Do fertility drugs increase the risk of ovarian cancer?

Fertility Drugs like Clomid, Menopur, Pergonal, Gonal F, Follistim, and others have been used for many years to induce ovulation in both women who don’t ovulate and those that need to produce more than one egg at the time.  Physicians have tracked whether patients have a higher risk of future ovarian cancers after receiving such drugs.  So far there is no evidence that shows that there is a higher risk of ovarian cancers after using fertility drugs.  What we know is that actually being pregnant or using a birth control pill can lower the risk of future ovarian cancers.  Here is a recent article that reassures us in this regard.  Note that patients that took Clomid and then never became pregnant did have a higher risk of future ovarian cancer.  This implies that the risk may not have been increased by the drug, but because the patients did not conceive and did not use oral contraceptives either.

Julio E. Pabon, M.D., F.A.C.O.G., October 2013IMG_0440 copy

www.geneticsandfertility.com

No Increased Risk of Ovarian Cancer Found With Common Fertility Drugs

October 14, 2013

 

By Lorraine L. Janeczko

NEW YORK (Reuters Health) Oct 14 – Women taking ovulation-inducing drugs are not at increased risk of ovarian cancer, researchers have found.

Writing in Fertility and Sterility, online September 6, Dr. Britton Trabert and colleagues note that the use of fertility treatment has been on the rise. It is biologically plausible, they add, that ovulation-inducing drugs could be associated with ovarian cancer.

But as Dr. Trabert told Reuters Health by email, “we found no evidence that either clomiphene or gonadotropins, the drugs in our study most commonly used to treat infertility, were associated with an increased risk of ovarian cancer.”

Dr. Trabert, from the Division of Cancer Epidemiology and Genetics at the National Cancer Institute in Bethesda, Maryland, and her colleagues analyzed data from women seen for infertility at five large U.S. practices between 1965 and 1988.

Nearly 10,000 women with at least one intact ovary were included in the study. The researchers followed the cohort for a mean of 17.6 years for ovarian cancer cases (n=85) and for a mean of 26.2 years for non-cases.

Overall, they found no association of ovarian cancer risk with ever use of CC (adjusted relative risk 1.34; 95% confidence interval 0.86 to 2.07) or gonadotropins (aRR 1.00; 95% CI 0.48 to 2.08).

However, women who used CC and remained nulligravid at follow-up were at higher risk of developing ovarian cancer than were those who successfully conceived, compared with nonusers (aRR 3.63; 95% CI 1.36 to 9.72 vs. aRR 0.88; 95% CI 0.47 to 1.63, respectively).

Dr. Trabert said it remains unclear whether nulligravid women on anti-ovulation drugs are at higher risk than are nulligravid women without exposure to the medications.

“These findings shouldn’t influence current treatment practices,” she said. “Our study evaluated drugs as they were prescribed mainly in the 1970s and 1980s, and many of the exposures were much higher than those with the drugs used today.”

Dr. Caren M. Stalburg, who wasn’t involved in the study, said the findings are reassuring and consistent with earlier meta-analyses that showed no link between ovulation-inducing drugs and ovarian cancer.

“They may also help identify a subset of individuals who are at increased risk for ovarian cancer long-term, that is, those women who remain nulligravid after the use of clomiphene citrate,” Dr. Stalburg, an ob-gyn at the University of Michigan Medical School in Ann Arbor, told Reuters Health by email.

“Given that we do not have effective mechanisms for ovarian cancer screening, it is unclear how these individuals should be monitored per se,” she added. “Awareness of the risks in this subset of women may be all that is possible for now.”

 

How Old is Too Old To Become a Parent?

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This is a difficult question.  As Reproductive Endocrinologists, it seems that the boundaries of acceptability are always changing.  In my practice, we do not discriminate on the basis of age.  Older patients are informed of the increased risk of pregnancy complications such as hypertension, diabetes, and pre-term birth that are more common as patients age.  Patients are treated into their late forties and  and early fifties.  We screen patients very thoroughly and require a cardiac stress test for those over 45.  Patients that choose to try to conceive in their mid forties or later are informed that they have to be in optimal health and not have significant “co-morbidities.”  The most common one of these is obesity.  If a patient wishes to try to become pregnant later in life, she needs to demonstrate  that she is not increasing the risk further by being obese.

I try to educate patients about the ethics of advanced age parenting and assess the family structure to make sure kids will be cared for if the older parents become ill.

There was and interesting case a few years ago in Florida when a lady called a Florida IVF clinic and was turned away by the receptionist “because of her age.”  It turns out the patient was in the legal profession and sued that clinic for age discrimination.

The article below comments about a terrible event in Italy and suggests that there should be legal age limits imposed upon patients and clinics.  Who is to decide what is the proper limit.  What about an older man that marries a younger lady or vice versa.  It is best to make these assessments on an individual basis instead of making more rules.  I hope that U.S. Reproductive Endocrinologists will use good judgement on a case by case basis.

Here is the article as reported in the A.P. by A Vasireddy and S. Bewley

Julio E. Pabon, M.D., F.A.C.O.G.

 

How Old Is Too Old to Become a Parent?

Tragic Outcome of Post-menopausal Pregnancy: An Obstetric Commentary

Vasireddy A, Bewley S
Reprod Biomed Online. 2013;27:121-124

Background

Initially, in vitro fertilization (IVF) was offered to overcome the problem of tubal disease. As experience has grown with the treatments and as the technology has improved, IVF has become available to a wider patient population, based on more heterogeneous indications. Nowadays, it is offered to treat male factor, tubal, immunologic, hormonal, unexplained, etc. causes of infertility. Over the years, it also became evident that the treatment can be successfully completed with donated gametes (egg, sperm donation) or when the embryo is implanted into a surrogate’s uterus. This has opened up new areas of use. The availability of such “nonclassic” methods also raises legal and ethical questions.

A trend in delaying childbearing can be observed in the past decades. Women in increasing numbers continue their education and seek a professional career. In modern societies, it also seems more difficult to establish stable relationships that could be the base of a family. The result of these changes is that more and more women start thinking about conceiving once they are already over 30.

The ovaries contain a finite number of eggs. Reduced oocyte availability and poorer egg quality are associated with increased reproductive difficulty as women age. While under 30 years of age, only 5%-10% of couples face infertility problems. By the age of 40, the incidence of infertility is over 40%. Over the age of 45, women rarely conceive on their own or with assisted reproductive technology (ART).

Age-related problems in the woman can usually be overcome with the use of donated oocytes. This commentary article discusses the ethical and biological aspects of oocyte donation at an advanced age in relation to a controversial legal case.

Commentary Summary

According to a 2011 report, an Italian court took a 1-year-old child away from a couple as they were considered too old to be fit parents at the female age of 57 and male age of 70. The child was conceived through ART treatment abroad.

The authors discuss that as women age, the proportion of embryos affected by aneuploidy increases, and this is a major limiting factor in achieving pregnancy in the late 30s and early 40s. The uterus also shows some signs of aging, probably related to suboptimal blood supply, but this seems to be less of an issue because the age factor can be overcome by the use of donated oocytes.

It is also known that pregnancies at the extremes of the reproductive years are associated with a higher frequency of medical complications (hypertensive complications, gestational diabetes, preterm delivery, stillbirth, operative delivery). A pregnancy conceived through egg donation in a woman with advanced age is also associated with an increased incidence of medical complications, so the use of “young” eggs does not prevent these complications.

Even if a pregnancy progresses uneventfully and results in the delivery of a healthy child, one has to consider the chronic medical problems and malignancies that affect women in the fourth through sixth decades of life when they need to raise the child. While one tries to help couples whose last resort is gamete donation, the interest of the offspring also needs to be considered. Should the parents become incapable of fulfilling their parental responsibilities, it will become the responsibility of the society to provide care for these children. Therefore, the authors feel that the fertility treatment of women of advanced age or even in menopause should be regulated to avoid future cases like that in Italy.

Age is probably the single most important parameter affecting reproductive success. A woman’s chance to conceive starts to decline at around the age of 30, and over 45 it is very rare to achieve a successful pregnancy. This is due to the reduced number of eggs available for fertilization as well as to their poorer quality that leads to increased aneuploidy rates with age. Women who delay childbearing can expect a longer time to succeed, more need for ART, and smaller family size. ART may compensate for some of the reduced chance but cannot make up for all of it. Pregnancies that are conceived in women over 35 are complicated by higher miscarriage and stillbirth rates; medical complications during pregnancy are more common too.

Women over 40 are more likely to require donor eggs to achieve a pregnancy when compared with younger women. An embryo that is created from a younger woman’s egg will have a high chance to implant, so women even after reaching natural menopause still have a chance to achieve a successful pregnancy. However, they need to be aware that these pregnancies are still complicated by more hypertensive complications, low birth weight, and need for operative delivery.

A child born to older parents may face relationship or emotional problems with his/her parents due to the big age gap. On the other hand, older parents are more likely to be able to provide the financial needs required to raise a child. The availability of social egg freezing is another issue that will likely result in more pregnancies among women of advanced reproductive age. Freezing eggs at a younger age allows women to study and start a job before they interrupt their professional career with a pregnancy and delivery. These women will probably not have big families that may have consequences to society. These women may also be diagnosed with medical problems or may be affected by undiagnosed medical issues by the time they decide to use their eggs, which may complicate the pregnancies and may lead to a higher rate of maternal morbidity/mortality.

Therefore, care providers have to be very careful when counseling women about pregnancies at an older age. Women should be encouraged to try on their own at a young age. Those who for various reasons cannot complete their desired family size early on should undergo a thorough medical evaluation before their own or donated eggs are used. An upper age limit should also be set to avoid problems like the one discussed in the article and to make sure parents will be there for their children until their children at least reach adulthood.

 

Sex Selection IVF

Sex Selection IVF

Sex selection IVF by Laser blastocyst trophectoderm biopsies and PGS with microarray 24 chromosome complete genomic hybridization techniques in our Florida Clinic is the most accurate method available.  While most clinics that provide sex selection IVF services are still depending on older technology based on the biopsy of a day 3 embryo and FISH (Fluorescent in situ hybridization probes), we have been pioneers in the application of blastocyst biopsies in the Southeastern United States.  The technology is so reliable that the majority of treatments can be completed with a single embryo transfer (fresh or frozen/thawed) with an expectation of pregnancy in more than 60% of patients that receive a single embryo.  We have been offering PGD, PGS, and sex selection IVF services since 1999.  Our first pregnancy with PGS/PGD technology and sex selection IVF was in a treatment completed in late 1999.  At that time and until mid 2012, all of our procedures were based on day 3 embryo biopsies.  Recently, we have brought the capability of blastocyst biopsies to the Southeastern United States.  The decision to lead in this technology was based on emerging science confirming the safety and increased reliability of the results based on the biopsy of the blastocyst.  The results for PGD, PGS and sex selection IVF are so reliable that we have increased our pregnancy rates while reducing the number of embryos transferred from 2 or 3 to only one in most cases.  This allows completion of the treatment without the risk of a complicated multiple (twin or triplet) pregnancy.

Family Balancing & Sex Selection

Technology has advanced significantly in the past several years allowing couples the option of selecting the sex of their next child.  Fertility Center & Applied Genetics of Florida and the offices of Julio E. Pabon, M.D., P.A.  participated in the MicroSort® clinical trial.   Dr. Pabon had a long association with the MicroSort® study team as a study collaborator.

The microsort trial had hoped to reliably sort sperm in order to reliably select a sample rich in Y chromosomes (to lead to a male child) or rich in X chromosomes (to lead to a female child), but the trial failed.  There were never reliable enough results to bring it to clinical fruition.  Research continues in this area of science.  Unfortunately, thus far sperm sorting procedures are not reliable enough for clinical use.  At this time the only reliable method for family balancing or sex selection requires “in vitro” fertilization and pre-implantation genetic diagnosis or screening of pre-embryos prior to implantation.

Pre implantation Genetic Screening (PGS) or Pre implantation Genetic Diagnosis (PGD) for Sex Selection IVF (family balancing)

PGS stands for pre-implantation genetic screening of embryos.  PGD stands for pre-implantation genetic diagnosis of embryos.  PGS or screening is the term for the procedures involved in determining that an embryo or embryos have the correct or incorrect number of chromosomes.  PGD or genetic diagnosis of embryos is the term for the procedures (very similar in the IVF lab) that lead to diagnosing a particular disease or condition in the embryo that has to do with a particular genetic disease.  PGD is usually performed to test embryos when the parents are “carriers” of a particular disease like Cystic fibrosis, spinal muscular atrophy, Fragile X, sickle cell anemia, etc.  For the purposes of screening embryos in order to determine their gender, PGD is carried out to determine the number of chromosomes and which sex chromosomes are present.  PGS also helps to prevent conditions that are caused by genetic errors in the numbers of chromosomes in embryos like the Down’s syndrome (trisomy 21) or other conditions like it where the embryo may have an incorrect number of chromosomes and may be used as part of sex selection IVF.

Humans with a normal complement of chromosomes have 23 pairs of chromosomes.  There are 22 pairs of chromosomes called the autosomes that determine characteristics other than gender.  In addition to these 22 chromosomes, there is a pair of “sex chromosomes” that carry the genetic information that leads to the differentiation of the fetus into a girl or a boy.  The Karyotype of a girl is 46 XX while that of a male is 46 XY.  The presence of the Y chromosome leads to differentiation into a boy.  The figure below is a computer enhanced image of the chromosomes in the nucleus of cell.

Scan 8

The sex of a pre-embryo can be determined three, five, or six days after the fertilization of the egg.  Our center had its first live birth after PGD/PGS sex selection IVF in 2000.  The patient carried a sex-chromosome-linked fatal genetic disease.  In this initial case, we were able to screen three day old pre-embryos for abnormalities in eight key chromosome pairs.  One of the chromosome pairs was the sex chromosomes.  We were able to select XX carrying female pre-embryos to transfer into the mother.  This avoided the severe neurological disease that was carried in the male offspring in this family.  Since then, we have treated numerous patients with PGD or PGS for not only sub-fertility, recurrent pregnancy losses, genetic disorders, as well as patients with a desire to pre-determine the sex of the next child.

Our patients are always counseled that no medical procedure can be 100% guaranteed.  It should be noted however thatsince 2002, we have treated hundreds of patients without one misdiagnosis or surprise regarding the sex of the child.

PGD/PGS technology has become more reliable.  In the first years of PGD/PGS, we relied mostly on the biopsy of day 3 multicellular pre-embryos.  Day 3 multicellular pre-embryos are usually composed of 6-8 cells.  While most pre-embryos are made up of identical cells, 7-10% of them can be mosaics.  Mosaic multicellular pre-embryos can lead to a sampling error that can give erroneous results since the cell sampled may not represent what ultimately becomes the baby.  In addition, in the early years of this technology, we relied mostly on fluorescent “in situ” hybridization techniques in order to identify the chromosomes.  The probes used for “in situ” hybridization were designed to bind to unique regions of chromosomes and relied on binding affinities that varied with each assay.  Nonetheless, we were able to have very reliable results with not a single misdiagnosis even in the early years.

Since 2006, our program evolved to more reliable 24 chromosome microarrays and complete genomic hybridization techniques.  These complex technologies expand the available DNA in a cell and give a reading of the genetics of the cell that is more reliable than the old “FISH” techniques.  Even more recently, as of the Fall of 2012, our program has moved from day 3 multicellular pre-embryo biopsies to the highest current technology.  This is the laser assisted trophectoderm blastocyst biopsy.

Laser assisted trophectoderm blastocyst biopsies raise the bar to the highest possible level because we sample embryos on the fifth or sixth day and we sample more than one cell per pre-embryo.  This increases the reliability and reduces the negative impact of mosaicism.  One can be 98%-99% sure that the results of  the embryo biopsy will represent the ultimate genetics of the fetus and subsequent baby.  Please refer to the PGD/PGS portion of this web page.

Family Balancing/Sex Selection Common Questions

Is Sex Selection ethically appropriate? 
At Fertility Center & Applied Genetics of Florida and the offices of Julio E. Pabon, M.D.,P.A., we treat all pre-embryos with great respect and encourage families to preserve through cryopreservation normal pre-embryos regardless of their sex chromosome status.

The ethics of sex selection are certainly controversial.  There are certainly those who feel that this technology should only be applied to prevent devastating genetic diseases or conditions.  Some feel it should not be an elective procedure used for family balancing.  Family Balancing & Sex Selection is an extremely personal decision.  We are fortunate to have the freedom to make such choices.  Choosing one blastocyst pre-embryo over another certainly is better than choosing further along in the fetal stages of the pregnancy.

Given the safety of the processes involved, it is our opinion that family balancing through sex selection is acceptable.  The processes are carried out on pre-embryos prior to any tissue differentiation or organ system development.  Blastocyst pre-embryos have not yet developed any differentiated tissues such as nerve tissues or cardiac tissues.  The potential for development exists just as in the stem cells in the bone marrow, the dermis of the skin, and even in the menstrual cells shed each month.

What if all the pre-embryos are of the opposite sex that we desire?

Patients must understand that there may not be any normal pre-embryos in any particular treatment cycle.   Very abnormal pre-embryos may arrest or stop growing prior to reaching the blastocyst stage for biopsy.  Also, the results of the genetic tests may not yield a normal chromosome complement of the desired gender.  These results are very disappointing, but are a reality of the biology involved.  Patients must decide whether they wish to freeze normal pre-embryos of the opposite sex desired or if they would accept them for implantation.  Alternatively, the embryos can be placed in an adoption program managed by our offices.   A treatment may be a scientific success while still being disappointing.

What are the procedures like?

Patients will have a thorough consultation that can be in person (local patients) or via SKYPE or on the phone.  Dr. Pabon prefers SKYPE instead of the phone because he can share his desktop with the patients and show tables and images to patients during the remote consultation.  Patients will be prepared for IVF in the usual manner.  They will be required to do some routine labs and pre-tests as described in the IVF patient guide.  Out of town patients can be prepared by their local physicians or clinics and travel to Sarasota at the very end of the ovarian stimulation phase.

Are the procedures safe?

Modern IVF procedures are extremely safe.  There have been recent changes in the ovarian stimulation and the egg maturation trigger that have virtually eliminated the risk of severe ovarian swelling or “ovarian hyperstimulation syndrome.”  In years past, the final trigger was with full dose hCG.  This led to ovarian hyperstimulation in 10-25% of patients depending on their clinic protocols.  Severe hyperstimulation was the most feared complication as it could lead to hospitalization and even severe complications like blood clots.  Recently, we have applied new science in order to trigger most of our higher responding patients with a very gentle “agonist trigger.”  This strategy leads to a very mild ovulation that leads to only mild ovarian enlargement and exceeding low risks of ovarian hyperstimulation. The only down side is that the agonist trigger results in lower implantation rates and therefore these cycles lead to the harvest of the eggs and the IVF and embryo biopsies, but the blastocysts have to be frozen for implantation the following month.

The other common complication that is feared by most specialists is a twin or higher order pregnancy.  Fortunately, this complication is quite rare now that we are able to complete most treatments with a single embryo transfer.

May I have Twins Please?

Dr. Pabon advices against the transfer of more than one “robust” embryo with normal genetic results.  In years past and in patients being treated without PGS testing of their embryos, it was quite common to implant 2 embryos.  The reason for this is that one cannot tell if an embryo is genetically normal based on its appearance.  Implanting 2 embryos without PGS results in average pregnancy rates of 45-50% in good prognosis patients in their early and mid thirties.  Implanting one “robust” embryo with known normal PGS genetic results results in a pregnancy in more that 60% of patients.  Implanting 2 in this situation has resulted in 100% twins in every case robust embryos were transferred (at the time of this writing).  A planned twin pregnancy is not good medicine because these pregnancies are very risky for the babies due to pre-term birth and much higher chances of severe congenital anomalies and cerebral palsy.

Our Medical and Laboratory Director:IMG_0440 copy

Julio E. Pabon, M.D. , F.A.C.O.G.

Fertility Options for Cancer Patients

The Sarasota oncofertility meeting last weekend reviewed fertility options for cancer patients.  The first oncofertiity meeting in Sarasota was successful in elevating awareness of the fertility options for cancer patients.  I give my thanks to Joann Heaton, MS, ARNP, AOCNP, ACHPN, Nurse Educator of Sarasota Memorial Hospital as well as the Medical Education committee of SMH for all the effort and planning of the meeting.  I also give special thanks to Dr. Quinn from Moffitt Cancer Center for her participation.

Sincerely,

Scottish Loch Copyright J. Pabon collection
Scottish Loch
Copyright J. Pabon collection

Julio E. Pabon, M.D., F.A.C.O.G.

Fertility Center and Applied Genetics of Florida

Sarasota and Bonita Springs, Florida  U.S.A.

Here is a recent publication form the American Society of Clinical Oncologists:

Fertility Preservation in Patients with Cancer: American Society of Clinical Oncology Guideline Update

Published online before print May 28, 2013, doi: 10.1200/JCO.2013.49.2678
Alison W. Loren, Pamela B. Mangu, Lindsay Nohr Beck, Lawrence Brennan, Anthony J. Magdalinski, Ann H. Partridge, Gwendolyn Quinn, W. Hamish Wallace and Kutluk Oktay

Purpose: To update guidance for health care providers about fertility preservation for adults and children with cancer.

Methods: A systematic review of the literature published from March 2006 through January 2013 was completed using MEDLINE and the Cochrane Collaboration Library. An Update Panel reviewed the evidence and updated the recommendation language.

Results: There were 222 new publications that met inclusion criteria. A majority were observational studies, cohort studies, and case series or reports, with few randomized clinical trials. After review of the new evidence, the Update Panel concluded that no major, substantive revisions to the 2006 American Society of Clinical Oncology recommendations were warranted, but clarifications were added.

Recommendations: As part of education and informed consent before cancer therapy, health care providers (including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, and surgeons) should address the possibility of infertility with patients treated during their reproductive years (or with parents or guardians of children) and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. Although patients may be focused initially on their cancer diagnosis, the Update Panel encourages providers to advise patients regarding potential threats to fertility as early as possible in the treatment process so as to allow for the widest array of options for fertility preservation. The discussion should be documented. Sperm and embryo cryopreservation as well as oocyte cryopreservation are considered standard practice and are widely available. Other fertility preservation methods should be considered investigational and should be performed by providers with the necessary expertise.

Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action. The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary. ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

Last updated 5/28/2013

Florida IVF Doctor with advice for Egg Donors

As a busy IVF Doctor in Florida serving Sarasota, Tampa, Bradenton, Ft. Myers, Naples, and Egg Donor IVF patients from all Florida and abroad, I had a good visit with a young lady that hopes to donate her eggs anonymously to a lovely couple.  During her counseling and education I was reminded of the great gift that our egg donor patients give.  As I do value them as dear patients, their wishes are very important to me.  Their anonymity is important to them as it is to the intended parents.  We had a conversation about her reasons for being interested in egg donation and as I spoke with her, I reminded her that she should be careful with social media and the internet.

Few of us realize that the internet is eroding our privacy gradually and surely.  For example, many people post many photos of themselves in social media sites. Unfortunately (or fortunately depending on your point of view), the technology exists for facial recognition software to search the entire internet to find matching faces.  For that reason, I remind anonymous egg donors to not post straight on face “shots” in their social media pages or in the internet at all if they truly value their privacy.

Also, anonymous egg donors are asked to not join the social marketing networks of the fertility center where they are treated.

Just a reminder from your doctor,
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All the best!!

Julio E. Pabon, M.D., F.A.C.O.G.

Fertility Center and Applied Genetics of Florida

Sarasota and Bonita Springs, Florida  U.S.A.

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