“Crohn’s and Ulcerative Colitis, Part Two: Before, during, and after pregnancy” – with Dr. Asher Kornbluth

In part 2 of this episode, Dr. Nathan Fox speaks with Dr. Asher Kornbuth, a clinical professor of medicine in gastroenterology at Mount Sinai about Crohn’s Disease and Ulcerative Colitis during pregnancy.

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Dr. Fox: Welcome to today’s episode of “Helpful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and Maternal Fetal Medicine Specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. I’m welcoming back. Dr. Asher Kornbluth, who is the Gastroenterologist to the stars in New York City and…

Dr. Kornbluth: Oh, no, no. To see the common people, stars can go elsewhere.

Dr. Fox: All right. And Asher was on last week. We spoke about Chron’s, and ulcerative colitis, and [inaudible 00:00:39] general…

Dr. Kornbluth: Despite that, I was invited back.

Dr. Fox: Despite that, invited back. No, you know, I wanted to talk about that because it’s an important topic itself, obviously for everybody. But I wanted to have a separate podcast to talk about that specifically related to pregnancy. So, obviously, when someone has a chronic medical condition or even acute medical condition, there’s usually a need to see both someone like you, Asher, for the condition, and someone like me for the pregnancy, and we work in cahoots for this. You know, we’re sort of talking back and forth, but I wanted to get your perspective. You obviously would be seeing these people before potentially they would see their obstetrician or gynecologist, right? You’ve been treating them for Crohn’s or colitis for X amount of time. And one of your patients who you’ve been treating for let’s say a couple of years or whatever comes to you and says, you know what? I’m thinking of having kids, right? What goes through your mind, or what types of things do you go over with her prior to getting pregnant? You know, in terms of let’s say, do you have to change your medications, you have to do this, wait till you’re this, you know, what are the things that you would start with her in that conversation, and how long does it take to get someone ready for that?

Dr. Kornbluth: Okay, great question. So, while a patient’s having active disease, I mean, it’s not hard for me to say don’t try to get pregnant because they’re not feeling well. Perhaps the last thing they wanna do. But again, as we said last week, this is a disease of people in the teens, 20s, and 30s, the prime of their life, their childbearing years. It has no predilection for more commonly women or men, so this comes up all the time. As we said last week, the only medication we will deliberately, very aggressively stop, and the patient should be off of it for at least three months is something called methotrexate, which fortunately we rarely use anymore. There’s a couple of newer drugs that we will try and wean the patient off that are oral. We’re not sure. They’re not safe. They just haven’t been studied. One is called Zendin, one is called Rinvol.

Dr. Fox: Right. It’s possible several years from now that’ll change. Then we’ll learn that they’re safe. We don’t know.

Dr. Kornbluth: And some of the other meds I’ll talk about, we didn’t know a couple of years ago either. So, I’ll tell the patient, and it’s rare that a patient’s sick and they’ll say, I want to get pregnant now, and I have to discourage them. But a patient just got better and said, okay, now I’m ready to try and conceive. I generally tell them, I’ll preface it by saying, I am not the one to give you life advice and the big plan in life. But in general, if you’re trying to get pregnant, I would like to see you perfectly well for six months because we know that some percentage of women will have an exacerbation of their colitis or Crohn’s disease purely due to pregnancy-related, probably hormonal changes. So, you don’t wanna be that patient who just got well, maybe isn’t entirely better, and now taking the risk that you’ll be that woman who pregnancy per se will exacerbate your Crohn’s or colitis.

Now I’ll make clear that’s not inevitable and probably well, well, well less than half will have an exacerbation purely because of pregnancy. But in general, I’ll tell a woman who’s gotten out of a flare-up, or has been well for some time, my general suggestion is at least six months of being well because that gives me some sense that you have some real healing. That you’ve had a durable remission, not that you just got better a month ago. And I’m hoping that’s sustained. I like to see at least six months. To basically summarize about everything I have a huncho [SP] asked me by far the most important feature of the mom doing well throughout pregnancy, and as a consequence, the fetus doing well, being able to deliver at term, being able to deliver a baby at an ideal birth weight, by far is the activity of the Crohn’s disease or ulcerative colitis.

The biggest mistake we see is that the gastroenterologist might be fearful, or maybe the obstetrician that these medications are not safe during pregnancy, and stops them, and god forbid then patient has a flare-up. We struggle with that because we know we’re putting the fetus at risk when we are struggling with ongoing inflammation. And again, fortunately, all of our medications are okay to take during pregnancy. So, we’ll just juggle those around. But that’s a big concern we have is that if the patient has severe flare-up, what’s happening to that fetus in the meantime?

Dr. Fox: Meaning, just so I understand you’re saying that in from your perspective, I’m not saying I disagree because I do agree, but from your perspective, if someone said, all right, I have Crohn’s, and I’m gonna get pregnant, or I have Crohn’s and I am pregnant, how would you predict how well I’m gonna do? It’s gonna be whether you do or don’t get flare-ups while you’re pregnant, meaning someone has Crohn’s and doesn’t get flares, you would expect them to do well, and someone who has Crohn’s, and has a lot of flares, and they’re pregnant. I mean, they might do well, in terms of them and the baby, but they have a much higher risk. Correct?

Dr. Kornbluth: Yeah. So, there’s no hard and fast rule if the patient’s never been pregnant while they’ve had Crohn’s or Colitis, what that pregnancy will look like. What I would say is, is if the patients with past pregnancies has had flare-ups, that’s a patient that I’m more concerned will have a flare-up again. History might repeat itself, and it’s probably because there are some constellation of hormonal changes that is playing a role. Similarly, some women will have their first flare-up that they will develop Crohn’s or colitis where it becomes manifest, or have an exacerbation in the postpartum period within a few months. They’re too probably due to hormonal changes, and if the patient’s been well for years during that postpartum period, I’ll just be ultra-careful making sure the patient stays on their meds, etc. So, they don’t suffer that same pattern of a postpartum flare-up.

Dr. Fox: Right. Now there is this concept that one of the reasons you want someone to be without flare for six months is also just as like a prediction. Meaning you were saying it’s nice because you know they’re healed, their intestines are healthier, maybe they’ve, you know, absorbed the right vitamins and nutrients, and they’re ready for pregnancy. But is there something to that, that someone who has not had flares for six months, just statistically is less likely to have it in the upcoming nine months, compared to someone who’s had two or three flares in the past six months?

Dr. Kornbluth: Yeah, so I tell my patients that unlike, I might not quote this exactly like you hear all the disclaimers, Wall Street, you know, past performance does not predict future outcomes. In Crohn’s and colitis though I’d say, well, we beg to differ a little bit because the longer you have stayed well now, the more likely you are to stay well. If you’ve been well for the last five years and been perfectly okay, on medications let’s say, and you have no history, that pregnancy triggers flare-up, you should do just fine. If on the other hand, you’ve been sick for the last two years, and you’ve finally got into remission, and you’ve waited the six months, you know, you have a more aggressive course. People’s Crohn’s and colitis behave differently. Some people have very severe Crohn’s and colitis by the nature of their history, and some it’s very mild and very intermittently. The patient has had multiple flare-ups, and a very aggressive course that patient, I’ll be super vigilant leading up to that attempt at conception.

Dr. Fox: Yeah, and it’s also really interesting in pregnancy when you’re saying that there’s some women who get flares because they’re pregnant, it can really go in any direction. You could have someone who didn’t get better because they’re pregnant, you know, because pregnancy itself is like a natural immunosuppressant. So, it’s like taking a biologic just by being pregnant. So, those women would tend to get better, then there’s certainly people who would get worse either because, like you said, something hormonal that we don’t quite understand like which hormonal and why. And also mechanically, like, you know, with the uterus growing, if they have scar tissue, that wasn’t a problem. But now the intestines have moved, you know, a foot to the right, and now that they do have a problem, and so, that’s a possibility. And then there’s some that just doesn’t seem to make ’em better or worse. They’re just kind of the same.

And when I see people before pregnancy, and I tell ’em, I say, I can’t really predict are you gonna get worse, better or the same. I would say there’s well more people who are either better or the same than worse. I think people get worse in pregnancy is probably the exception. Unless they’re always sick, but then they’re not really worse, they’re just that. And so that’s, you know, reassuring. And then the ones who maybe get better could usually be the ones that get flares after delivery because their immune system sort of coming back up, and they’re like, you know, attacking their colon again.

Dr. Kornbluth: Again, [inaudible 00:09:15] Dr. Jan, he had a rule of thumb. I’m not sure it’s really born out more recently, but his rule was one-third, one-third, one-third. And it doesn’t exactly gel with what you said, and your point of view is probably more accurate these days. One-third of patients will have no change in their symptoms, one-third of patients will get worse, one-third of patients will get better. But that doesn’t really necessarily hold up. And every patient I think is their own, you know, study so to speak. You know, if you’ve always gotten worse on pregnancy, I’m worried. Some patients will literally say, and I could almost mouth the words with them because I could see it come. They say the best I’ve ever felt is during pregnancy. If I could always stay pregnant, I’d be great. And I don’t advocate staying pregnant all the time, but some patients know that they’re going to have, like you say, maybe it’s due to hormonal changes, acts as an immunosuppressant maybe. So, it’s hard to predict. But again, the longer you’ve been well, the more likely you are to stay well.

Dr. Fox: But I think a really important point you made, and this is something that, you know, we always encourage, but not everyone sees us before they get pregnant. Sometimes they just come to us pregnant is anyone who has a chronic medical condition, who is well because of the medication. If someone tells you to stop that medication because you’re about to get pregnant, get a second opinion on that one. Double check that because that is something that is…listen, there are medications, like you said, someone’s on methotrexate, and your doctor says you shouldn’t be on this. Okay? Like, I would agree with that, but they should put you on something else. But if someone just says, oh, you’re about to get pregnant, stop it. Fortunately, that’s not usually from doctors or sometimes it is. There are doctors who give incorrect advice, but it could be a family member or friend. It could be the Google, right? People can find that. And if you’ve ever heard that, question it. Speak to an obstetrician. Get another opinion from the medical person because it’s rarely the case. Almost never. And you have to stop something because you’re about to get pregnant.

Dr. Kornbluth: Yeah. I’ll tell the patient that if you’ve been on a long-standing medication, I’ll give you a couple of exceptions in a minute. And the obstetrician tells you before pregnancy or during pregnancy, I want you to start that medication. I tell them very bluntly, you need to go to another obstetrician because they might be brilliant, but they’re just ignorant in this regard, period, the end. I can’t stress it enough, the much bigger risk to the mom’s health and to the fetus and the baby’s health is keeping the Crohn’s and colitis under control. Active inflammation is the worst possible outcome. And there are meds we try and avoid, and we work very hard to get patients off. The ones again, never to be on if you’re contemplating pregnancies, methotrexate.

During pregnancy, we’ve worked very hard to get patients off steroids especially the first trimester, antibiotics that are sometimes these days rarely use Cipro and Flagyl. We try and shy away from them. And unfortunately, even our old imodium or Lomotil or Loperamide, we are not crazy about using them during pregnancy, which is unfortunate because they’re very effective to just be non-specific, anti-diarrheal meds. But all of the biologics, all our other drugs, methotrexate absolutely our first trimester. We don’t like steroids at all. But your biologics, the anti-TNF drugs, Remicade, Humira typically, Entyvio, Stelara, we emphatically say stay on them. The newer ones, which I mentioned a couple of times, we just don’t have enough information. One is called Xepazym, one is Rinvoq, one is Xeljanz.

Dr. Fox: Now, do you have any concern that these medications will affect the baby’s immune system? So, we have pretty good data that they don’t cause birth defects. They don’t cause, like, neurocognitive issues and stuff, but is there a concern that the baby’s gonna be born, and get some crazy infection because they’ve been exposed to this immunosuppressant so to speak?

Dr. Kornbluth: Yeah, so let me refer and pitch for every woman who is ever thinking about getting pregnant or talking to a family member who’s pregnant. What I consider an international treasure is something known as the PIANO, which stands for pregnancy in something, something neonatal something. But that’s the abbreviation, the PIANO registry. It’s online and I’m sure it’s online in many ways that it is for laypeople, not for doctors. Started by someone who I consider now a really a hero for all these moms. Uma Mahadevan, who was one of our residents at Sinai, now is a giant in the field of UCSF, where she has prospectively followed several thousand patients. Now, prospectively means looking forward. We still have this data. We’d ask moms, oh, you had a baby five years ago, what was your pregnancy like on that bed? So, you get very skewed data.

So, with this registry, Uma asked many of us around the country, if you have a pregnant mom, please call us. I’ll have my research coordinator call that mom, and talk to her throughout the pregnancy, and now for up to 12 years. So, she’s really tracked outcomes of the babies born on these meds, and the take-home messages, as long as you have the disease under control, the baby, the newborns, and with development do at least as well. I’ll prove that point in a minute. As babies born to moms who are never on immunosuppressives, or who never had Crohn’s and colitis. So much so that she has tracked developmental milestones very formally, and at every age group she’s analyzed this so far, and that number’s grown as years gone. Those babies now kids do at least as well as kids born of moms not on these drugs.

So, if you want your kid to go to Dalton or to Harvard, start taking, you know, one of these immunosuppressants from pregnancy. It might be that those things are suppressing stuff that in part hinders development. We don’t know. But certainly, the babies are not born at a disadvantage. There’s some literature, not universally, that they might be more prone to early child infections, but none of them are severe. In terms of vaccinations, the only vaccination we ask them to avoid is rotavirus because that’s a Y vaccine. And babies who get rotavirus don’t tend to get very sick with it far and large. So, the kids do just fine.

Dr. Fox: And so, if you have a patient, and you’ve spoken to her, and she’s on her med, and she’s on one that you’re comfortable she’s getting pregnant, and she gets pregnant, do you have to change either the dose or the frequency of the medication or it stays the same? Like, let’s say we’re talking about one of the biologics?

Dr. Kornbluth: Yeah, great question, and there’s some differences of opinion among experts in this. So, the biologics that have been studied the most are the ones that have been around the longest, namely Remicade Numar. As do some of the others that do, they do cross the placenta, and you could actually measure it, and Uma Mahadevan has, you know, gotten placental blood and fetal blood on some of these babies, and you find this drug is present in the baby’s blood. Does that cause any risk to the baby? Maybe a slight uptick in not severe infections, and not in developmental delay in any way. So, we certainly don’t reduce the dose. We don’t eliminate the drug really ever. Sometimes if it is a drug that we give every eight weeks like Remicade, we might try and pull the drug back. So, instead of at week 38, maybe we’ll give it at week 34. So, there’s less circulating drug in the mom’s blood. That is not even a universally held concept. But sometimes you’re a gastroenterologist, and they really should be expert in the management of Crohn’s and colitis, and dealing with hundreds of patients on these drugs, might jiggle around your schedule, but not stopping.

Dr. Fox: Right. So, a little bit maybe chicanery at the end just to dose it slightly…

Dr. Kornbluth: [vocalization] chicanery sounds a little sleazy.

Dr. Fox: And then and then presumably, right after they deliver, they’re still on. Yeah. Because you don’t wanna get a flare after. Now, do you have to see that bit of more regular frequency than you would normally, or just based on their symptoms? Like, what do you like to do if you have someone who’s pregnant?

Dr. Kornbluth: Yeah, so if the mom is doing well, my rule of thumb is every trimester, and the third trimester, depending on what their past history is, maybe a couple of weeks before their delivery because there’s issues, which I will probably get to in terms of mode of delivery. But generally, if they’re doing well, every trimester, if they’re not doing well, obviously more frequent than that.

Dr. Fox: Yeah. And if someone is potentially having a flare, they’re getting worse. The things you would normally do, you can still do when they’re pregnant. If you had to take a look with a colonoscopy, you can’t. It’s a little complicated in pregnancy. You try not to, but you know, if needed you have if you could, but the medications you give acutely, you pretty much can or you have options.

Dr. Kornbluth: Right. Again, prednisone, which was our go-to. But again, fortunately, now we have so many other safer meds, we avoid in the first trimester, Imodium or Imodo for diarrhea we try and stay away from. But the biologics, no we keep them on those meds for sure.

Dr. Fox: In terms of like an RN, we don’t do that much different other than making sure people are following up with our gastroenterologist, making sure they didn’t stop their meds, making sure they’re well. You know, we make sure the baby’s growing well just because potentially there’s nutritional issues. But usually, if the mom’s gaining weight and without symptoms, everything’s gonna be fine. And then you were mentioning before, there is definitely a conversation that comes up around delivery. So, I could tell you on our end, generally, women with Crohn’s can deliver vaginally unless they had surgery, and have that J pouch, and there’s a concern that it’s not so much the delivery, but that there’s tearing and it’s a big tear, and it gets close to that pouch, which is unusual. That doesn’t typically happen, but if it did, it’d be a disaster. And so, we do not want a disaster. So, that would be reason number one. And there are also some women, unfortunately, way fewer nowadays because of the medications who similarly will have Crohn’s disease with fistulas that come near their bottom. And it’s the same situation. If there’s anything there that could get really harmed by a tear, we try to avoid it. So, on our end, that’s basically it. Is there anything else in your end that you would tell someone to shy away from a vaginal delivery?

Dr. Kornbluth: Yeah, so if you have had the term we use, you just refer to it is perianal fistula or abscesses. What is that? Peri means around the anus, is the opening. Patients with [inaudible 00:19:25] fistulas, not an ulcerative colitis? Interestingly enough. But in Crohn’s disease, might not be related to any other inflammation in their gut. It might really focus in that area. They develop these little fistula. What’s a fistula? It’s basically a little tiny tract that forms usually from the anus, and breaks out somewhere on the skin, usually within a couple of inches of the anus. And sometimes it just drains a little mucus, or sometimes you develop a big abscess. What’s an abscess? Very plainly a collection of puss. That little abscess could be the size of a pea, could be the size of a grape. I’ve seen people have abscesses the size of a softball. They’re disastrous.

Now, if you have active perianal disease, it can fall an independent course from the rest of your intestines. I would say let’s get that perianal disease under control. You don’t want to have even any risk of a vaginal delivery causing problems. And very active perianal disease, I frankly tell the patient, you shouldn’t get pregnant now anyway because I know the effect of pregnancy on that. Let’s say you’ve had severe perianal disease, and there’s about 15% to 20% of women have a history of perianal disease. Now, there’s mild history of perianal disease, and the remote past, or recent and severe perianal disease with multiple fistulas, big abscesses. Those patients we actively discourage. Recent or severe history of perianal disease or abscesses, really discourage them from vaginal deliveries. But that’s a minority of patients who have been that severe that recently. Otherwise, we say there’s no reason you shouldn’t get a vaginal delivery. The J pouch, which we talked about last week, some surgeons don’t mind that you go back and you do a vaginal delivery after they work hard to make that J pouch, and some obstetricians will cautiously proceed with the vaginal delivery. It’s somewhat dependent on the physician you’re seeing, but the Crohn’s disease per se, in the absence of a bad fistula in the perianal area, there’s no reason they can’t have many, many deliveries vaginally.

Dr. Fox: Yeah. Most of our patients with Crohn’s have vaginal deliveries and they do well. Unfortunately, if they do end up with a cesarean, a lot of people with Crohn’s are worried that they’ve either had surgery before and have scar tissue, or might one day need surgery. Fortunately, works out that if you have, like, scar tissue from prior Crohn’s surgeries, it usually is not in the same place we do a C-section because either it’s behind the uterus, or the uterus has pushed that north, you know, higher than your belly button. So, even people that have Crohn’s and surgeries, and we’re doing a C-section, it does not tend to be more complicated on our end. If someone has had a lot of Crohn’s surgeries, sometimes we’ll have the surgeon come in, they wanna take a look, they’re sort of like, hey, you’re opening up her belly anyways, lemme come in and see. But they rarely have to do anything, it’s usually just because we can, and it’s like a service, you know, to the patient. But I agree, we’re pretty encouraging for women to have vaginal births. Now, postpartum other than continuing or going back on if they were changing the timing of their medications, do you warn people of anything specifically? Do you have any concerns about nursing related to Crohn’s or Crohn’s medications?

Dr. Kornbluth: Yeah, great question. So, the short answer is, no, keep doing what you’re doing. If you jiggle the timing of let’s say, Remicade, which is every eight weeks. Get them right back on it. I’ve had women who are due for their Humira, let’s say, which is every two weeks and they take it, you know, postpartum day number one. No, they could do everything. And if all the medications we said are safe during pregnancy, they are safe to nurse on. We’re not quite sure about Cipro and Flagyl. But all of the biologics, Remicade, Humira, Entyvio, and this again is thanks to Uma Mahadevan, Stelara, they’re safe to nurse on, and we don’t discourage our moms from nursing.

Dr. Fox: And again the same thing. Even if you could potentially find some of the medication or breast milk, these kids who are exposed to it have been found to be fine.

Dr. Kornbluth: Right? And she’s even gotten some breast milk from moms and studied them, and even some blood from the babies getting breast milk, to whatever degree it might show up, it has no clinical impact. And again, I tell the mum, remind the pediatrician because it ain’t the obstetrician making this call. Tell them the baby shouldn’t get the rotavirus vaccine and if they do, it’s not tragic. There’ve been some kids who have gotten it, and they have a case of diarrhea. The reason we say no rotavirus is of the childhood vaccines they’re gonna get in that age group that’s a live vaccine. So, we try and not use it because the baby might have some minor degree of immunosuppression.

Dr. Fox: Wow. Yeah. And a lot of what we were talking about was Crohn’s. But again, the treatment in pregnancy would really be no different on your end, whether it’s Crohn’s versus ulcerative colitis because again, it’s really what are the treatments they need? What is it they need to get better and whatnot? And basically, they both do well in pregnancy typically if they don’t have flare ups and they’re treated well.

Dr. Kornbluth: Right. And I’m not sure we’re gonna get to surgery, but unfortunately, there’s some women who are going to need surgery because they just can’t be without it for whatever [inaudible 00:24:11] reasons on pregnancy. And many of those pregnancies and the fetus survives and they do very well. But I will make an extraordinarily strong case that if they have a mom who’s pregnant and need surgery, they absolutely should be in a hospital, a tertiary care center that sees patients like this every day of the week. Mount Sinai, make a point for Mount Sinai with Mount Sinai Penn, University of Miami, perhaps Mayo, University of Chicago, Cedar-Sinai. Fortunately, these centers are becoming more prevalent. But that patient, even if you’re in the hospital and you’re not getting better, make plans to get transferred from a hospital to another hospital. That surgery requires not just technical expertise but judgment expertise.

Dr. Fox: Yeah. Fortunately, it’s rare. It does happen. But I mean, you take care of a ton of Crohn’s patients. We see a lot of ’em obviously because many of them get pregnant. And it’s so unusual that someone, I mean, A is admitted to the hospital for a long, prolonged period of time. B, would need to have surgery while they’re pregnant. Again, it has happened. Okay. And they tend to do okay and, you know, we can work out everything with the fetus, and like, it’s all doable. But it is really, fortunately, the exception, particularly, in someone who is well-controlled when they’re coming into pregnancy. So, it’s every room to be optimistic if you, unfortunately, have that diagnosis and you’re thinking of having a baby. If someone’s considering pregnancy, we were talking about sort of what you do to prepare them for pregnancy. What about fertility? Do these treatments, or do these conditions affect their ability to get pregnant potentially?

Dr. Kornbluth: Yeah. So the medications do not, and you could think of it if the medications are getting you better, or make you more likely to successfully get pregnant. In terms of fertility rates in general, in particular, the Ileoanal J-pouch operation does reduce fertility on a population base. If you have 100 patients who had a J-pouch, versus the 100 who didn’t, the ones who had the J-pouch will have a greater risk of having difficulty getting pregnant, or taking more time to get pregnant. And it’s specifically the J-pouch when the pouch is being constructed. The operation where the colon is taken out, they’re not near the tubes of the ovaries. When they’re down in the pelvis, creating that pouch, that’s where there’s risk of scarring. Not necessarily damage to the tubes or the ovaries at that time, but just scarring may develop. Crohn’s operations by and large, or even the ileum, which I mentioned is in the right lower part of your abdomen is really nowhere near the tubes of the ovaries. It’s really that ileoanal pouch. And it’s not to say those moms don’t get pregnant, and in fact, there’s sort of mixed data, but very encouraging data that they are just as successful if necessary with IVF.

Dr. Fox: Awesome. Asher, thank you for coming again to talk about Crohn’s and Colitis in pregnancy with us. I’m sure our listeners really appreciate it, and they’re all gonna be calling you for appointments next week.

Dr. Kornbluth: Well, hopefully, they’ll get pregnant. And hopefully, they’re not calling me because they’re sick during pregnancy. And this was really a treat for me. Thank you so much, Natty. Thanks for having me.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L-W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in Healthful Woman is intended for educational uses only. Does not replace medical care from your physician. Healthful Woman is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.