes for patency and tubal shape. And we would do that somewhere between cycle day 5 through 12. This would also be via a transvaginal ultrasound or a saline-infused sonogram, which is pictured here both in 2D and 3D, and by a hysterosalpingogram or an HSG, which is a quick procedure, slow infusion of dye via a catheter into the uterus. And that's really similar to a saline-infused sonogram, but the HSG would be with a couple quick pictures using fluoro. We'll do preconception testing, including all first trimester labs and then carrier screening panels, which are great because they can check for individual carrier status of over 200 inheritable genetic abnormalities. And last but definitely not least is a semen analysis if that is applicable. A medical history and evaluation of the male partner is really important to be done simultaneously with the female workup. After the evaluation, we find that in general, one-third of all cases are due to male factors, one-third are due to female factors, and about a third are combined, and infertility definitely does not discriminate. So what are some key things that you can do to optimize your future fertility or your chances of trying to conceive or when you're preserving fertility? So first, on top of everything, is optimizing your own health. It's one of the most important things you can do to improve fertility and treatment success. There's certain comorbidities, including obesity, cardiovascular disease, diabetes, that can definitely decrease fecundity and fertility, and they can lead to higher risk of maternal and fetal pregnancy complications, both intra- and postpartum. Diet is a really powerful tool that can be either used to improve or impair fertility, and it's a whole talk within itself, so I won't go into that, but findings tend to show that Mediterranean-style diets that are high in fruits and veggies and whole grains and fibers have been shown to improve various parameters that are helpful for fertility and health, including egg and sperm quality. Also important to note that some conditions like PCOS and endometriosis are really important for fertility, but also for other health implications. For example, women with PCOS, and that includes all phenotypes, are at increased risk of developing metabolic syndrome, and they also have higher risk of having manifestations like acne and hirsutism in irregular cycles, which can be pretty distressing. Additionally, women with PCOS tend to have a lot of follicles, but counterintuitively tend to have a lot of trouble actually ovulating without help. So month-to-month, while they have more eggs, it doesn't mean that they have higher chance. They actually have a lower chance sometimes without assistance in conceiving. Another really big key is that quality is always more important than quantity, and there's a big difference, and you just need one good egg and one good sperm for pregnancy. And lastly, timing is everything. Timing for natural conception or when to initiate a fertility workup. So it's always good to ask and to seek help sooner rather than later, so that will give more options for treatment and for higher success. So I'll end my part by leaving you with just a few important reminders, and the first one, which is so important for people in medicine especially, is that there is no right time. There's no right time to get pregnant, right time to start trying. It's just do whatever feels right to you, and that's going to be different for everybody. And this is a really personal choice, and everybody's path is really different. There are so many ways to build a family, and that's what so many of the panelists are going to discuss tonight, which is amazing, and this is not something that you are alone. And please don't lose hope because this process does seem daunting and intimidating, but we're definitely here to guide you throughout the entire process. And just like tonight, let's talk about it. This topic should not be taboo, and most importantly, to be supportive of each other while we're in training and beyond. So these are my references, and I hope that this was helpful, and I look forward to answering your questions and anything that you might have tonight or in the future, and I'll pass it off to Dr. Jelani, who will talk more about the treatment options that are available. Thank you, Sabrina. My name is Ruhi Jelani, and as Wendy stated, I'm in Chicago, Illinois, and I'm also a fertility specialist, and I'll continue the second aspect of it. What do you do once you get these results? Let me make sure I can click. Perfect. So there's two main treatment options, depending on what you're hoping to achieve. I'll start with hoping to conceive, and I'll start with the differences in medications and the differences in the two main treatment options. So you might have heard of what's called an IUI, and that stands for intrauterine insemination. That's where we take sperm and wash it, clean it, and put it right in the uterus. And then there's IVF, which stands for in vitro fertilization, and ICSIs, enterocytoplasmic sperm injection. That means microinjecting each egg with a sperm. Then there's different ways to stimulate the ovary. There's oral medications like Clomid and Letrozole, and then there's injectable medications, which are synthetic versions of the hormones Sabrina just discussed. So they're synthetic FSH. So an IUI is very simple. It's kind of like a pap smear. It's a speculum exam, a tiny catheter that looks like a noodle. It's floppy. We load the catheter with sperm, and we lodge that sperm right into the uterus. Then the sperm has to travel to the fallopian tubes, as depicted by the pictures that Sabrina had shown, to then hopefully fertilize the egg. When you have an unexplained infertility, or if you're doing a single-parent option, if you're saying, well, I'm a single-parent, I'm missing the sperm factor, but I want to try an insemination, the chance of conception per cycle falls under that 10% to 15%. So I'll walk you guys through the next way. How do you stimulate the ovary when you're doing an IUI? So the advantages of an IUI, and I saw a couple questions pop up about cost. It's less costly. There's way less intervention, and then it doesn't take away as much time from your schedule. So being a surgeon, we have a busy schedule. We also don't have that luxury of going in and out for multiple appointments. With an insemination, you go in for one baseline testing, second monitoring, and then a third for your actual insemination part. So the success range does vary depending on your baseline testing and the sperm parameters. So it's ideal for patients with unexplained infertility, meaning we test the eggs, we test the sperm, we don't really find out what's going on, but let's boost your chances. Mild male factor or mild endometriosis. It really doesn't work for patients who are missing their tubes or have damaged tubes because that's kind of like the highway where the egg and sperm meet. So if that's not working, then there's really no point in doing an insemination. If there's severe endometriosis, so endometriosis is an inflammatory disorder, and it causes a lot of scarring internally, and it also damages your tube. So even though we might not grossly see it, but the chance of success in patients who have severe endometriosis is much lower, because once again, that transport, that connection is not there. Once you fail IUIs a couple of times, then the success drops down, not because we're doing something wrong, but because there's something that we're missing. So whether, if you're morphology, meaning how the sperm appear abnormal, then you're not a good candidate for this. So an average cycle, and then I'm going to kind of condense both of these in one because it's very similar. So the first slide is an IUI while taking oral medication. So the two main medications that we use are letrozole and clomid. They're basically a form of anti-estrogen. So they hide that ovary. They make that hypothalamic pituitary axis work. So then you don't get that positive reinforcement. Your internal FSH goes up, which serves as a food for the ovary. So then you super ovulate. So instead of producing one egg, you may produce two eggs or one really well fed egg. So the risk of multiples goes up with this. So you come in and baseline, which is your period. I tell my patients it's like a baseball game. So think of your period as your baseline. We check your hormones. Then you take this pill for five days. You come in once more mid cycle, and then you monitor for growth. Then you take one shot only to time it. And as surgeons, timing is very important to us because we want complete control. I did this during my residency to have my first child. So this was much easier doing as compared to doing IVF. So you have the luxury of taking the trigger shot at any time you take that trigger. Then you have an insemination 36 hours later, 24 to 36 hours later. So that day or the next day. And we also encourage intercourse if you're doing this with your partner. Then you wait two weeks for your period or your pregnancy test. When you do an injectable cycle, remember injections are synthetic forms of that FSH. It's way more monitoring. This is a good option for residents. So for me, I had no coverage for IVF. So after I failed a couple medicated IUI cycles, this was my in between. So I said, okay, well, how do I boost my chances of an IUI yet not have to do the full out IVF? So you take the same hormones as you would with in vitro. So those are synthetic injections. The monitoring may vary depending on how you're responding. So each egg grows about one to two millimeters a day. So based on how your growth, they dose you, and then they tell you when to come back. So still the luxury of time doing monitoring at more your hours, and then still doing the IUI. So it's cost effective, but those meds are also expensive. So if you have no coverage, this was my kind of my gap before I went to IVF, if it would work. So very similar baseline, injections, a little bit more monitoring, trigger, and then the insemination, and two-week waiting period. So IUIs are a great option for patients who have a slightly lower egg count or slightly lower morphology, like a mild male factor. So what we do is we wash the sperm. So it kind of boosts the quality of it, and we concentrate it when we do the insemination. So if you're grossly abnormal, meaning the three parameters that Sabrina discussed, if all of them are grossly abnormal, then this is not a good option for you. So we ideally say greater than 10 million sperm for an IUI. We also, patients often ask, well, is it uncomfortable? Can I go to work? That was my biggest thing while going through this. If I get somebody to cover a case for me or I run in between my clinic, what am I going to experience? So there's really no lag time or downtime. You do the insemination, and then you can go back to work. You don't really have to, you're not under sedation. It's very quick. It's like a pap smear. Risks associated with it. So Clomid, and I'm a big culprit of this, we like to take things in our own control. So Clomid is only recommended for three to six cycles. If you do it for longer or unmonitored, you may start having negative side effects of it. So I started having thinner lining when I did Clomid, and that was really trying to balance being a resident and trying to do what's best for my fertility. So you also, you want to see what the risks are based on the medications. Ovarian hyperstim, meaning if you're doing an injection cycle, you may over-respond, and you may put yourself at increased risk of multiples or getting sick when your hormones get too high. So that's why as fertility specialists, that's our least favorite option. So I always tell my patients, if you're doing the injections and you're monitoring as much, then I'd rather have you just do IVF, unless you're a really poor candidate for IVF. So now getting to the big gun, that's IVF, that's in vitro fertilization. Most people believe it or not, and even me, having been an OB kind of specialist while going through this, an OB doctor, I really didn't know what that entailed. So it's a minimally invasive procedure. There is downtime. It is done under IV sedation, so you can't drive or work that day. One of the things that I found very hard for me was that it's done at very short notice intervals. So you get a 36-hour heads up, basically a two-day heads up that you're being retrieved in two days, fine coverage for your cases. So while I was doing this in residency, I had my point person, so it was my best friend who was also a senior and a chief, and I said, my retrieval may fall any time in the next 10 days, will you cover me if I need to? So that was very important for me. Monitoring happens very early in the morning. So believe it or not, most clinics are open at 630, 615, to get you in for blood and ultrasound. So with IVF, what you do is you take injection medications for about 10 to 12 days, monitor every second or third day, then you take a trigger shot at a very specific time to have your egg retrieval at a 36-hour interval. You need that day off to recover, but you're ready to go back to normal activities after. I did an egg retrieval in residency, in fellowship, and two as an attending. So besides that one day off, very little lag time. The benefit of it is it has a higher success rate, so you're regaining control as doctors. So what we do is we give you the FSH based on what your body needs. So if your eggs are not growing how we predicted, meaning that one to two millimeter a day, then we up your dose. If they're growing too fast, then I decrease your dose. We also have the potential, like my very last cycle that I did, I did it more for fertility preservation. So I have two kids after a lot of infertility, but I know I want more kids in the future, and I'm at a new job at a new practice where I'm looking at partnership tracks. So having a kid was not ideal for me at this moment, but age is, of course, very important as Sabrina highlighted. So I did IVF, and I genetically tested my embryos to make sure there's no abnormalities, chromosomal abnormalities like Down syndrome, trisomy, anything that I need to worry about. It's also ideal for patients with tubal issues. So if you have a tubal issue or endometriosis or a severe male factor, this might be good. For unexplained infertility, there was a study that was done not on, they compared an injection IUI cycle and IVF for unexplained infertility, and then they saw that even though there was a benefit of time by jumping straight to IVF, the patients who did multiple injectable cycles ultimately ended up paying the same amount as IVF, and when they did an IVF cycle, they realized there was a severe egg and male factor coming together. So there was an embryo quality issue. Patients with also, with a uterine factor, if that's why they're trying to go through IVF, it may not work as well for them because that's a complete, even though we're bred to think that the ovaries and the uterus are one organ, they're two separate systems. So it's very hard for fertility doctors to say, look, your period doesn't matter. For us residents who are going through egg freezing, I don't really need to align your period. You don't really have to come in on the first couple days. That's more so if I'm looking to implant. So your uterus is completely different than your ovaries, okay? Ovarian failure, meaning if you don't have any eggs left, then IVF is not as successful for you. So as we're getting better and better with technology, you may see numbers as high as 70, 80% success per transfer, but ultimately, remember, getting that embryo and the eggs is the hard part. So how an overview of IVF. If you initially have your consultation, which Sabrina highlighted, your testing is typically done in that same cycle, and then your egg retrieval the following month. Most clinics don't, especially now with COVID, as we've converted to telemedicine, you can pretty much get in to see a doctor within a month's time. In addition to doing that, you can start your stimulation at a time that's convenient for you. So if you know you're in residency at a harder clock, then you may choose to defer to a following month where you know you have an ambulatory setting. And then you can choose to do an egg retrieval, let your body heal, which is called a freeze-all cycle, and then wait for implantation in the following month. It doesn't have to be done necessarily consecutively. Freeze-all cycles, meaning doing a frozen embryo transfer, actually has a much higher success rate, so we recommend that. So if you notice, we do one month for an egg retrieval, and then the second month for embryo transfer. So brief timeline. It's also done in a month period. I know a lot of people have that common misconception that this takes a long time. It doesn't. It's rapid. I could see you today for a consult, and I could have you into my office for an egg freezing cycle in a week. So you come in, baseline, you stimulate for 10 to 12 days. Average is about 12. It may be a little bit longer, a little bit shorter, depending on how you respond. Trigger, egg retrieval 36 hours later. You recover that day. Somebody, no working or driving that day, somebody will drive you to and drive you back. If you're doing IVF, we'll call you the next day and let you know how many of your eggs were mature, meaning completed that final phase of maturation and separated into half of you, then join half of that sperm. So the reason why Sabrina highlighted this female's age is important is because our eggs are created as 46 chromosomes. So when we ovulate, it has to separate into 23, and males only make 23 chromosome sperm. So then they join to make one unique 46 chromosome baby, and that's what ovulation does. So ovulation completes that final process, but doesn't assure that it's going to break even. So as we get older, these chromosomes get stickier and stickier. So that's why the risk or an incidence of abnormality goes up and the risk of miscarriage goes up with age. So they stay in our lab in culture for about seven days to then convert into what's called a blastocyst. That's when they separate into baby and placenta. At that point, we can genetically biopsy the embryo to test if it's a healthy normal embryo, or you can choose to opt out of it and freeze it. Most insurances do not cover that PGT unless you're working for one of those very tech companies. So in Chicago, we have Facebook, Google, Uber, LinkedIn. They started covering, they go through a company called Progeny, which then offers genetic testing on your embryos as a part of their plan. So most people ask, well, day five versus day three transfer, and when do we do transfers? So in general, frozen transfers are preferred, meaning you get a bleed and we start. Day five embryo is further along in its developmental stage. So it has a better success rate because it's proven itself. It's gone from now the cellular stage, which is a day three, meaning just a cluster of cells, to the actually separating into baby and placenta, meaning cell lineage. So it has a higher success rate. It's also a common misconception that multiples are much higher if you end up going through a fertility route. Although it's true when compared to the general population, it's not necessarily true when you look at IVF. So as fertility doctors, we're really advocating for single embryo transfer, and that one embryo splitting into two is about a 2%. So the risk of multiples is fairly low. The risks associated with IVF. So one of the most common is OHSS, that's ovarian hyperstimulation syndrome. So once I take the eggs out, those hormone levels are still very high. So it's very important to kind of go back to our internal medicine and understand that fluid shift. So we start third spacing. I tell my patients all the time to increase their salt, protein, hydration, make sure that you know that you're keeping well hydrated. You will be uncomfortable because you feel very bloated and flat. So try to fight that as much as possible and really drink a lot of fluid and flush that out. As soon as you get your period or back to normal, the first seven days is when you're at the highest risk. As far as there's a lot of questions around, well, what about malignancy? So there's really no increased risk of breast and ovarian cancer. There's a slight risk of increased borderline ovarian cancer when you look at retrospective studies. But once again, it's something that we mentioned, but nothing that you need to worry about. The likelihood of success typically varies from clinic to clinic. So you wanna look around in your area and never be shy to seek a second opinion. As a fertility, as a fellow trying to be, get a job in this field, I had no shame in kind of being my own advocate and saying, it doesn't feel right or it doesn't feel comfortable, let me switch. And I think I switched about four clinics before I went to a clinic that just felt right. And as Wendy started off this conversation, it's a very intimate conversation and I can do this day in and day out. And I was still very uncomfortable when I had to sit in front of my colleague or somebody and say, hey, look, this is what I'm experiencing. It took a lot. So it's nothing to be ashamed of and it's nothing to, you can leave any clinic and you don't have to be shy about it. So now medical egg freezing, more and more insurances are covering that as well. In Illinois, Blue Cross Blue Shield does not differentiate between egg freezing and IVF. For them, it's fertility preservation and they're covering it. Most states and most insurances and most universities are actually starting to cover it. When my institution, I was at Wayne State, I ended up staying as a professor, they switched to tenant and they had full coverage for my egg retrievals and my fertility when I was looking and seeking help for baby number two. So this is very similar to the IVF process. The reason you hear and see about it more and more is because we've gotten better at freezing our eggs. So before 2012, the method we used to freezing our eggs was slow freezing under nitrogen. So it slowly decreased the temperature, kind of shrink the water out. So the thaw survival rate wasn't as good. Right now we do what's called vitrification, also known as flash freezing and recovery for your eggs is about 80%. So that's the biggest difference between the two methods and the reason why we hear about it more. So since 2012, ASRM removed the experimental label off of egg freezing, and they said it should be suggested to females who are trying to preserve their fertility. So your thaw survival rate is about 80%. When you look at the studies, it shows that you need about eight to 15 eggs to yield one child or one pregnancy. That may be from one egg retrieval or that you may need two. It truly depends on your baseline reserve and your testing. I typically tell my patients to at least consider two cycles because you never know what's gonna happen and how your plans may change, right? The biggest thing that we learned kind of going through our medical journey is plans change. We start off with one thing, but we end up wanting another. But the process itself is very similar to IVF. You take the same medication, the same duration, egg retrieval, but at that point they're frozen. Remember not all the eggs extracted are mature, meaning completed that phase of maturity. So they're not all of you. So 80% of your eggs will be mature. So the big thing to kind of take away from this is in IVF, there's a big attrition rate. So if you start off with 10 eggs under your ultrasound, 80% will be mature. So we'll freeze those eight. Out of the eight, another 80% will survive thaw. Because if you're freezing them just like that, so let's say six, out of that 70% will fertilize and out of that 50% should make a blast. And out of that, if you're in your mid thirties, 50% will be abnormal. And that's why you need so many eggs to yield one child. And that's why I recommend doing multiple rounds, at least two rounds for freezing your eggs. So the advantages are younger eggs are better, but that does not mean that if you're over 35, you shouldn't freeze your eggs. Or if you're over 40, you shouldn't freeze your eggs. If you're thinking about freezing your eggs, that probably means you have reasons to freeze your eggs. Younger the better, of course, but there's no cutoff. That's the most common question do I get. I'm 40, should I not do this? No, because that means you're not, there was a great article by the New York Times and it showed that patients who froze, and it's based off of a PubMed study, that patients who froze their eggs at age 37 and over were more inclined to use them, but they also did a survey and they said, well, what about the females who froze them under that age? And they said that even though they might've not used them, that level of anxiety and stress and that pressure to find the right partner to go ahead and have a child were alleviated, which is huge. The benefit of freezing your eggs younger is the risk of abnormality goes down, but it doesn't necessarily mean your reserve. So remember your reserve and your abnormality may not necessarily go hand in hand, especially for patients like PCOS, which I have and Sabrina mentioned. So you have a huge reserve, so anytime I can walk in and get my ovarian reserve tested, it'll show that it's really good, but it doesn't really reflect my quality. My quality always bounces back to my age. There's medical indications of it, and you can get your insurance to cover it. Through that is if you have cancer, if you're autoimmune conditions like lupus, we're using a lot of chemotherapy with that. So you wanna advocate for your patients, and if you have any of those conditions in your family, to go ahead and freeze your eggs. The most common reason for freezing eggs is not being where you wanna be in your career or not having a stable partner or not being where you wanna reproduce. So timeline very similar, come in for baseline. Because we're not using your uterus, remember this, we have the luxury of time. I can essentially stimulate you at any point. Like my cancer patients, the minute they get the diagnosis of cancer, I see them that same day, I order their meds and I start them two days later. Then they're with me in between that time. So I'm the director of Oncofertility. What we do is we wait that while they're getting their port, so then there's no delay in their chemotherapy. Very similar to egg freezing. You come in, I see you, you start right when you need to start the egg retrieval, then you recover and you go back. So at what age? So if you look at a medical perspective, we say anybody over 36 and 37 should consider their egg freezing, but younger the better. I tell all my patients to freeze their eggs. I was 29 when I started trying to have kids and I didn't have my first child till I was 32. So very important that age does, fertility does not discriminate. You need about eight to 15 eggs for one live birth. And then that we reviewed the chance that the egg will make a baby kind of the attrition. So that's why you need more eggs. Cancer patient can be seen very quickly. And I'm sure Sabrina can attest to this. Most clinics have a program in place dedicated just to cancer patients. So we have a liaison that knows, so all the oncology nurses, there's a nurse navigator that will connect with our nurse navigator, which then will get plugged in to see us that same day. They'll know oncologists know exactly what to send them with and there's great financial plans that these pharmacies have put out to have donated meds to these patients. What side effects will cancer patients experience from the medications as compared to non-cancer patients? It's very similar. The only difference is that my cancer patients are undergoing a lot of port placements and Lovenox and starting chemotherapy. So I tell them that the day I do your egg retrieval, typically they start their chemo the next day or the very next day. So they might feel a little bit more bloated and uncomfortable. Luckily, most cancer patients who I do this for are very young, like Hodgkin's lymphoma, they're in their 20s. So when I counsel them and tell them like, hey, you're gonna feel really crappy, you may be throwing up a little bit more, they always come back and say, I don't know what you're talking about. And it's fine. So I think the younger you are, the more likely you are that your body is a little bit more resilience. That is it for my part. All right, awesome. So I'm really excited to move on to the speakers. As we're switching over, I just wanna introduce the first one. But all the panelists are really accomplished in their own right. But I'm not gonna focus on that because I wanna focus on how they became parents. So Dr. Jessica Lee is a pediatric plastic surgeon and director of the Gender Affirming Surgery Program at the Children's Hospital of Los Angeles. She and her wife, Dr. Taylor, have a son they conceived through navigating some sperm banks. So Jessica Lee. Well, thank you, Dr. Chen, for inviting me to speak about my family's journey today. My talk is entitled, Have Eggs, Need Sperm. So this is a little bit like that Elena S. Morissette song, when you have 10,000 eggs and all you need is a sperm. So I was lucky enough to meet my wife, Laura, in medical school at the University of Pittsburgh. I tricked her into marrying me. But first, we couple-smashed into plastic surgery for me and family medicine for her. This picture on the right is from our wedding. We got married in 2014, and this was about three to four weeks after the law changed in Pennsylvania to recognize gay marriage, which was great because we didn't have to go to New York to elope, which had been our plan. So we had initially thought about starting a family during my mandatory lab year between PGY-3 and PGY-4. That was a pretty popular thing to do in my program. But the lab year became optional, and so I opted not to do that. And so then we thought about having a child maybe during my chief year, when I would no longer be taking call at all after taking five years of primary call. And then also my wife would be done with residency training and she would have better hours, and then she would actually have a three-month maternity leave as opposed to maybe the few weeks that I was going to get. And so then in terms of who is going to carry the baby, she had always wanted to be pregnant, and I had always wanted to keep doing surgery and keep playing basketball while not pregnant. So we each selfishly decided that she would carry the baby. And initially we thought, wouldn't it be neat if my twin brother donated his sperm? But ultimately we went with a sperm bank, which in the long run I think was a better choice for us. So you buy it fair and square, you don't owe anyone anything, and there's no strings attached, it's yours, you can do whatever you want. But if you do use a known donor and we have friends who've done that, then it's better to have them donate through a sperm bank because then there are fewer questions about legal parenthood. In any case, you probably want to get an attorney. So options for getting sperm include ICI, which just means putting sperm on the cervix, IUI, which was gone over in the previous presentations, is intrauterine insemination or putting the sperm inside the uterus, and an IVF, and you can do the first two at home. So the next step would be choosing a sperm bank. There are a lot of different sperm banks around. If you are going through your doctor's office, they may have a relationship with a few of the sperm banks, so you may be limited in that route. Or you might want to look at a lot of different ones and see what they have available. The number of sperm donors is different in each one. And for us, we were looking for a Chinese sperm donor, and we found one bank that seemed to have more than the rest, so we ended up going with that bank. So next, how do you choose a sperm donor? It's like going through college applications or residency applications. So first, you can choose between an anonymous sperm donor or an open donor. And what that means is with an open donor, the child at age 18 is allowed to write to the sperm bank, send a letter that gets sent to the donor, and then the donor can decide whether or not to write back. With an anonymous donor, there's no hope of future contact, so we chose to select a donor who said that he was an open donor in case our child in the future wanted to make any contact. So next, you can look at race and ethnicity. I'm half Chinese, so initially we thought, let's look for someone half Chinese. There were maybe two half Chinese sperm donors, so then we opened it up, and so we ended up selecting a Chinese sperm donor so that my child would be half Chinese like me. And then we also decided that we were gonna use my last name since my wife was Karen. And then you can pick other things like height and weight and hair color and eye color. Since we were picking a Chinese donor, then hair color and eye color seemed kind of moot for me, but for other people, you may wanna select somebody who maybe looks like your partner or looks like yourself. And then you can see what their occupation is, their SAT scores. Almost all of the donors in our bank seem to be graduate students who are very smart and maybe just a little low in cash. And then you can get a full medical history and family history, so we looked to make sure there weren't any red flags. They also do a lot of genetic testing as well. And then you can look at their hobbies and their interests. Our donor was really into art and music, did some sports, but wasn't a professional athlete like some of the other donors were. And then you can get an idea of their personal qualities by reading their essays that they write. And so the donor we chose I thought was really kind and outgoing and positive and people-oriented, and that was really important to us. Some banks also provide baby photos, some provide adult photos, or a combination of the two. The bank we used provided, at that time, baby photos and then celebrity lookalikes. You'd see a couple baby photos and then a couple of random celebrities. You'd click on the link with the Google images and then you'd kind of get an idea of what they were going for. We were just looking for a cute, chubby Asian baby, so it didn't really matter for us. But anyway, in terms of choosing a sperm donor, you really, I think, get to think about what qualities are important to you. We thought about what would we be getting from my wife's side and what we wanted to add. So people think about qualities from somebody important in their life or a family member. Okay, so you finally waded through all of those applications and you're ready to buy your sperm, that's great. So what's next? You can choose to do it at a doctor's office or if your spouse is comfortable doing it at home and maybe is a plastic surgeon and watched a few YouTube videos and you can get the supplies at home, then you can do it at home. I'm sure I'm making Dr. Gerkowitz and Dr. Jelani totally cringe here. And I wouldn't recommend doing this maybe if you're older and really should get on top of egg freezing. So we chose to do it at home. You have to figure out timing. So you need to start tracking your cycle with ovulation test strips so that you can figure out when to order the sperm, assuming that you don't live in the same city as your sperm bank. So it'll get sent to you in a nitrogen tank and that lasts about seven days. So you have to time it pretty well because your cycles will vary. Then you also have to pick it up from the FedEx office, which can be a little stressful. But the positive side is that you really can time it when it's good for you. In terms of costs, for us, each IUI vial was something like $800 and there was $200 for shipping. And you'll probably plan on trying a couple of times and then if it doesn't work, then think about IVF. So for us, it took four times total. This is me with our nitrogen tank for the ICI, which failed, which was fine because now we have a great kid. Then my wife did IUI at the doctor's office, office which didn't work. And then we did two at home and we were successful on that fourth try. We did have a family medicine friend who was on standby in case I needed any help, but it all went smoothly. So we were finally successful and welcomed Henry in August of my chief year. Okay, so it's not over. Don't forget that even if you are married to your wife and you're listed on the birth certificate as father parent, that if you are a woman, you do not have legal parental rights. So even though this was 2017 when he was born and 2015, gay marriage was legalized across the country, across the US, it's not the same thing as legal parenthood. So you have to do something called second parent adoption. Now it's only available in certain states. So it was available in Pennsylvania. And even though it's only available in certain states, it's recognized by all states. So it's something that involves getting a lawyer, having to do a home study with a court social worker, and then having to go to court to legally adopt your kid. So Henry was born in August and we finally were able to get it done, I think by March of the following year. It cost us about $1,500 to do it. It's not available in some states. So we moved next to Ohio. And if we had stayed there, then we couldn't have done second parent adoption. I think we would have had to do step parent adoption, but we ended up moving. But in any case, I would consult your attorney about it. Especially if you're an LGBT couple, you'll want to protect your family and make sure you have legal parental rights. So I am not only Henry's mommy, but I'm his father parent on his birth certificate and his second parent on his adoption certificate. So I wear many hats. But reflecting back on our journey, do I have any regrets that my genes are not in my son? And I'd say no. It's all about choice. I chose my partner. I chose to have a child. I chose the sperm donor. And I also knocked up my wife. I helped catch the baby. I cut the cord. I gave him his first bath and I'm raising this child. So no, I don't have any regrets at all. So thank you very much. I'm happy to take any questions at the end. And my email address is up. You can always email me with anything. Thank you. Awesome. So while we're changing over to Dr. Schwenker, I'll introduce Dr. Schwenker. So Dr. Anne Schwenker is also a Pitt Plastic Surgery alum, shout out. And she's a pediatric plastic surgeon at Cincinnati Children's. She's also the program director there. And she's been a personal role model for me for almost 10 years. So she's gonna talk about her process with her biological children and also adopting internationally. I'm gonna talk loudly because it just started pouring here and I hope you can all hear me okay. So my husband and I really wanted a large family, but because I was already a plastic surgery resident when I met him, actually give birth. And we weren't sure that just as a personal choice, we wanted to more than replace ourselves in the world. So we thought maybe we'd adopt and that would be how we'd increase our family. And we thought we'd have maybe one or two children and then adopt one or two. So that was the plan. But there's this proverb about best laid plans. And I like that Dr. Gurkovich already talked about this. There is no perfect time to do this. You just have to seize the moment and do it. So I was in the lab, I was six months pregnant and my mother came back from a mission trip to Honduras with this. This is my daughter, Tanya. She obviously has very complicated medical history. She is a partial ischiopagous twin. So she had extra legs, extra vagina, extra urethra, no anus and this face. So how could you not want to keep this kid? And somehow I talked my husband into being willing to adopt her. And we had no idea what we were getting into, but we knew we were the right people to handle her medical issues. And we just seized the moment and went ahead with it. So she came to live with us a month and a half before our biologic daughter was born. And we had instant twins. They learned to talk at the same time because bilingual twins kids learn to talk later. They learned to walk at the same time because of all the operations that she needed. They learned to potty at the same time. And they were the exact same size for many years just because Hondurans are so much smaller. And also because of everything that she had been through in her early life, she didn't grow as much early on and remained very, very small. We have researched adoption ahead of time. So I'm just gonna go through some of the options that are available to you if adoption is something you're interested in. There's of course domestic adoption where you get a child from here or international adoption where you get a child from another country. And then of those, they can be either open where the biologic family know each other and talk and exchange pictures and cards and birthday cards and stuff like that, or a closed adoption. Ours was a closed adoption until my daughter's birth mother messaged her on Facebook when she was 14. So first world problems. Domestic adoption is fairly pricey. You can expect to spend somewhere in the range of 35 to $40,000. You can either go through an agency in which case they handle all the legal work and finding the baby and everything for you. Or you can do an independent adoption where you work generally with a lawyer who is experienced in adoption matters. You place ads, you identify a birth family or a birth mother yourself. And in that case, in the first case, most of the money goes to the adoption agency and the second case, most of it goes to the lawyer, of course. If that is a daunting to you because it's so, so, so expensive, there are ways to do foster to adopt, but there's a lot of hoops you need to jump through and there's a lot of things that come with this, but it's incredibly cheap given the other options. If you do a special needs adoption, there are most states funds available to help with that. And we were able to take advantage of it even though my daughter came from overseas, because of all her needs, we were able to get some assistance. There's an adoption tax credit in 2020 that was over $14,000. And if you don't have tax liability that's that high, you can spread it over six years to make sure that you get all of it. And if you have additional, say, like Jess was talking about, if you have to adopt a kid later and then the second parent has to adopt it later, then if you spend it in a different year, you can still go back and take that tax credit if you haven't exhausted all of it. And I encourage you to research the parental leave options at your employer very, very carefully and just know what you're getting into so that you can really plan if you need to with the kid. No matter what you do, you're gonna need to do some sort of home study, which is where a social worker or some government person comes into your house, asks a lot of really invasive questions, has some potentially unreasonable restrictions, like you have to be married to a man or one of you has to be home all the time or you have to be Christian or something like that. And the requirements vary by state and they vary by state within the US and then they vary also if you're going internationally by which country you're dealing with. They're gonna check to make sure you can afford the kid, they're gonna check to make sure that you have the time to spend with the kid and of course, a criminal background check. If you go for an international adoption, that is gonna cost you about the same amount, maybe a little bit more. And most of that money is gonna be spent in travel expenses, which are pretty expensive. A lot of these countries require you actually to go and spend a month or two in the country while you're processing the adoption. Otherwise, if you're a toddler or an older child, I knew this ahead of time, my husband was not prepared for it. Be prepared for some psychological issues. The kids that have not been loved and nurtured from birth are likely to have some lifelong problems. And if you are prepared for them and you have the capacity to deal with them, they are something that you can manage, but you really need to know that that may be the case. Our path is not that typical. So Honduras actually doesn't allow international adoption. So there was no way to just go back and adopt her there, which we tried initially. And we spent a lot of money with lawyers trying to do that. She was already here. And we had letters from doctors saying that she couldn't safely go back to Honduras anyhow, because of all of her medical issues. And then her mother was actually still living, but had abandoned her at birth. And so the US didn't consider her an orphan and she wasn't able to be adopted the way you typically do it. So usually what you do is you identify the kid, you go to the other country, you adopt the kid, and they automatically get a passport, but that doesn't work if the kid's not an orphan. The father was unknown. And then the really weird factor is that she had entered the US on a short-term medical visa. So when she filled out her visa form at the age of 18 months, she lied and said she didn't intend to immigrate here. And that gave us unbelievable hassles with the US immigration system. So we were able to obtain legal guardianship with the help of a lawyer, and we were able to get her to go back to Honduras. We got legal guardianship with the help of a lawyer, and that got us access to, first we were her guardians, we could sign medical stuff for her. It got her on our insurance, and we were able to claim her on our taxes. And then we vacated mom's legal rights in a Honduran court. We were able to find her, track her down. She was willing to sign her rights away. We advertised in multiple Honduran papers for the father to come forward, and when he did not, we had his rights vacated by a US family court. And then we were able to adopt her in a US family court, which we had to do via video deposition to be deployed back at the time. And many, many, many years later, we were able to get her a green card because we had done the immigration thing backwards. And then once she had the green card, she automatically got citizenship because she was our daughter. So even though it was super complicated, it is so, so, so worth it. And this is all the cousins in my family, including Tanya in the top holding the baby, and two of her cousins, my cousin and her wife have two adopted children as well, and then all the biologic children in our extended family. So it's been a really great journey for me. My daughter is now 22, the other one's 20, and my son is 14. You can ask me about any of these other things or email me separately, and thank you very much. What an amazing story. All right, while we are changing over, I'm gonna introduce Dr. Greg Borski, who's the only ENT and the only man here today representing. So he practices in Houston where he and his husband have two kids. He's gone through the adoption process as well, but he's also gone through surrogacy. And so we're gonna hear about that. Thank you, I appreciate that. I'm honored to be the only male on this panel. And my husband and I actually have three kids. Our two oldest we had through surrogacy. We used a gestational surrogate in California because at the time in Texas, a gay couple could not have kids through surrogacy. You could if you were single, but not as a couple. So we went to California to do that. And then a few years later, we adopted my husband's nephew from Alabama. He was two when we got him, and that was another huge legal issue. But I think for men, the big question is surrogacy versus adoption. And there's a lot of very strong opinions, and it's a very personal decision. For us, when we did it in Texas, we started the process 12 years ago. It was pretty straightforward because at the time there was a bill before the Texas legislature to ban gay adoption. And I was like, I'm not gonna be in the middle of adopting a child and have it taken away. So we did the surrogacy route, and we used an agency in LA. It's quite expensive, but it's totally worth it. And I think that's, when you look at surrogacy versus adoption, surrogacy is definitely more expensive. Our first child cost us around 120,000, and that's all upfront, and insurance doesn't cover anything for, didn't cover anything for us. But our third child that we adopted, it was still about 40,000. So it's not cheap anyway, and you really can't look at the money. It's totally worth it, whatever you decide to do. But surrogacy, you have more control. I think it's maybe a quicker process. The adoption, you're giving a child at home that needs it, and it's awesome, but it can be a little more risky. It's usually not as expensive, but it can take longer too. So I think it's a very personal decision, and I don't think there's right or wrong answer either way. It's whatever's best for you. But for men, you need to look at all your options and really decide what you want. Is the genetic part of it? Do you want a biological child? That's important. So either way, it's a very emotional rollercoaster. It's not an easy process. If you're a male couple, I think there's a couple of good organizations you need to look into. One is Men Having Babies, and they have a lot of very independent information about surrogacy options and fertility clinics. And the other one is familyequality.org. It's a national organization, and it's good for anybody. And they actually have a lot of good information there for LGBTQ families and even trans families. They have a process where they've had some trans patients, and there's some good information out there. If you ever have any trans patients who want to start a family, it's a really good organization that has gotten some of the information together. I have to put in a plug in for them. But I agree, there's never the right time to start a family. Just go ahead and do it. And it all works out, I hope. Thank you so much. All right, next we're gonna go to Dr. Cassandra De Soulas. While we're switching over, I'll introduce her. Maryland, DC area. And she chose to become a single mother by choice. And for those of you who don't know what that is, it's when you are a single woman and you wanna have kids and you got the uterus and the eggs and you just have to go find some sperm somehow and make it happen by yourself. So she had her son during fellowship and she's gonna tell us all about it. Thanks so much, Wendy. So this is my story. So I did my residency in medical school at University of Virginia in Charlottesville. And then like Wendy said, I went for surgery at a private hospital called Mercy Medical Center and now I'm with Kaiser and DCSN. All right, so I was 29 years old and 29 years and three months old when I contracted baby fever. I remember this very specifically because that is when I held my nephew for the first time. I was 31 and nearly five months old when my ex-husband and I separated. So there I was husbandless with an intractable case of baby fever and nowhere near ready to be in another relationship. I was introduced to the idea of being a single mother by choice or SMC when I happened upon a Cosmopolitan article on the topic. Inspired and empowered by this, I launched into R&D mode. I read essays by SMCs. I read essays by children of SMCs. I came to find that Charlize Theron and Jennifer Walden and numerous other women are SMCs. I spoke with family and friends and received nearly unanimous support. Once I decided this was happening, things took on a life of their own and there was a lot of playing to do. Since I was still a plastic surgery resident, I needed to figure out how to pay for the donor. So I did this with personal loans specifically available to physicians in training. I listened to a series of podcasts covering logistical planning involved. This included a specialty specific disability insurance policy, a will with a guardianship clause and life insurance. The fun part about all of this was choosing the donor. So I was naive to think that things would work on the first try and actually ended up using two different donors after the first one sold out. This is the first donor. The one that I ultimately worked was an art student in Los Angeles. They, like we've covered already, they give you a lot of information about him, including an interview. I could actually hear an audio interview of his voice and I felt like I knew a ton about him, but the best part was I didn't actually have to meet him. So we went through two more attempts and two more failures. Yeah, there's me on the first try. And there's the one that actually eventually worked. That's my son's donor. I was getting kind of grumpy at this point. The relief and inspiration of having taken on this quest was being overwhelmed with the anxiety that it just wasn't going to work or that it wasn't going to work within my very specific time and financial constraints. But much to my surprise and relief, James was conceived on the fourth try. 12 weeks into my pregnancy, I was a microsurgery fellow at a private hospital in Baltimore called Mercy Medical Center. It turned out that the physician's assistant, who according to my secret plan that I had devised was supposed to take over for me during my maternity leave, was also pregnant and due at the exact same time. So I was incredibly fortunate to have supportive attendings and a team of PAs and things ended up working out fine. Um, those are my attendance from that fellowship. There were also some awkward moments, like when a nurse told me the father must be so excited, to which I would just smile and nod. Typically though, when meeting new people and the bumps started to show, I would just tell them my SMC status within the first several minutes of meeting them. I just wanted to clear the air and make sure that it was understood that this was not my ex-husband's child. I didn't forget how to take birth control. This was actually a pregnancy that was a product of years of planning and the search of independence, my belief in my ability to do hard things and above all, the little boy that would ultimately be my everything. I was proud of him and the choices I made that led to his existence. So he actually decided to come two weeks early. I was in Bethesda, Maryland, visiting my parents when my water broke, although it wasn't like the movies where it's a big gush of water everywhere. So I was in full on denial and I thought it was just incontinence. I drove myself and the dog back to Baltimore, which is an hour drive. And then once I was at the hospital, it turned out that I was having a child. So James was born via elective C-section, straightforward, uncomplicated. The sound of his voice brought me to tears. It was the most beautiful little pair of lungs claiming air for the first time. The nurses in the room were great and took lots of photos, including the first time I held him, which was a good thing because there are really no words to describe this moment. Leaving the hospital with the car seat on my lap, the gravity of the situation finally landed. I was singularly responsible for another human being's life. My mom stayed with me for that first week, but then after that, I was alone. The day-to-day routine quickly became second nature and I became confident in my ability to care for him. The overwhelming big picture was quickly replaced with sleep schedules and measuring meals in ounces and pumping and fitting showers into nap time and how to keep diaper rash at bay. And like anything else that is hard, one foot in front of the other is how you get through. I went back to complete my fellowship at six weeks postpartum. My mom was my nanny, which worked out beautifully and I paid her with more personal loans as she had quit her job to do this. Following my fellowship, I was briefly in practice in Virginia with a live-in nanny and ultimately took my current job with Kaiser, which brought me back to the DC area and close to my family. I eventually did start dating on my own timeline, which was separate from my baby fever timeline, which worked out really well. I met an incredible man who also has a child similar age to James and I'm so grateful for the success of this relationship as attributed to and not in spite of our experience as parents. There's a shared understanding of priorities and perspective and maturity that comes with being responsible for another human being's life and a deeper understanding of unconditional love that parenthood has revealed to both of us. So obviously there's not a right way to cure baby fever, but this was my path and I'm incredibly grateful for the choices I made and the things outside of my control that ultimately transpired in my fever. And this is a lot of the resources that I used here. Awesome, thank you so much. All right, for our last one, we have Dr. Divya Srinivasan. She's a microsurgeon on the USC faculty in California. She's got three kids, a physician husband, and each of her children were born at a different stage of her training, general surgery, plastic surgery, and microsurgery fellowship. So here we go, last one. But certainly not least. So for me, I think I had baby fever from when I was like 13. All I wanted to do was have children. And for me, I have been very unapologetic about most of my decisions in my life and that's how I felt about having kids. And it was pretty naive actually. And I look back now and I think of how lucky I was to have the resources that I do have and how lucky I was to have the resources that I did, but also lucky because I don't regret any of it. And I really think if you want to have kids, there are some reasons not to have kids, but being in training or worrying about your job should not be reasons to hold you back. Okay, so my disclosure is I am a mother of three. I had three kids in three different training programs and I love all three of my kids. And I'm also a full-time reconstructive microsurgeon in an academic practice. When's a good time to have kids? So as I said earlier, don't let being in a training program or worrying about your job be a reason not to have kids. But in my opinion, I think you should have kids, A, when you can afford them. And I think that you should have support from two out of the three. So family, paid help, or a partner or a spouse. I don't think you have to have a partner or a spouse as we've actually just heard. And I think that was such a lovely story and actually really inspiring. And I think if you have two out of three, which is what I needed, you can make it work. If you can afford paid help, that's great. But I had a lot of friends in residency who couldn't afford it, but they had family nearby. And so they were able to meld those options together. So for me, I have two nannies that are full-time that are hired help, but I actually still rely on my family, which is why I moved back to LA quite a bit. And again, I'm gonna keep saying it, training should not affect your decision to have children. It's 2020. It should absolutely not only be acceptable, but promoted that you are as happy outside of work as you are at work. What kids cost. So I'm not gonna speak to what they cost after they're born, but I will tell you that I had really interesting experience with insurance coverage of my pregnancies through each one. When I was a resident, I had a PPO that I signed up for through my residency program. However, it was a really complicated delivery. It was an emergency C-section. I was in the ICU for two weeks. And so I had a $12,000 bill to pay. And I entirely took that for granted. I sort of just assumed like, oh, I'm pregnant. I'm gonna have a regular delivery. Don't take anything for granted and don't assume anything. And definitely don't assume that your quote good insurance or your PPO will cover everything. The reason it turns out that this happened was because I didn't choose the exact hospital that I was working at. I chose the affiliated hospital down the street. My reason for not wanting to deliver at the hospital I worked at is I knew everybody there and I didn't want that for where I delivered. And my OB was actually covered, was in network. But interestingly, even though my OB was in network and my OB worked at this specific hospital I delivered at, all of the services that were rendered were not in network. So I would really recommend looking into all of that, obviously, before you plan where you deliver because definitely that was a hefty bill we didn't expect. Then my second pregnancy was in fellowship, also a PPO. It was in Ann Arbor. And it was a straightforward C-section and my total cost was $21. And I delivered at the hospital that I was working at. And a lot of that decision was I didn't even bother looking into a different hospital because I didn't wanna get a similar bill. But again, something that I don't necessarily know that I would have done if I hadn't had the first experience. And then my last pregnancy was tough because my husband and I were actually living in two different cities. I was a fellow at UCSF and my husband was faculty at UCLA and my two kids were living with him and my parents. That was insanity. But that aside, I actually had two separate plans. I had signed up for whatever the cheapest HMO was at UCSF because I wasn't planning on getting pregnant. I wasn't planning on having a third kid. But I was also on my husband's PPO. Of course I got pregnant and I was shuttling between San Francisco and Los Angeles. And even though I was living in San Francisco, I actually ended up delivering in LA. And that bill at UCLA, even though I had insurance through UCLA because it was my secondary insurance, that left me with a $21,000 bill. And so it, again, really took us by surprise, not something I was prepared for. But I think these are kind of situations that come up when you're in training, especially if you have a spouse who you may be also on their plan. So look into which plan you're on. And if you're in a separate city or you're planning on delivering somewhere different than where you got pregnant, especially if you're in training and you plan on moving or you're gonna be starting a new training program, really look into those things because trying to fight these bills on the backend is quite a headache. So pay attention to your insurance provider, especially if you have a partner and you have two plans or if you are going to be moving to a different city. Otherwise, yes, kids are really expensive. For me, I went back to work at four weeks after the first two and I needed a night nanny. And that's not something that I thought that I would need, but I definitely did. And that ended up being an extra expense that I didn't anticipate. I am in a dual physician family. And so we require, our version of full-time is more than what a full-time nanny or caregiver usually would work for. It's more than 40 hours a week. So we actually have to have two caretakers. And at the very cheapest, it's usually $15 an hour. So when you're thinking about having kids, I think it's important to have really realistic goals of the care that you'll need in addition to what you're able to provide and what that's gonna cost you. So lessons learned. For me, take more time off. I took off only four weeks because there was this weird feeling like I owed them something or that I owed them coming back to work earlier. I did it and it was fine, but it wasn't fine actually. I look back and I should have taken off more time. And I didn't realize that until I had my last, my third baby and I actually had time. I had more time between when I finished fellowship and when I started my job. And it was really beautiful. And I think everything's different for each, it's different for everyone and there's no right answer, but this feeling of owing your program something, I think that is something we all need to get over and you should take off the time that you need. For me, I really just was naive, which is almost embarrassing to admit as a surgeon. I should know that people have complications, but I was really naive about it. I sort of just expected, oh, I'm gonna work till 39 weeks and four days and then I'm gonna deliver my baby and everything's gonna be great and I'm gonna go back to work. Didn't work out, I ended up in an ICU with bilateral pleural effusions and septic and needing all sorts of medications and tubes. And I still went back to work at four weeks and the psychosocial impact of having a child, I think I totally underestimated, but also taking for granted the process. And I would say, just don't assume anything. And I think this can also speak to even conceiving. For me, my complications were with delivery, but don't take for granted how long it may take you to get pregnant or complications during your pregnancy or complications after pregnancy or your child may need a NICU stay. It's, they're hard things to think about, but I think being mentally prepared and actually physically prepared for potential complications will leave you in a much better place to deal with them. There's a lot of noise on breastfeeding and other good mom paradigms. Do what feels right for you. I felt a lot of stress and a lot of pressure trying to balance sort of East Asian requirements of motherhood with being a surgeon, with being a resident. And that was really stressful for me. And I learned with my subsequent pregnancies to really try and ignore that noise. What's gonna work for someone else is not gonna necessarily work for you. And you should create a paradigm that works for you and your family. Last, but definitely not least, I absolutely do not regret having children during training. I interviewed for my current job seven months pregnant. It did not affect my career path or success, I don't think. But I will say that I did have struggles along the way. I had a hard time with program directors. I had a hard time with my own colleagues. I had a hard time sort of feeling that I had to rationalize or explain why I had kids. I can't tell you how many times I've answered the question, you already have two kids, do you really need a third? And it's just not anybody's business. This is your life. You should live it. You should do what feels right for you. And again, the rest is just noise. So if you feel ready, and if this is something that you want, ignore everybody else, ignore the noise, and definitely don't make compromises on your fertility and your family planning because of your training program. Anyways, this worked for me. It may not work for you. I tried to keep it sort of vague in general. I think just as I had kids during training and that worked for me, I also hear the opposite. I hear people say, well, I definitely don't wanna have kids in my first year of practice, or I don't wanna have kids during partnership track. Those are, you know, there's always gonna be the next thing that you have to achieve. And there's always gonna be the next goal, especially as a surgeon or a physician, you're always gonna have to have some metric or milestone that you have to meet. So I would say as much as you can, try and ignore that and really make a decision that's right for you if you're ready. That's it. Awesome, thank you so much. So I had texted into the chat, but thank you everybody. If anybody has to run, this is gonna be recorded and posted eventually. If you have any questions or feedback, feel free to email me where I've said, but now for the rest of the time, we're just gonna try to get through all of the questions and everybody's welcome to stay for as long as everybody's around. So I think one of the biggest questions that people had was money because of where we are in our lives. And so I was wondering if the two reproductive endocrinologists could comment on why based on the state you live in, it's so different in terms of insurance coverage of freezing, IVF, IUI, all of these things. I can speak to the fact that I'm in a mandated state and practice in a not mandated state. I think it's truly governed by your local authorities, what kind of state it is, Republican versus Democrat kind of getting down to the nitty gritty, but there is resolve.org and they are hosting a virtual advocacy day. So if your state is not represented kind of to take it to the house and talk about really that it's much needed and most states should be mandated. I think that's what we could do as providers. I think the more and more we learn about it and the more we see the need of it, it's gonna get better, but really up until even if you look at a freezing since 2012, it's not considered experimental. So it's just educating ourselves and educating our patients and educating legislature. And I think Sabrina speaking from a not mandated state, would you agree? Yeah, I mean, it's so dependent on different employers and insurance programs and coverages and it definitely varies state to state. A lot of that has to do with those policies and things with the insurances, unfortunately, but that's the truth. And do you know why certain employers or hospital systems choose to cover versus not cover? So I think it's because now as we're trying to navigate and become more family friendly, and Divya, she stated that before it was a taboo and I can really tell you, I've seen from my very first pregnancy and that was in 20, when I first started trying was like 2011, 2012. One of my attendings, my gynec attending kicked me out of the OR because I said I had to go monitor and he said, well, then you're really not here to be a surgeon, you need to get out. And I think as now things like that aren't happening and we're welcoming family building, they're looking at it and kind of changing the conversation around it. Like I went from having absolutely no coverage for any of my testing and my treatment to being bought out by a really large company who supports family building than covering an IVF cycle without asking anything. So I think as we're raising awareness about this, and especially in California, there's really progressive companies which are really advocating for all of this, adoption and surrogacy and infertility. And I think it still relies so much on the employer though. And I know like even just where you are as a trainee, talking to some of the, either the academic institutions, some of those people have some pull. I know just in my lifetime of fellowship that they were really pushing to actually push the coverage to expand to IVF coverage at my fellowship program. And it happened or slowly happened in just the couple of years that I was there. And a lot of it had to do with my program director really pushing the department and the department being really open to kind of pushing the university as a whole. So I think a lot of people can kind of, they underestimate the power of their words and the power that you can have presenting to your institutions, especially at academic centers that have REI and fertility programs. But definitely the advocacy is a big thing, unfortunately. So if you are on one institutional insurance, is there anything you can do to supplement, like get another insurance or something? Is there any other way that you can find another way to pay for it? So if you're in Illinois, there's also loopholes. It's not easy, like, oh, you're in Illinois, you get coverage. So there's a lot of companies and that people work for in Illinois, but are not LLC or headquartered in necessarily Illinois. They might be, so I can tell you, my husband has his own firm, but he's headquartered in Michigan. So his employees don't get that state mandate coverage. So in a state that's mandated, what you could do is get a secondary insurance plan through like your local provider. So like Blue Cross Blue Shield of Illinois as a secondary plan to provide that coverage, which your employer might not provide. There's also loopholes around that mandate. So if you're a religious institution that doesn't believe in fertility, then you don't have to cover it. That's the bylaw. Or if you're a company less than 100 employees, then you don't have to cover it. The main thing is it's financially driven to have that clause or to have fertility coverage. It's very expensive. It's a very expensive thing for the employer. So they look for things not to cover it. Just like Sabrina said, you can, your employer can easily go and say, hey, Blue Cross, I wanna add in a fertility clause, but I want my employees to have coverage, but then that would mean that they have to eat that cost as an employer. I see. Yeah. All right, our next biggest chunk of questions come about freeze, I call them freezing things. So I found that this was a little hard when I was looking for research as well, which is, which is better, freezing an egg versus an embryo, and then how do you translate that frozen thing into an alive thing that's alive and healthy? So if you guys can talk about that, including fresh transfers. That's a big. Oh, go ahead, go ahead, go ahead. No, I think probably both of us will take little stabs at it, but yeah, I mean, certainly a lot of it just depends on where people are at in their life, because making embryos, while we have 30 years of experience as a field in freezing embryos and thawing embryos, they're heartier, they're composed of a couple hundreds of cells as opposed to the egg, which is one cell, and it's a really sensitive cell, and it tends to have a pretty high water content. So that freeze, the freeze-thaw process took a while for our field as a whole to kind of optimize so that if you do freeze an egg and then later thaw it and then go to use it, that thaw success percentage will be enough to be considered successful. So it really depends on where each person is as an individual in their life situation, because if you have a committed long-term partner and are ready to make embryos together, or together with donor sperm, et cetera, then really embryos are gonna tell you or better chances of what you're gonna have to use, because of all those same steps that Ruhi mentioned, and that attrition, I always give the example of imagining a staircase, and you're starting at the top with the number of eggs that you retrieve, but then you have so many steps down to where you actually end up with what you have to use for pregnancy, which are those embryos. So if you're starting at the top by freezing eggs, there's sort of an average projected attrition, but you might fall on the end of the spectrum where there's higher attrition than expected, and you end up with fewer kind of final outcomes, which are the embryos or more. So depending on where you're at, you'll know what's right for you, but certainly with eggs, there are a couple more unknowns, and that's why those numbers are requested or recommended to be a lot higher from that eight to more, eight to 10, eight to 15 eggs per projected embryo, with that hope that you're taking into account that attrition of once you go to use the frozen egg, you've got a thought, so that's already step one where you might lose a couple, and depending on the practice, those rates have gotten much better. Like Ruhi mentioned, they used to be pretty terrible, and now they've gotten so much better that probably close to 90, sometimes more. You can expect to survive the thaw as long as they were good, mature eggs, but then they've gotta be fertilized, they've gotta be all those steps along the way. So if you're in a place where you can make embryos, you're gonna know your final outcome, and with each embryo, based on usually the egg supply, and their age, that tends to dictate the percent chance of success in a way, and if you do the genetic testing of the embryo, and you have confirmation of a genetically normal or a euploid blastocyst embryo, then that is gonna ultimately give you kind of the highest future success that you'll know for sure. So, and that can be upwards to 60, 65, to sometimes 70% chance of a pregnancy from that genetically normal embryo. So it's really a personal decision with each one of those steps, but the egg freezing is such an amazing option for people who are single and not yet ready to kind of commit to a sperm source, essentially, to make those embryos, because that does have really major implications. You can't undo the embryo if something happens with the relationship or life circumstances change. So that's a pretty permanent decision. You wanna be really certain that when you're making those embryos, it's really clear, kind of the disposition of those embryos, and what happens if the relationship ends, what happens to them. There's a lot of stuff that goes into making an embryo that requires a little bit more, you know, dotting the I's and crossing the T's, whereas with the eggs, you really have every single option available to you, and, you know, the hope might be that maybe you don't have to use the eggs, and you might be able to, you know, conceive naturally when that time is ready, or, so there's a lot of different factors that go into it, but I think every decision is super personal, and it just really depends on where you're at in your life and what you feel comfortable doing, and really talking about all the different options and knowing the numbers as they pertain to you. And I wanna mention that I don't know if everybody knows this, but, you know, obviously there are a lot of different fertility clinics, and they all have kind of, there's an opportunity to know their success rates for different things, and so, you know, some clinics are like really famous, quote, unquote, for things, and so that's data that you as a patient can go and dig out or request, and so you can look around you for like different branches of the same clinic that uses the same algorithm, or you can kind of just look around for what your insurance is gonna cover. And it's also, sorry, I was gonna add one more thing to Sabrina, that you don't necessarily have to commit, so when I deal with my cancer patients, you may have a boyfriend or significant other that you think you wanna be with, so I always tell them, like, when you do a cycle of the egg extraction, I call it, that's the first phase, you can decide to commit some eggs to just eggs and some eggs to embryos, so you can do a half-half cycle. So you can say, well, you know, I'm with this person now, and they're likely gonna be my significant other, or I even have patients that say, like single mothers by choice, that say, I do wanna have a child, and this is my sperm donor, because I wanna get pregnant, but age is important, and I know I want more kids, and what if I meet somebody? So you can fertilize some of your eggs in the same retrieval, so split, we call it a half-half, so like half for egg freezing and half for embryo creation, and then go from there, and when you do that, you also learn the developmental potential of your eggs. So say you create some embryos, and you realize, wow, that was not a good cycle, and kind of like what Cassandra highlighted, she had to switch sperm donors, and maybe not necessarily it was a donor, but how egg and sperm meet are not, we tend to think all eggs and all sperm make good babies together, but some eggs and some sperm don't come together well, so you'll learn about that when you're creating embryos. So you can do, you can basically kind of change this to whatever's your optimal and what's your ideal. There's no hard and fast when fertility. Yeah, there's a lot of options, and whenever you kind of talk to us and meet, like really that just depends on everybody's specific situation, but really you can make anything possible with a couple or with an individual. There's a lot of flexibility. While I have as many panelists here as possible, Dr. Schwenker had to leave, but she wanted to say, anybody's welcome to Google her email and ask her about her life, but while I still have people of different training backgrounds, different specialties on, I want to ask this question, which is what do you think a surgical residency or departments can do to facilitate family planning, I think both for trainees, but also for junior faculty? I know that OB-GYN is ahead of us in some things in terms of, for example, like paternal leave. So I invite all the panelists after becoming a parent, what do you think in all your different practice settings, residencies or departments can do as new policies as we evolve as a specialty to make things better for families? I think that for me, the biggest issue was it's like people don't even want to acknowledge that you're pregnant. You know, I felt like in one of my training programs, I was very open about it and I said, how can we categorize my time and my rotations to try and make this not an issue? So like the last month before graduation where we're trying to decide when my end date is, and it was difficult to even have that conversation. So I think one, having a very proactive relationship with your program, and that's, I think, also important for the program to say, hey, we're here for you. We're here to discuss family planning so that you can work with them because there's a lot of, I don't wanna call them loopholes, but there are some areas of flexibility. So for example, in plastic surgery training, part of your total number of weeks that you have to complete, I was an independent resident, so for the number of weeks I had to complete, I think up to six of those weeks, it might even be 12, can be research weeks. And so you can use that time to do research and still kind of count that as part of, as you transition from maternity leave back to work. And that was a really nice option that I think had I known about it or had it been more of an open discussion, would have allowed for a much easier transition to go from pumping and breastfeeding and having a newborn to moving back to work. I think another thing is I absolutely hate it when people refer to maternity leave as vacation. It's not vacation, it's hard. And so kind of being able to talk about that time away as something different and separate from vacation, I think is really helpful. And the third point I'll make, which I tell anybody who's a program director that's willing to listen to me, is that everyone is rallying for a milestones-based education and if we're talking about and bragging, certain programs are like, we're milestone-based or we're piloting this program, yet you're not able to apply that to what I think is one of the best places to apply it is for women who have to take time off to have babies and for maternity leave, or say someone has an illness. If you meet your milestones and they're willing to say that you're someone who could otherwise graduate a year early or six months early, we should also be able to apply milestones to training programs and evaluation of trainees to allow them to flex some time so that maybe they didn't meet the exact number of weeks they needed to graduate, but if they really do meet their milestones and they're able to practice independently in the way that they need to, still graduate them on time. Yeah, there was this article that was published in JAMA, I think it was in March, and I actually like, I posted it to my Instagram because it was actually like one of the first papers I've seen about residency programs, like actually making proactive changes to their, you know, the maternity and paternity leaves and implementing some of those exact kind of measures and even with breastfeeding. And I think ACGME, I'm just like looking it up right now so I don't misspeak, but I think even ACGME like made certain changes to their requirements and rules that all ACGME accredited programs do have to kind of attest to. And so it's definitely at a program level adapting to those new norms. And like, of course, the surgical specialties are like the last ones to do that oftentimes. So you're kind of fighting that uphill battle a little bit, even in non-surgical, but surgical too. So definitely at the program level and maybe, you know, disseminating that JAMA paper to all the program directors in the US would be great. But also even just amongst the level of trainees because still so many papers and so many studies and none of us have to resort to PubMed to know this. We all know this from our own training. You know, there's still like a lot of, there's a lack of support and people don't necessarily get excited about covering someone while they're pregnant or on maternity leave. And that problem also starts with us, you know? So I think talking about it and talking about all these different ways to still do both and to kind of remove some of that negativity from supporting each other is a really huge thing. But that's a culture shift that has to start from us, but it also has to start from the people above us. So stuff like this is huge to be talking about it and just getting this conversation out there. I think ACJME is important. I think that was the hardest because even navigating my delivery during residency, it's, okay, you get total of six weeks off in a year. How do you stack your vacation? And that includes maternity leave. So either you don't get vacation or you take one week and shorten your vacation or follow it up with an ambulatory rotation, not necessarily a surgical rotation where you might come in early and stay longer. But I really do think it has to come from ACJME because once you try to separate, like Divya said, vacation is not maternity leave. Like you can't bundle that. I think that's a huge problem because you're not on any vacation. And then penalizing you saying, well, if you're gonna take six weeks and you don't get any vacation, that's also another penalty. So I think policies need to change. And I think that's very big to look at it from that end. And then it trickles down. Thank you. Anybody else have any bright ideas that can make it easier? Okay, so then there were some questions that were a little bit more detailed. So one that I think is relevant is for people who are considering getting pregnant, freezing eggs, doing all these things at any point, how does COVID play into that? What should people pursuing any venue of biologic procreation think about with COVID right now? Yeah, that's a great question. Our field is at odds with this for a little bit. I would say this is probably the one time that our field was divided up initially. So when COVID first came to the US, we took a hard stance mid-March and said we're stopping everything, no fertility treatments until further notice to decrease the burden. Very similar to what plastic surgery did. Except our field was like, well, this is not necessarily elective and you need fertility and we're not here by choice. So a month later, we slowly started opening up our clinics and the precautions that we're taking, and most clinics you're taking are following your local department of health precautions, temperature monitoring, screening for COVID, pre-op screening for COVID like most hospitals are. What our main concern or a patient's concern is vertical transmission, meaning mother to baby. Is it safe to get pregnant at this time in light of COVID? And right now there's two documented case reports, but if you look at both the case reports, there were flawed in that there was no direct precautions taken or testing immediately after to see if the mom did transmit to the baby because the mom was positive, but there was no PPE in place. So that being said, right now we're saying there's no documented vertical transmission. They've yet to find it in breast milk. So that's the first. And then the second, there's now a huge controversy on sperm. Does it carry COVID? There's a bunch of studies that go back and forth from China that some males who had tested positive did have antibodies on their semen versus some that didn't. So we don't know that yet. Eventually it'll kind of be like CMV. So when you pick CMV cytomegalovirus, which is another virus we screen for in male sperm when they're donated, that we also want to make sure that the female's negative or kind of coordinate with the male partner. So I think eventually how COVID is trans, how the data we're getting eventually kind of be like that, the risk of transmission. But as far as egg freezing goes, eggs are, remember, they're not like sperm. They're not rapidly dividing. They're stored in your body. So they don't have the ability to carry the antibody. So if you're COVID positive, then you don't have to worry about that egg. So say if I was taking my egg and transferring it to somebody, you don't have to worry about that antibody factor. But we don't know. So what we do know is that we don't know a lot of it. So we're extra screening, as I'm sure you guys are in the OR. And we're also, eventually it'll be on our FDA questionnaire for third-party reproduction. So that's donor egg, donor sperm, surrogacy, but it's not there yet. But that's how I feel it's gonna transpire. But I wouldn't say it's any reason to not have kids because there's not, we're not telling people not have sex and have kids. I think it's very similar when it comes to fertility for now. Yeah, I'm waiting for that COVID boom nine months from now. Yes, I've had so many patients get pregnant while they were waiting, which is good. But I was like, maybe it was the stress. That's why you guys aren't getting pregnant. You just needed less stress, more sex. Yeah. So we have maybe about 12 minutes left. I'm gonna try to condense these questions and hit as much as possible. I know that Dr. Schwenker and Dr. Borski have had to leave. But in terms of finding a surrogacy company or an adoption company or intermediary, does anybody know how to go about picking one? Yeah. Do your research. So these are third-party companies that are not funded by anybody. Most surrogacy companies are started by somebody who's gone through surrogacy themselves. I find it very, very, I love that they're there and I love that it's available, but sometimes they have a stronger connection to the patient. So sometimes something that you may not approve as a provider has already been presented to a patient who might not necessarily understand. So you become, you're trying to navigate three different interests. So one, the agency interest, because you don't wanna piss them off as a doctor, then the interest of your patient, then the interest of the surrogate. So I always say go to an agency that has a lot of data, review, support, kind of proven. Anyone can start an agency and there's agencies popping up everywhere. So as far as surrogacy goes, because there's a lot of agencies out there that don't necessarily have the greatest reputation. As far as donors, Sabrina, I'll let you take the donor if you have any tips on finding agencies for donors. Yeah, I mean, I think really your local fertility clinics are really the best resource in a way. I think certainly by word of mouth and learning about other people's experiences, that's really important and it's very valuable for people, but your fertility clinic and very much like somebody brought up here with kind of looking at their success rates, it's so, so important. And if you go to SART.org, S-A-R-T.org, you can do a find your clinic and search by zip code and you can look at all the different practices that are in your area and look at their actual specific pregnancy rates broken down by age group, broken down by type. So using a woman's eggs versus a donor egg, using donor sperm, like they'll break down a lot of these different things, which is helpful. And then if you pick a good clinic or one that has good success rates, oftentimes we work with so many different banks for donor egg, for donor sperm. We have so many connections with different surrogacy agencies and lawyers. I mean, we literally have all of these resources and they are wealths of information. It's still, you have to do your due diligence in a way. It's like anything that you make or any big decision you make, you're gonna learn about it and you're gonna kind of do the homework so you can be familiar with it and make sure that you're going with the best option for you and feel comfortable about it. But I really think the clinics have such great resources and we have our third party teams, which deal with all the donor egg, donor sperm, surrogacy cycles, and they have years of experience with so many different banks and agencies. So a lot of times we kind of have, kind of sifted through the weeds and have established really good connections with some of those. So I think that that's a really great resource for all, for donor eggs, donor sperm, and for surrogacy agencies. And even sometimes connections to adoption agencies and resources there too. All right, I think we're getting down to the last few minutes here. So I wanna thank everybody for holding on here and staying on as an attendee. And I wanna thank all the speakers and all the panelists. I got so much private text messages about people tearing up and just being really inspired, people who thought they weren't gonna have kids and now they're second guessing themselves. So if I didn't get to your specific question, I got some pretty specific questions that I personally don't actually understand. From a reproductive endocrinology standpoint, I encourage you to look up Dr. Herkowitz and Dr. Jelani on their Instagram or on Google for their, they can leave their emails here also as well. They're both very welcome to people contacting them afterwards. And I think a lot of people really enjoyed this. And so again, feel free to email me feedback about next topics to discuss. And yeah, thanks everybody. Thanks for attending. This will be posted as a recording as soon as we kind of blur out the children's faces and everything, both so the PDF as well as the recording. So have a wonderful night. Thank you. Thank you so much.

family planning

infertility

fertility treatments

medical professionals

Dr. Wendy Chen

reproductive endocrinologists

fertility preservation

IUI

IVF

egg freezing

insurance coverage

adoption

surrogacy

COVID-19 impact

medical training