Fertility Treatments And Twin Pregnancy
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DR. BROOKE FRIEDMAN: The last two decades, the rate of twin births has grown dramatically due to the use of fertility treatments. For many women who have faced fertility challenges, conceiving twins may seem like a desirable outcome. However, twin pregnancies can pose substantial health risks to moms and babies. If you are considering fertility treatments, how should you approach the possibility of having twins? I’m Doctor Brooke Friedman, an Infertility specialist of Reproductive Partners. I’m here to talk about the relationship between fertility treatments and twin pregnancies. This is twin talks.
CHRISTINE STEWART-FITZGERALD: Welcome to Twin talks, broadcasting from the birth education center of San Diego. Twin Talks is your weekly on the go support group for expecting and new parents of twins. I’m your host Christine Stewart-Fitzgerald. Have you heard about the Twin Talks club?
Our members get bonus content after each new show, plus special giveaways and discounts. You can subscribe to our monthly Twin Talks newsletter and learn about the latest episodes available. And another way for you to stay connected is by downloading our free Twin Talks app available in the Android and iTunes marketplace. Before we get started, let’s introduce our panellist in the room with us today.
I’ll introduce myself, I’m mom to a now five year old identical girls. We just celebrated their birthday last week. And we started kindergarten. That was the big milestone for them. And I do have a singleton who is, will be two next month. So we got all girls in the house.
SUNNY GAULT: And I’m Sunny, I’m the owner of New Mommy Media which produces this show as well as parent savers, preggie pals and the boob group. And, let’s see, I’ve got four kids, sometimes I lose track but there’s four, there’s four of them. So the oldest is four, a boy. Two is my next child, and that’s a boy as well. And then I have identical twin girls that are ten months old.
SHELLY STEELY: I’m Shelly, I’m the producer here at Twin Talks. I have identical twin boys who just turned two. And I have a singleton girl who is three weeks old. She’s here in the studio today. I want to let you guys know if you’re listening at home, if you’re not able to get into the studio, you can still be part of our conversation, you can follow us on Facebook and Twitter. You can also use the #twintalksvp to participate in the conversation.
SHELLY STEELY: Before we start today’s show we have an app review for you, so, as you all know probably a phone can be a mom’s best friend for keeping track of all things baby related. Today’s app is called Mommy Log. And it’s designed to keep track of expressed breast milk. So, most twin moms will be familiar with the pump at some point in their journey of breastfeeding.
What I like about this app is that it’s really simple. So, a lot of baby feeding or pumping apps have all the things to keep track of what time did they go to sleep, what time did they wake up, what time did you feed. Was it left? Was it right? How many? How much? And that can be really overwhelming if you’re just trying to keep track of one thing. And so, for moms who are pumping especially if you go back to work or if you end up exclusively pumping or you have feeding concerns, this one just keeps track of how much milk did you make? What time did you make it?
And so I think that that can be really helpful. I know that when I was working I was using an app to keep track of what I pumped. But all the other things kind of made me feel like I was slacking, like , well should I have recorded their sleep and gosh I forgot to put the last feeding and how many diapers have they had. And so for me this would’ve been great because it’s just very simple. And it would just keep track of exactly how much milk you kind of had on hand. It does have charts so you can kind of see when did I make the most, when did I make the least, how many time have I pumped?
So those are all pretty good features, I think. The one down side is, is it has ads. Obviously it’s a free app so that’s great. But I would, I’d be definitely willing to pay to get rid of the ads on there because I find them just a little bit distracting.
SUNNY GAULT: Yeah the one feature I really liked on this tool this may have been updated recently but you can also, if you are using a double pump, you say how much one breast is producing versus the other. You can combine it if you want. Like for example, I don’t do a lot of pumping because my girls take up all of my milk.
For example on taping days, like today, I do have to do some pumping before. And I have a single pump because I don’t like to invest a lot of money in pump. So, I have a single pump and so, I actually combine mine but I know a lot of moms that have like the double pumps, it’ll be really easy to track how much one breast is producing over the other. If that’s a concern of yours, I know it’s not always even right? And so that’s one thing that I really liked about it. I liked that it’s free. And I do like that it is a very simple user interface.
I do think that it could be a little bit prettier than it is honestly. But it’s functional, it’s very functional, you know and it makes a lot of sense. But it would be nice to have some pretty pictures of babies or something like that
CHRISTINE STEWART-FITZGERALD: I haven’t used the app but I’ll just say, you know, I hear a lot of twin moms talking about how their pumping in different locations. So if you’re a working mom, that might mean you’re pumping in a closed office. You might be in your car, you might be at home. And I think this is, I love this idea that this is a portable thing that you can, I mean it’s on your phone. So you don’t have to have a piece of paper or you know, board or something you carry around with you. It is just wherever you’re at doing it, it’s right there
SUNNY GAULT: It’s very app
CHRISTINE STEWART-FITZGERALD: Yeah, that’s a great thing
SHELLY STEELY: It does also, I noticed it has the option that you can have it send you a spread sheet
CHRISTINE STEWART-FITZGERALD: Oh my gosh
SHELLY STEELY: Of your pumping outputs. So if you were having like concerns with your milk production perhaps. Or you just really wanted to know if that was normal, you can actually, there’s an option where it all just email it to you as a CSV comma-separated values. And you can print that out and take it to a lactation consultant and say, you know, this is my pumping output, these are my averages. Can you, you know, is this normal, can you take a look at it?
CHRISTINE STEWART-FITZGERALD: Oh my gosh
SUNNY GAULT: Or you can just send it via email to
SHELLY STEELY: Yeah, just email it over to somebody
SUNNY GAULT: IBCLC
SHELLY STEELY: Yeah
CHRISTINE STEWART-FITZGERALD: That’s great
SHELLY STEELY: Yeah
SUNNY GAULT: So, what do we think? Thumbs up on this
SHELLY STEELY: Definitely thumbs up
SUNNY GAULT: We like this
CHRISTINE STEWART-FITZGERALD: Yeah. Awesome
CHRISTINE STEWART-FITZGERALD: Well today’s topic is fertility treatments and twin pregnancy and today we’re talking with Dr. Brooke Friedman who’s here to help us understand common fertility treatments and how they may result in a twin pregnancy. So, well thanks for joining us Doctor Friedman
DR. BROOKE FRIEDMAN: You’re welcome. Thank you for having me.
CHRISTINE STEWART-FITZGERALD: Well you know first of all, I mean, you know, fertility treatments becoming much more common and maybe you can just share some of the different reasons that women do come to see you
DR. BROOKE FRIEDMAN: Absolutely. So, I’m with Reproductive Partners, so, that’s our private practice in La Jolla that’s affiliated UCSD. And so, we really see a wide variety of patients. So the majority of the patients we see are couples who were struggling with their infertility. We know infertility is incredibly common affecting one of every eight couples. So we do see a lot of women struggling with infertility. We also see women who perhaps are single, looking to conceive with donor sperm or looking in to fertility preservation with egg freezing. So there’s a wide variety of patients that we see. But most are couples struggling with infertility
CHRISTINE STEWART-FITZGERALD: Now, so, can you tell a little bit more about the demographics of your patients? I mean are there any commonalities, in either age or their overall health or lifestyle
DR. BROOKE FRIEDMAN: Sure. You know I would say that it’s a pretty diverse patient population that we see. I think the one commonality is that women tend to be a little bit older. We know that age does negatively impact fertility. So most of the patients we see tend to be in their thirties, mid-thirties or late thirties or early forties. But that being said there are also reasons for infertility that have nothing to do with age such as a blocked fallopian tube or male infertility. And so, in those patients we typically see women who are younger. So it’s really a wide variety.
I think the one myth is that, really a few can take care of yourself, and eat organic and are healthy that that can kind of protect us from the negative impact on age on fertility, and unfortunately, it’s not true. I wish it were true. But unfortunately were born with all the eggs that ever going to have. So we do lose them over time. So, unfortunately, age is something that we can’t change so which is why I really encourage people if they have been trying, if they’re under the age of thirty five, and it’s been more than a year to see a fertility specialist.
If they’re over the age of thirty five, really if it’s been six months, to go see a fertility specialist for a check-up. Just to make sure, you know, they can check in about where they are and what may be the best path for them.
CHRISTINE STEWART-FITZGERALD: So, really can be, really proactive in terms of just saying ‘hey, I don’t know what’s going on, but I just want to make sure that, you know, I’m in good health and we got everything in place and yeah
DR. BROOKE FRIEDMAN: Absolutely. And I think, I mean, being healthy is one of the best things that you can do for your fertility. So, I mean taking care of yourself being healthy, body weight, eating well, exercising. All of those things absolutely help your fertility. So, I think as healthy, you can be avoiding smoking, avoiding drugs I mean things. Be as healthy as you can be. I sometimes tell people how would you, if you were already pregnant in terms of avoiding some of these toxins that it makes sense to kind of think about that when you’re trying to conceive
CHRISTINE STEWART-FITZGERALD: That’s great. Well so now before we talk about twin pregnancies, let’s look at some fertility treatments in general, just so we can kind of understand, you know what the, fertility treatments mean. So can you describe the different types of treatments that are available?
DR. BROOKE FRIEDMAN: Absolutely. So there’s a wide variety of treatments, I think the one thing, one method like [inaudible] people are reluctant to go to the fertility doctor because they think, ‘oh that means I’m signing up for IVF’ And that’s just not true, I mean, there’s a wide variety of treatments that are available. One of which you know someone doesn’t get periods regularly, if someone has what’s called anovulation, where they’re not releasing an egg regularly.
Sometimes a low tech treatment like clomid or there are other medications we now have called Letrozole can help them release an egg so that they can have intercourse at home with their partner to help them conceive. So that’s one treatment if they’re not ovulating on their own or if they’re not releasing an egg on their own in a predictable manner.
We have a next category is what’s called intrauterine insemination. Where the sperm of the partner is placed inside the uterus around the time of ovulation. And that’s typically combined with a medication to help increase its efficacy. That’s called Intra Uterine Insemination or IUI.
CHRISTINE STEWART-FITZGERALD: IUI okay
DR. BROOKE FRIEDMAN: Yeah, exactly. Maybe you have heard IUI. But basically it’s intrauterine insemination is what it stands for. And really the next category then is IVF. We do know that IVF is the most effective treatment that we have because it helps overcome a wide variety of obstacles that maybe contributing to infertility. IVF stands for in-vitro fertilization, so women takes medications to stimulate multiple eggs to grow. Their retrieve with the procedure and then fertilized in the lab with the sperm. And then the embryo or fertilized egg is transferred back to the uterus
CHRISTINE STEWART-FITZGERALD: Now I think, I mean IVF is what we hear most about
DR. BROOKE FRIEDMAN: Right. Absolutely.
CHRISTINE STEWART-FITZGERALD: Is it the most common treatment that is used today? Or are the other treatments that you mentioned, are those used equally or
DR. BROOKE FRIEDMAN: Yeah. I think that IVF is becoming increasingly common. I think, certainly IUI is quiet common. But IVF is the by far in a way more effective than IUI is. We know that since IVF was introduced, thirty five years ago, over five million babies have been born worldwide from IVF. And in 2012 which was the most recent year that was reported online with the CDC of 1.5% of all babies is born in the US are the results of IVF treatment. So that’s over sixty thousand births. So it’s definitely becoming more and more common and we know that it’s a really, it helps millions of people worldwide. Help conceive that otherwise would not have been able to
CHRISTINE STEWART-FITZGERALD: And I think from a twin perspective the statistics are that in the last twenty years we have seen the twining rate double I believe, so
DR. BROOKE FRIEDMAN: Right
CHRISTINE STEWART-FITZGERALD: Which is pretty significant
DR. BROOKE FRIEDMAN: Right
CHRISTINE STEWART-FITZGERALD: So, so then over the pregnancies that are resulting from fertility treatments, I mean so, do you know how many of those are resulting in multiples?
DR. BROOKE FRIEDMAN: Absolutely. So it depends on which treatment we’re referring to and also which age groups. So we know that looking in IVF specifically the risk of a twin pregnancy goes up with younger age. The younger woman is, she’s having IVF increases her risk of really that stems from IVF is how many embryos that the physician is choosing to transfer that the couple and the physician have decided to transfer.
So the more embryos are transferred the higher risk of there being a twin or higher order multiple pregnancy. Overall, about thirty percent of IVF treatments have resulted in interim pregnancies. That rate can be even higher in younger age groups in certain clinics, so, but nationally that rate is quite high.
CHRISTINE STEWART-FITZGERALD: Well, so thirty percent of all IVF treatments, I mean, on average are resulting in multiple pregnancies
DR. BROOKE FRIEDMAN: Yeah it depends, it varies in terms of which clinic and also varies in terms of age group. But there are definitely a very significant percentage of IVF pregnancies resulting in twin birth
CHRISTINE STEWART-FITZGERALD: Wow
SHELLY STEELY: Do you have percentages for clomid because I know that’s a main concern
DR. BROOKE FRIEDMAN: Absolutely. Yeah. The risk of twins with clomid is about eight to ten percent
SHELLY STEELY: Well that’s lower than they would have
DR. BROOKE FRIEDMAN: Yeah
SHELLY STEELY: Not from what we hear
DR. BROOKE FRIEDMAN: Yeah. It actually is lower and so typically the success rates with an IUI with clomid you know, generally don’t exceed ten percent. So that’s why with IVF with live birth rate substantially higher than that depending on the age group. You know up to seventy percent. Sometimes for younger women that’s a very, that’s why IVF really is the, tends to be the more effective treatment.
CHRISTINE STEWART-FITZGERALD: Hmm so when, so women are considering different treatment options and looking at whether they want to have twins
DR. BROOKE FRIEDMAN: Yeah
CHRISTINE STEWART-FITZGERALD: That’s something definitely something to consider maybe trying the clomid or the IUI
DR. BROOKE FRIEDMAN: Yeah. I mean I guess I just have to, I have to say, you know from my perspective as a fertility specialist, where I work with reproductive partners, we are actually really strong advocates of one healthy baby at a time. So I know I’m talking to a group of moms who are moms of twins and you can kind of speak to some of the challenges involved in that. From a medical perspective we do know that the safest pregnancy is one healthy baby at a time. So our position is that fertility treatments really should not be, the goal should not be to conceive twins
CHRISTINE STEWART-FITZGERALD: Right
DR. BROOKE FRIEDMAN: So, really our goal is one healthy baby at a time. Because we really want moms to be able to avoid the potential complications that can be involved with a twin pregnancy
CHRISTINE STEWART-FITZGERALD: Alright, well, we’re going to take a break and then when we come back, we’re going to talk about some of the common factors that might lead to a twin pregnancy
CHRISTINE STEWART-FITZGERALD: Welcome back, today we’re talking with Doctor Brooke Friedman about the relationship between fertility treatments and twin pregnancies. Can you tell us maybe a little bit more about what factors in fertility treatments may promote a multiple pregnancy?
DR. BROOKE FRIEDMAN: Absolutely. So with, let’s say an intrauterine insemination, for example, when a woman takes medications like injectable medications that stimulate multiple eggs to grow, then multiple eggs are going to be released. And with an insemination, where a sperm is placed in the uterus, we don’t have control over how many eggs fertilize. So all of those eggs that develop have the potential to be released and fertilized.
So, that, that is called super ovulation, can definitely increase the chance of having a twin pregnancy. That’s with intrauterine insemination with injectable medications or with clomid. Whenever there’s more than one egg that develop as a result of medications that are taken, that can increase the chance of having a twin pregnancy. With IVF it’s slightly different because it really stems from how many embryos are chosen to be placed back into the uterus. And so those are kind of the two ways that chance of a twin pregnancy can be increased
SHELLY STEELY: And now both of those will result in dizygotic or fraternal twins right?
DR. BROOKE FRIEDMAN: Absolutely, you’re absolutely right
CHRISTINE STEWART-FITZGERALD: And now when it comes to IVF and you know, selecting how many embryos are going to be implanted. Now, I’ve heard that the success rate of IVF implantation has gone up dramatically and so now the standards, the ethical standards have changed
DR. BROOKE FRIEDMAN: It has. Yeah. I mean, I think you know, if you look at, it’s in the Netherlands or other place in Europe. In many cases it’s actually illegal to transfer more than one embryo
CHRISTINE STEWART-FITZGERALD: Wow!
DR. BROOKE FRIEDMAN: A single embryo transfer is mandated because if you look at those health care systems which are closed system, wherein that system they’re going to be responsible for taking care of the cause of pre-termed delivery of twins for example. It’s really; the state has decided they know the safest pregnancy is a singleton pregnancy. And so in those countries is they’ve come together and mandated that one embryo should be transferred at the time.
So you’re absolutely right that the implantation rate, the pregnancy rate per embryo has gone up dramatically. And I think one of the things that, it’s important for people to understand is how to interpret statistic which can be pretty confusing. So if you go on sart.org which is where fertility clinics are encouraged to report their statistics with IVF, there are many things listed. And one of which is pregnancy rate per transfer. And unfortunately that’s a motivating factor for many fertility doctors to want to be aggressive at transferring multiple embryos because it can artificially make the pregnancy rate per transfer look higher.
But the best thing to look at it is really implantation rate which is pregnancy rate per one embryo. And that’s not influenced by how many embryos are transferred. So really for implantation rate we know as you mentioned are as much higher for us. We know our implantation rate for example, reproductive partners is quite high so we have excellent success rates transferring one embryo at a time particularly in younger women.
And so single embryo transfer may not be the right decision for each patient, it’s really important to come up with a personalized plan but I would really encourage patients approaching fertility treatment to discuss with their physicians about the options of single embryo transfer because often you know it’s a clinic that has experience with that and their pregnancy rate per embryo was high. They’re not going to be compromising their chances and really giving themselves the best chance at a healthy pregnancy
CHRISTINE STEWART-FITZGERALD: Hmm so this is really part of kind of the research process too. I imagined you know when a woman decided she wants to engage in fertility treatments and looking for a provider to use that website as a resource and come prepared in asking questions about what is your implantation rate
DR. BROOKE FRIEDMAN: I would say, I think, often that’s unfortunately buried kind of seven lines down on the side. So the first line is quite you know and it’s not explained what that is, what is implantation rate.
You know pregnancy rate that makes sense right? But the implantation rate really isn’t something that we talk about. I think that really should be the first line and I think the CDC and other organizations are trying to change how fertility data is reported and to consider looking at, you know, live births per single embryo transfer and looking in other metrics that can really help kind of tease apart the data because that can be a mess.
I don’t want to over emphasize that because every clinic is different and it’s hard to generalize which you can take data with their [inaudible]. But I think that’s a place to start to kind of look at what the pregnancy rate is per one embryo. So, patients are in a position where they feel they have to transfer multiple embryos and put them at a higher risk of having a multiple pregnancy.
CHRISTINE STEWART-FITZGERALD: Right, absolutely. And I think, okay, having this conversation, I mean everyone comes to mind of the octomoms. So, we can’t leave that out but, I mean in that case there were multiple embryos transferred, yeah
DR. BROOKE FRIEDMAN: There were, and that was a really a greedious example of something outside the standard of care. And that physician lost his medical license as he should have. So, I think that was a real black eye for the field and it’s really something that is not the standard of care and not the norms. So I think really as a fertility specialist as you mentioned there are guidelines and we’re really careful to want to avoid something like that to the point where we really strive to help people achieve one healthy baby at a time.
So for us at Reproductive partners we know, we really want to have an uncomplicated pregnancy for couples that you know, infertility is such a journey and at the end of it I understand that desire to want to have instant family. To have all of these at once and I absolutely can appreciate that and I respect it but at the end of the day I really want my patients to have a healthy baby. And not to be in a position where they feel like they have to be transferring multiple embryos
SHELLY STEELY: So, in talking to some of my friends who had used fertility treatments, strangely all of us in here have identical twins, if at least spontaneous but travelling in twins circles we all know somebody.
DR. BROOKE FRIEDMAN: Sure
SHELLY STEELY: So I was talking about the increased success of single embryo transfers and what I was hearing from a lot of moms was we get that their numbers are on their side now but after so many years of just like heartache and struggle. It’s really hard to find comfort in statistics. So how would, how do you kind of deal with that in your practice knowing that you know, you have the numbers on your side but they’ve got heartache and struggle and
DR. BROOKE FRIEDMAN: Absolutely
SHELLY STEELY: You know they really want what they feel would be better success and if they’re only going to have one chance and they’ve always wanted to like, how do you kind of address that emotional concern?
DR. BROOKE FRIEDMAN: Absolutely. I think it’s a really important question. I think one of the things that have really been a game changer in the field of fertility is the way in which we’re freezing embryos now. So the old way in which we use to freeze embryos compromise their fertility potential.
The new way of flash freezing or Vitrification, which is what I gave a talk at the family fair fairly recently, we know that the fertility potential the embryos are not harmed and all freezed up process. If it’s at a clinic that has a lot of experience with that procedure and so we know that patients don’t have to feel blackmail to transfer all their embryos at once. They can rest assure that they can have their extra embryos frozen.
And if the first transfer is not successful that next month, they can transfer another embryo. And their cumulative chance of success is the same. You know really as opposed to them having transferred to that one that same month as opposed to the waiting transferring one and the next month transferring another embryo. So they don’t have to feel as pressured too like this is my chance I have to transfer them all at once.
So I absolutely, I hear it all the time and I’m very empathetic to that concern. But at the same time I just kind of really encourage patients to take a step back and to think about, you know, they have come this far and what we really want them to have is a healthy pregnancy. Interestingly IVF twins are increased risk of pre-termed delivery above those of spontaneous twins for reasons that you know we may not understand all of them but it’s a complex emerging area of research. But we know that IVF twins are an increased risk of things like pre-term delivery above and beyond those of what spontaneously conceived twins have.
So, really sixty eight percent of IVF twins delivered prematurely. So, the statistics are pretty staggering. And so now that the implantation rates are higher with single embryo transfer. I really, I just talk with my couples and say, you know ‘I really think these would be your chances and you know, would you consider transferring one at a time’. Again it’s not the right decision for all couples but I think we have to really individualize it but often it really is the right decision
CHRISTINE STEWART-FITZGERALD: And when you have those conversations with you know, with your patients and talking about the risks of a twin, you know, multiple pregnancy. I mean what does that conversation, you know, look like?
DR. BROOKE FRIEDMAN: Absolutely. So, basically I have, we all have a talk on my, in my office and I have slides and I kind of go through everything but basically I share with them that there is an increased risk of pre-term delivery with twin pregnancy especially with IVF twins. And if babies are born prematurely, unfortunately, their increased risk of complications later in life in terms of neurologic outcomes and other outcomes that relate to pre-termed delivery. So, I really discuss with them the various health risk of a twin pregnancy. And then talk about, you know why I feel like single embryo transfer is what I’m recommending that that would be the right decision for them.
CHRISTINE STEWART-FITZGERALD: Well this is great. Well, thanks so much to everyone who’s joined us today, and for more information about fertility treatments and twin pregnancy, or for more information about any of our speakers and panellist, visit the episode page on our website. And this conversation continues for members of our Twin Talks Club. Sorry. This conversation continues for members of our Twin Talks club. And after the show, Doctor Friedman will demystify some of the common beliefs about fertility treatments and twinning. For more information about the twin talks club, visit our website, www.newmommymedia.com
SUNNY GAULT: Alright we have a fun segment today; it is called ‘We’re expecting what?’ It is all about the funny stories of how we found out we are pregnant with twins and this one comes from Michelle.
Michelle writes: I felt preggos and I was going past the docs and I thought I’ll go in there and get a test done so I don’t have to pay for one at home. The test was positive. I burst into tears. A pregnancy right now isn’t the greatest timing. So we had to wait two weeks to get an ultrasound to see how far we were. But when we went just short of two weeks because I just couldn’t wait, the conversation went something like this:
Me: This is just a misunderstanding isn’t it?
Sonographer: Why? Have you been cramping or bleeding?
Me: Uh no, I was just joking. Just don’t tell me its twins
Sonographer: Why is that? Did your doctor say your pregnancy hormone levels were extremely high?
Me: Uh no. Just joking again
Sonographer: Well you are having twins
Me: Shut up!
Then she showed us on her monitor the two little sacs, each with its own beating heart. My partner Richard and I walked out in shock.
So Michelle, thank you for sharing your story, if you guys have an interesting story, we all do right, when we find out we’re pregnant with twins. Go ahead and send us an email, you can also call our voicemail at 619-8664775
CHRISTINE STEWART-FITZGERALD: This wraps up our show for today. We appreciate you listening to Twin Talks.
Don’t forget to check out our sister shows:
• Preggie Pals for expecting parents
• Parent Savers for moms and dads with newborns, infants and toddlers
Thanks for listening to The Boob Group, your judgment-free breastfeeding resource.
This has been a New Mommy Media production. Information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though information in which areas are related to be accurate, it is not intended to replace or substitute for professional, Medical or advisor care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.
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