National Infertility Awareness Week #012

This week in honor of National Infertility Awareness Week, we have special guests Dr Torie Comeaux Plowden and Jessie Bernstein, LMT on to talk about caring for people along the fertility journey.  We discuss stigma, access to care, cultural considerations, impacts within communities of color, supporting legislative efforts, and limits of care in the time of COVID-19.

Transcript

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Maggie, RNC-OB:   0:05
Welcome to Your BIRTH Prtners. We're here to break down barriers and cultivate community as we discuss issues that impact pregnancy, birth and postpartum. We welcome you, no matter what your background is on, are so excited to learn together. Today I am blessed with two special guests on the show. We have Dr Torie Plowden and Jesse Bernstein, who will share a little more about themselves and what brought them to work with people on their fertility journeys and especially with those struggling with infertility.  You're gonna learn a little bit more about some of the stigma that's associated with infertility. And why this week we're honoring National Infertility Awareness Week.  Hopefully, you'll gain a greater understanding about how this impacts different communities and different cultural aspects of infertility care. And hear a little bit more about care discrepancies that exist in our country around racial and ethnic lines along with socioeconomic status.  We hope you leave this episode with a greater understanding of the issues impacting those struggling with fertility and what you can do as a care professional or loved one to help provide more support and understanding. On to the show!  

Maggie, RNC-OB:   1:08
All right, so today I have the pleasure of welcoming Jesse Bernstein and Dr Torie Plowden into the podcast, and so I'm gonna let them tell that you're a little bit more about themselves and what you know brings them here. Why they, you know, are inspired to talk a little bit more about infertility and struggles people have around fertility hiccups, and so I'll let them take it from here.

Jessie, LMT:   1:28
I am Jessie Bernstein. I am a board certified therapeutic massage body worker and licensed massage therapist in the state of Maryland. I specialize in reproductive health, so I see clients with fertility hiccups, pregnancy, and postpartum. And then I also specialize in oncology, so I see the whole gamut of wellness through all stages of light. And I also run a peer to peer support group called Pineapple Connections in Baltimore. And it's just pretty much, it's not your typical support group, but it's a very casual peer to peer support with everybody, just kind of giving insights and support. Just go with the flow.

Torie, MD:   2:10
Hi, my name is Dr. Torie Comeaux Plowden and I'm a double board certified physician. I am an OB-GYN and I'm an REI doctor, so a reproductive endocrinology and infertility specialist.  I am chief of the OB-GYN department  at Womack Army Medical Center and I mean, I guess this work...I have a passion for helping people to achieve their dreams of starting a family. And so that is what kind of brought me into the infertility space in the first place.  It has been really, really very rewarding. I also am passionate about trying to educate patients and help them to understand these very complicated topics that they may not have experienced with.  The infertility journey is really, really challenging, and it can be a prolonged experience, unfortunately, And so I focus on ways to help my patients deal with that.

Maggie, RNC-OB:   3:13
Great!  And then this episode is being released during National Infertility Awareness Week. So if either of you want to speak to that that movement, why, you know do we need to have a week about this? Why is that important for people?

Torie, MD:   3:25
So I think that it's important because of decreasing stigma. About one in eight couples are impacted by infertility, and it can be it could be a very lonely experience. It can be an isolating experience. Often when women are going through infertility, they feel that they are the only person ever who has experienced this. This is not something that people often talk about with their loved ones or even with their circle of friends. So some people really do feel like they're the only ones struggling with this issue. And when you feel that, so dealing with infertility is already hard, when you feel also isolated on top of that, you feel like you can't necessarily confide in family members or talk to your friends about it. That makes it that much more difficult. So I think that National Infertility Awareness Week is just to increase awareness, obviously, for people to say, "Hey, infertility is a very common disease. It is something that people can get treated just like any other disease is. It does not mean that there's something inherently wrong with you as a woman, or that that something's wrong with your body" and just to increase the idea that many people go through this and you're not alone.

Jessie, LMT:   4:53
Yeah, just to expand on that. So I think that what's really important is that a lot of people, especially during this time of this pandemic, there's a lot of the conversations around it. It's like "Oh, so many people are gonna get pregnant during this time and we're gonna see this massive explosion in nine months." It's taking quite a hit on a lot of the people in the TTC (trying to conceive) community. It's really, really taking an impact. And as someone who works really closely with a lot of the doulas and the midwives in the area, I'm hearing a lot of that, and then I'm hearing it from my support group how frustrating that can be. And so, with the events that I planned for zoom, of course, we've definitely made it so that these events are open to general public to learn about how they could be better supporters and advocate for their friends, their clients and their colleagues so that they can kind of have media hint of why this is so challenging for people. And so with this week, you know what? There's also an intense amount of advocacy on a legislative level for coverage through insurances, through workplace support, and all of that, because there's a lot that goes into it. People have to take time off work, and they have to miss things and it's a lack of awareness in the general public. Unless you've walked through it, you don't understand it. And I think from a personal level, you know, I started doing a lot of this work before I had my own infertility hiccups, and I think that my drive kind of really revved up a lot with wanting to make sure that we were able to provide these events for National Infertility Awareness Week to do better with letting people kind of take a peek into the emotional and the physical tolls that going through fertility treatments as well as just the anxiety that's around all of that.

Maggie, RNC-OB:   6:52
It is. It's so necessary, I think. That's one of the reasons why, you know, for our podcast, we primarily speak about obviously, you know, issues that have to do with pregnancy, birth, postpartum and you know, that whole journey. But obviously it starts with, you know, becoming pregnant, being able to conceive. And so I think so many of us as like birth workers and professionals, like people listening to this podcasts where our head is very baby focused, right, and we kind of already got into that piece. So you know, can you speak to things that we can do to be sensitive for this when we come into contact with people who've gone through infertility, whether they're, you know, currently still working, you know through that or if it's something they've experienced perhaps with that pregnancy. I know I can speak, you know, briefly as a nurse, sometimes when we're taking care of patients who've had infertility along their journey, they have a lot more anxiety going into, you know, labor and delivery and the postpartum period. And, you know, so if you could speak to kind of any tips and tricks, we can use to help increase comfort for them and, you know, show more compassion and awareness around that.

Jessie, LMT:   7:47
Well, I think from a lot of what I've seen, since I haven't been successful personally yet. But as someone who supported my pineapples, who have gotten pregnant successfully after X amount of cycles, their biggest thing is that there's the anxiety throughout the entire pregnancy until there's a child in their arms. And so I think that for care providers, it's to be validating, which a lot of times people don't hear the validation that their anxiety and the sadness that goes around it because they been through this journey of all these treatments and that has one set of anxieties. And now the anxiety of carrying to term has a whole other set. And then what will happen when this becomes like then that becomes a whole another set of anxiety. So I think as care providers, the one thing that I hear is that the validation is really, really important, that the journey has been hard, the journey has been challenging and that, you know, they're being supported however, it is that they need to be and not brushing off any of those concerns.  I think that that's probably the biggest piece and why, sometimes people do tighten up when it comes to labor and delivery is because that they held on to this for so long. And now that it's here, what happens now kind of thing. And nothing has prepared them for that journey after birth with having had fertility challenges prior.  So that's been like probably the biggest thing is the lack of validation from care providers, and I think that you know it's great to have affirmations, and it's great to have like those goals, but they only take someone so far. If they been spending months and years and cycles and monetary struggles to get to that point, it's probably the biggest thing.

Torie, MD:   9:42
I agree, and I think that validation is very important. You know, you can go a long way when you say to someone, "Wow, your experience have been long" or "Wow, that must have been really difficult to deal with." And just kind of opening the door for them to talk about those experiences that they desire. I think that reassurance is important too...so certainly miscarriage is something that's very, very common, just in general. About 20 to 25% of pregnancies can end in miscarriage, but on the flip side, that means about 75% of pregnancies don't and so sometimes my patients are super anxious, and just because you've had infertility doesn't in and of itself me that you are at higher risk of having a loss or something like that. And so I tell them, you know, statistically, what is most likely to happen is that all will go well. But I'm here for you at each step of the way, talking them through the process, allowing time for them to ask questions.  I often tell people to write down the questions that they have because you know when they get home, they start thinking, they might start spinning and kind of thinking of all these things that they forgot to ask the doctor. And then when they get in front of the doctor, they forget what those questions were. And then they go home and they remember, and then they still have to stew on those questions until they have interaction with a health care provider again, which just revs up anxiety. So a lot of times people just jot down questions that they have just on the note section of their phone or something like that. That way, when they come in, they can have the opportunity to ask those questions and have the questions answered. I think it's important to sit down when you are talking with your patient, just that body language and kind of getting more down to eye level with your patients. It might sound odd, but I think that it opens up the floor and it makes the patient feel like you are not as rushed. We all are busy. We all have many patients to see. But if you just take that second and say,  "Okay, what other questions do you have?" a lot of times it doesn't take that long to answer the questions that they have.  Then that kind of makes the patient feel more reassured as to what is going on with that next step is.  These are highly desired pregnancies, many pregnancies are highly desired pregnancies, but in the infertility community they have been trying and trying and trying so long to get to this point. I think that sometimes they have more anxiety than maybe a woman who has conceived spontaneously. They've already had a lot of interaction with the medical system that they didn't necessarily want. And what I mean by that is no one really wants to be infertile. It's super great if you can just become pregnant with just normal intercourse, that is excellent. But our patients don't have that same experience. So they've already been, you know, I have heard people say, "poked and prodded" a lot, and so they're already coming into it anxious. So just given that reassurance, taking the time to listen, you know, having open body language and allowing them to ask the questions that they desire.

Jessie, LMT:   13:02
That's the biggest part. That probably the next, aside from the validation, is people not feeling that they can ask the questions that they need to ask, or that it's a repetitive question.  Because this is so scary, there's so many terminologies that fern out in the middle of all of this. But I think that when people feel like they're not belittled, when you say about the non verbal communication about where you place your body, it's warmer and it's a lot more inviting, and you also make yourself seem more welcoming to your patient. And it eases anxiety when interacting with the care provider instead of just looked down to and rushed out the door. Because it is, it is a very sensitive topic to definitely process for both the partner and the gestational carrier together.

Maggie, RNC-OB:   13:55
Yeah, absolutely.  I love all those suggestions. That idea. I think it's some you know we can all get easily caught up as health care providers and you know it's "yep, we're doing this again, like yes check" and kind of forgetting that individual piece of, you know, the journey and who you're taking care of. And I also, I feel like part of it culturally in our country. There's this feeling of, like, privacy that we're supposed to be giving people, and I think part of National Infertility Awareness Week and how we're trying to kind of break down some of those like barriers and let people be more open and understanding that, like this is something that's going on. And absolutely people deserve to have privacy, you know, as much as they want along their fertility journey. You know when someone wants to talk about it. You know, if you guys could speak a little bit to some of those kind of cultural expectations around fertility and infertility and how that kind of plays out.  I know for, you know, people I've spoken to, friends and family who have experienced this, that piece of it to of navigating with loved ones who don't know what to say or when to say or who are really not in agreement with treatment options that they've chosen to pursue, you know, becoming pregnant. I think that can get really complicated for people as well.

Jessie, LMT:   15:01
We could probably talk an entire podcast, just cultural components, for sure. I mean, I have people who are of various different religions that come to me as a body worker, as well as in the support group.  And their religions, or even just the expectations of where they grew up, was that you get married, you have babies and you have more babies and more babies. And it's like a wham bam type of thing and that you shouldn't be having any issues and that if you're not having babies within the first year getting marriage, then there's clearly something wrong with you and, and then the thought is like there's a lot that's wrong with you because you can't produce a baby within the X amount of time frame. And I think our society as a whole as a cultural component with the expectations, has definitely put a lot of that pressure on family building, so that makes it a little bit more challenging and a lot more isolating when it comes to the topic of family building. And how do you have these conversations? Because not everybody in your family is gonna go through this. But sometimes there will be multiple people in a family, and nobody knows that anybody else has struggled with it because of the clear expectations of what family building is supposed to look like..

Torie, MD:   16:14
This is a tough questions just because there's so many different aspects to try to cover.  The first thing that I would say, is that in some communities, and in communities of color, infertility is often something that is not really discussed. There have been multiple studies, that have kind of shown that in America, black women and Hispanic women often seek care for their infertility after they've had infertility for a more prolonged time period compared to Caucasian women.  And there can be many factors related to that, some of it is access, some of it is, you know, not really knowing what the treatment options are. A lot of people have heard of IVF, which is in vitro fertilization, although not everybody knows exactly what it entails, and some people will think what I don't want all that, and so they think that there are no treatment options for them, which may or may not be true.  There are often things that can be done that are less aggressive, than IVF that can help people get pregnant,depending on what the diagnosis is. There have been some studies that have shown that implicit bias and racism played a factor with the health care system. There was a study that showed that even in the setting of cancer, African American women were less likely to be referred for counseling for fertility preservation.  And that, referring to infertility specialists with a person who has cancer, is like standard. It's pretty much what we are supposed to do and all of our society's agree that that is what is recommended. But even in that setting, those women are less likely to be referred by their providers, which is upsetting and obviously that puts up with an added barrier for access to care. I think that in African American culture, or some African American women, they don't feel like this is something that other women in their family or the women in their culture have addressed or have encountered.  I have heard people say, "Well, I thought that infertility, I didn't know that we could be infertile.  I didn't know that we could have infertility." Just a lack of awareness. It is true that there have been studies that have indicated that the typical reasons that African American women  can have infertility may vary or may be different than the reasons for Caucasian women. So that is also, you know, the appropriate work up to figure out what what it is that is going on and talk to patients about treatment. Women of color are more likely to have fibroids, for instance, and although fibroids in and of itself is not typically the main reason for infertility it can be, and it can impact their fertility or can be a factor.  There was a study that was done years ago. It was Walter Reed National Military Medical Center, and it found that in the in the military setting access to care is a little bit better because all of the people have access to the same way, meaning that they're all insured, they all have access to primary care doctors, they all have access to OB-GYNs and that sort of thing. And what they found was that in a setting where there was enhanced access to care, African American women did utilize services more within that system than they did on the outside. But they did not find that to be true for Hispanic women. And it wasn't exactly clear why that was.  For the author's space, they made a conclusion that it could possibly be related to language barriers. So that's a whole other group of people that might not have access to care or might not be willing to seek treatment. And then, of course, even more disadvantaged groups of people, immigrant women, those women who are maybe not in the country legally, those women may be less likely to seek care because they don't have, because they're afraid, essentially.  So it's a very complicated question. So years ago, ASRM, which is American Society for Reproductive Medicine, they put out a statement, and they basically said, you know, define infertility as a disease. This was important because there is this concept that fertility treatments are elective or optional, and that is the reason that some insurance places, some insurance companies kind of used as a reason why these services are not covered. But no one elects to be infertile. No one wants really to be infertile. And so to say that this is elective is not really the appropriate terminology. These treatments are necessary. Just as treatment for any other disease are necessary. And I think that we need to take that stigma way too.  These women who must undergo in vitro fertilization are other fertility treatment, and this is just elective and they must pay out of pocket, and you know, it's their own decision. They can save up for it until they can afford it. And that's not really fair; that's not really appropriate. And we have to get away from that sort of thinking, as a nation, as a culture like the American culture.

Jessie, LMT:   21:33
Yeah, and I was gonna say to hop on to the what the ASRM has been talking about with regards to infertility being a diagnosis, that part of the reason why right now, so many people are struggling with their treatments coming to a halt or not being able to pursue elective procedures because of the guidelines that came out. And I think that's even more pertinent to celebrate, not necessarily celebrating but honoring and recognizing National Infertility Awareness Week is because community is needed so much more now because people don't know when you know they're gonna be able to pick up on their fertility treatments. And that's a little hard on the mental health that's taking quite a hit on patients all across the world. 

Torie, MD:   22:21
Unfortunately, that's so true, COVID has obviously been a quite quite an interesting phenomenon. It has impacted so much of our daily life, and it is not something that any of us have ever dealt with before. And it's just been, you know, incredibly disruptive and also deadly and scary.  You mentioned the ASRM guidelines, and they did put out that we needed to pause or,  stop infertility treatment for now.   It is hard; ASRM is filled with REI doctors. They certainly want to help patients get pregnant, in this setting it's very difficult, and I don't think that any of us would call the procedures that it takes to get women pregnant elective, but I think that we would call it, I think the better word for it would be non urgent, meaning that just as a person might might need to have like a colonoscopy done. Colonoscopy is a medical procedure; it needs to get done, but it doesn't necessarily have to get done today, versus treatment for an ectopic pregnancy, which must be done urgently, and ASRM, those guidelines are being revisited every couple of weeks because we're trying to figure out as a group when we can, we all want to start treatment again.  We're trying to figure out, like, when is that going to happen? And it's harder for our patients because, you know, some of them have been waiting for a time period, a long time period. And I also wonder, and worry that with the COVID impact will be more prolonged even after we have opened up to regular practice again. Because a lot of the costs are out of pocket and with the economy being what it is, some people may have had job layoff, some people may have had pay cuts, some people may have been saving for fertility treatments, and may not be in the same financial position to pursue those treatments when this COVID crisis improves. And so I worry that this will impact our patients for an even more prolonged period of time even after we're fully up and running again.

Maggie, RNC-OB:   24:44
Yeah, absolutely, every time I talk to someone in a different line of work or with a different sub-specialty even within health care, it's just profound all of the different ways that COVID, and the pandemic and all the fallout from that is just making lives a lot harder and, like you said potentially for people for much longer outside of this initial, you know, difficult time.  To that point because I know you touched on this briefly, Torie. You know, there's obviously a vast range of fertility treatment options and different modalities people could do if you want to just kind of briefly touch on some of those, some are highly medicalized and you know certainly you're gonna be, you know, stopped by these guidelines, but, you know, talking about those options briefly. But then also talking about kind of other other holistic things. Like, what are the things kind of best practice for people to start do or to keep doing before other options become available?

Torie, MD:   25:40
So I think that part of the problem right now with the COVID crisis is that there is certainly a feeling of loss of control, a lack of control, and that is pervasive for all of us. None of us know, when things are gonna go back to normal, and I think that it's going to take much longer to get back to quote normal. Then we had initially feared, and so that can cause a lot of anxiety. The whole, like not being in control, not knowing what's next. If people are waiting to restart their fertility treatments, some things that they could pursue now would be to continue to exercise, move their bodies, continue to eat healthy. There's no particular diet that must be endorsed to help with fertility, there's no proven particular diet, but an overall general healthy diet is recommended. To continue to take their prenatal vitamins is important. I think to continue to have some sort of wellness, whatever that means for you. The thing about COVID is that the social distancing is very isolating, obviously, but staying connected with your family and friends in whatever ways that you can. So, for instance, a lot of people are doing like zoom happy hours; I was in a zoom book club last week, and it was actually really great.  Staying connected, you know, we're a social culture, staying connected is important. Even though we can't physically interact with people in the ways that we typically do.  Related to treatment for infertility, it probably depends on what the diagnosis is on and so when patients have infertility to come to us, we work up both partners, the female partner and also the male partner. Certainly, if a person has a female partner, then there are treatment modalities for them as well, they don't necessarily have to go straight to IVF either.  So dependent on the diagnosis that can help us understand what sort of options there are. So for a woman who has a male partner, but she does not ovulate regularly, it could be as simple as giving a tablet, a pill, that she could take on a certain time in her cycle so that she can ovulate and then having timed intercourse at home.  Timed intercourse just basically means having sex around the time of ovulation to increase the likelihood of pregnancy. Sometimes if there is a problem with the fallopian tubes, for instance, depending on what that is, it can be surgically treated, or it's possible that the person may need to go straight to IVF in that setting.  With male infertility, depending on the cause, what the sperm count looks like, the semen parameters, there can be some treatment options and sometimes insemination can be used to overcome that. But if it's severe male factor infertility, typically the couple will need IVF to conceive.  With women who have a female partner, often that woman could become pregnant just with insemination, and that typically is something that is, I mean, insemination are fairly not invasive, and people can become pregnant with those in that setting.

Maggie, RNC-OB:   28:49
I appreciate you going to explain to his options. Like you said, I think people jump kind of feeling either that you've just gotten pregnant by, you know, having sex regularly or "great...It's IVF," and it's this whole, you know, very expensive and time consuming and invasive procedure. So it's good to know there's, you know, different options and certainly be able to kind of explore those with care professionals and finding out what matches up best with with you and your partner and kind of what your needs are. Do you have anything to kind of add to that, Jessie? What are you seeing people pursuing during this time, and generally?

Jessie, LMT:   29:19
I think just in general I would definitely say the physical activity. I mean, our bodies were designed to be, we are creatures of movement, not static creatures. And so, our body depends on physical activity and the nutrition piece clearly eating well and also taking care of your mind. I encourage people to seek out mental health professionals, to kind of give them some coping skills and techniques of just kind of working through whatever their journey is taking them on.  And then also, acupuncture is definitely a traditional Chinese medicine is really, really supportive for that, from lining to boosting the immune system to helping increase blood flow and balancing out hormones and things like that, and then for bodywork, like the work that I do. I do a lot of scar work for people who are trying to go through fertility treatments. They've had repetitive abdominal surgeries and things of that nature with the adhesions that buildup. We kind of work on that to allow more movement and also managing the stress through bodywork as well. That's usually what I encourage my client to do, in addition to whatever their protocol is with their RE.

Maggie, RNC-OB:   30:41
And as we close up, if you know there's any you all can recommend in particular for where people should reach out for support. If this is something that you know, they are going through or a loved one and they want to kind of know and understand more about this.

Jessie, LMT:   30:51
RESOLVE has a lot of really great information on their website. I think there's a lot of really great resource is that are out there for people seeking. The two organizations that I refer to a lot are RESOLVE, the National Infertility Organization, as well as the Tinina Cade Foundation, which is based locally, but they provide support nationally for people who are family building.  Those are the two big ones I usually refer to.

Torie, MD:   31:21
ASRM, asrm.org, when you go to that website there's a portal for positions and there's also a portal for patients, so there can be really nice patient handouts there that provides some accurate information, kind of break down some of the terminology that we use it.  It has frequently asked questions for different issues that a patient may have been diagnosed with, like endometriosis, fibroids, etcetera. The Cade Foundation I was also going to recommend, is run by a very good friend of mine. And they provide grants couples that are family building, whether that money be used towards adoption or that money could be used toward fertility treatments; it's a great organization. There's an organization called Fertility for Colored Girls focused on black women. Because again, I kind of mentioned earlier, a lot of black women kind of didn't know that infertility was something that they might encounter, And so that organization actually provides a lot of support, it actually kind of normalizes infertility, and what I mean by that is to say "yes, you can be a black woman with infertility. And yes, there are treatment options for you. And yes, you could have a family in the future" and kind of addresses a lot of those questions. So it is a really good resource that a lot of patients like.  There is a an organization called the White Dress Project. And it's more about fibroids; they they basically provide a lot of fibroid information. And the reason I bring this up is because, as I mentioned, fibroids can play a factor with infertility, and it does, it's a condition that is more prominent among women of color. And so it is a good resource, has lots of information about fibroid treatments and options and what you might be able to do in order to treat fibroids.

Maggie, RNC-OB:   33:11
Awesome. Well, that sounds great. I will link all of those in the show notes so that everyone can find those easily. You know, I really appreciate you, you know, drawing attention to those that gonna reach out to communities of color and help to kinda break down some of those barriers to having awareness and getting, you know, same access to care. And then I know Jessie had mentioned earlier about kind of legislative work, this being done at the same time.  If you want to say real quick, Jessie was there, are there bills that are kind of being brought out at this point is RESOLVE like helping to sponsor those or?

Jessie, LMT:   33:38
It's mostly state to state depending on what is going on legislatively. I know, at least locally, the big one that got passed now two years ago was, providing fertility coverage for cancer patients on, especially with regards to fertility preservation. So that was like a really big one locally, and New York has been working on surrogacy.  So it really depends on really the state by state, as far as making sure that insurances are covering and that infertility is an actual diagnosis. I want to make sure that people are vocal to their legislative representation so that way their wishes are heard so that it is considered a necessity, not just elective. 

Torie, MD:   34:23
I would echo that the advocacy part is super important, and, you know, if we really want to talk about, you know, improving access to care across America because, you know, they there is even access in rural area. Some places don't have an infertility provider like in their state, and they have to travel across state lines to get treated. We really do need to get infertility treatment covered by insurances.  There are only a handful of states that have some sort of mandate that infertility coverage be offered, and even within those states, the mandates vary substantially. So in some places, something has to be covered, but not necessarily IVF, versus some states do have, like a certain number of IVF cycles could be covered, and it can vary. But really, that advocacy piece, that RESOLVE does that ASRM does is also important if we want to break down those barriers in access to care.

Maggie, RNC-OB:   35:23
Yes. Thank you for highlighting that because it is, as someone who is not, like intimately involved this work day-to-day, I had no idea that it was that low.  You know, that it's not the vast majority of states that are covering that, which is unfair.  And it's obviously I think it does have to do with a lack of understanding and education about what's really going on, because I feel like most people, if they listened to you all talking, if they listen to, you know, people who have gone through infertility, they would not think that it was elective. They would, you know, I feel like most people's hearts feel like, of course, it's someone's option to choose to grow their family.  This is not something that there they need to be paying out of pocket some extreme number in order to do something that comes very naturally to a lot of people. So I do appreciate you calling that out, and will definitely will find some more the stats and put them up on the show notes too so people can can look into that and see kind of where their state is along those lines. Well, thank you both so much for being here and talking with us and sharing about your experience and all of your professional wealth of knowledge. I appreciate you.

Jessie, LMT:   36:23
Thank you.

Torie, MD:   36:25
Thanks so much for having me.

Maggie, RNC-OB:   36:27
Thanks for tuning in. We love to talk all things birth and would love to talk about it with you. Please join the conversation by finding us on Facebook, Instagram or Twitter, we're Your BIRTH Partners on all platforms or comment on our show notes blog at yourbirthpartners.org.  On our show notes you'll find information about the organization we discussed today who are addressing infertility, how you can reach out and support them in that work, how you can educate yourself and others. So please look there, and we just want to recognize everyone out there who's struggling right now with fertility hiccups and their fertility journey.  We see you, we hear you and we're here for you.  Till next time!