Posted on February 13th, 2020by RMANY

Ep 6: Breast Cancer and Fertility with Dr. Matthew Lederman

Fertility Forward Episode 6:

Today we have the great pleasure of welcoming Dr. Matthew Lederman to the show! Dr. Lederman is an incredible doctor who specializes in reproductive endocrinology and BRCA. We get to hear about his journey in medicine, his family history in the field of fertility and his early interest in following this path. He tells us about his favorite parts of his job, some of the more difficult tasks he has to complete and why family is so important to him in work and at home. From there, he turns to his expertise in breast cancer, unpacking its relationship to fertility, delivery and the lives of offspring.

Transcript of Episode 6

Rena: Hi everyone! We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Dara: We are so thrilled today to have the esteemed Dr. Matthew Lederman in the house. He is an incredible doctor who I see all the time in the halls of RMA. But whom I've never had the pleasure to actually hear his whole story in his background of how he got started. So let us know. How did you begin this journey of becoming a reproductive endocrinologist?
Dr. Matthew Lederman: Well, my story, I think, started early on. My dad was an OBGYN, my uncle is a maternal fetal medicine specialist. So I grew up in an OBGYN family. No other physicians, but my dad, uncle both OBGYNs and from being young I worked in his office, spent some time shadowing him in high school and college, and was always interested in the field of OBGYN and also the field of infertility. And I spent some time with one of his colleagues. I think when I was in college and my interest in fertility further peaked, as I thought it was very rewarding to help others who are struggling, you know, to get pregnant and conceive and assist them along the journey, which is not always so easy. And I thought my personality, I might just fit very well with the field.
Rena: Oh, sure, I could definitely speak to your personality. You know, my patients who I share with you they all say oh Dr Lederman is the best. He's so warm, he has the best bedside manner. So and for sure, I think you chose the right field. And I know you're such a great voice and support for our patients.
Dr. Matthew Lederman: Patients, you know, couples who are going through infertility. You know, remember, most women spend most of life trying not get pregnant. And when they try and get pregnant and doesn't come so easy, it's very hard. It's frustrating. And what drives most women and men crazy is a lack of control, you know, they always say to me what can I do to make things better? The majority of times is not much they could do. Most women, men are healthy, and the lack of things that they could deal makes it even frustrating. And so it's very hard and challenging to emotionally go through it and I try and stay, very patient and positive, and let them know that it's not uncommon and that you know most patients get there just sometimes it takes some patience. It doesn't always work the first or second time around whatever treatment that we go ahead with them and some journeys are quicker and some are longer. And you know the key is just just to stay positive and be a cheerleader for the patient. I'll let him know that you know not only I'm here for them, but as well as the team because it's not just me. It's a whole team that helps take care of the patients, whether it's their nurse, whether it’s the financial coordinator, the IVF coordinator, whether or not it's from nutritional standpoint, whether or not it's from a psychological standpoint and our social support system, it's a whole team that helps take care and assist these patients along their journey.
Dara:I love that you say that the power of positivity because, you know, we hear that a lot, you know I know Rena and myself speak about that with our patients. But it's nice to hear that from a doctor. The idea that, yes, working as a team but also being positive and being champions for each and every patient that you meet with.
Rena: Sure. What would you say some of the hardest parts of your job are?
Dr. Matthew Lederman: So some of the hardest parts of my job I mean, it's always nice when obviously someone gets pregnant and, you know, I always let you know whenever someone’s say doing IVF, and they have an embryo transfer usually comes after the pregnancy test you know nine days after, and usually I’ll let the nurse make those calls to share the news because they’re always excited to share the news. When there's not so good results, I'm the person who's making the calls, whether it's for a negative pregnancy test after an embryo transfer cycle, whether or not it's a miscarriage or they've done IVF and we’re screening the embryos for chromosomal abnormalities and we get no embryos that are nomal or they have no no embryos to even evaluate to to biopsy.
Rena: That’s so hard.
Dr. Matthew Lederman: So I'm always the one, you know, I want my patients to hear these things from me so obviously they have questions maybe not questions at that time because there’s a lot racing through the head but letting them know, you know, I think it's better than hearing it from me ask whatever questions and also let them know that I'm here for them and that also being a cheerleader at the point that I don't want him to give up hope that they could still get there. We just maybe have to try again. Do something you know differently. So giving negative news is not easy. And there's also because that's, you know, challenging but that also, you know, when someone who's pregnant and things look like they're going smoothly and they have a miscarriage. And I'm doing the ultrasound and I'm looking for the heartbeat and don't see a heartbeat and you know, that's, you know, tough. Um, too, because they've done a lot. They think everything's okay and to then have a miscarriage, you know, it's hard giving that news.
Dara: Especially in person. It's one thing over the phone, which I'm sure is still quite difficult. But usually you’re there with the partner, so having to let them both know I'm sure is extra challenging.
Dr. Matthew Lederman: Sure. And I never you know, I never thought about you know, when you make a call, you know, you prepare, You know, before you call someone what you're telling them, but for you, if you're going in, you know the room you're doing an ultrasound, a patient you built a relationship with. You know, as you said, you're a champion for someone you know, you're hoping you’re just doing an ultrasound, you're gonna see where they're at in the pregnancy and then to go in and not see it that must be so hard for you to kind of keep your game face on because you can't lose it in front of a patient.
Dr. Matthew Lederman: And that could be any time. Six weeks, seven weeks, eight weeks, nine weeks and lot of times everything's going so smoothly. It's completely unexpected that they're excited. They're waiting, and then I’m doing the ultrasound and don't see a heartbeat. And obviously I check very closely and giving that news on who thought everything was fine even if they did IVF, they screened the embryos it’s a chromosomally normal embryo and it still happened those situations are hard not for me because, you know, I really want them to have success. And I want it to be as easy as possible. But to have to go through that and emotionally go grieve and then kind of start again from wherever they are in the starting point.
Dara: On the flip side, what are some of the highlights of your job? The things that you really do enjoy most?
Dr. Matthew Lederman: I mean, I enjoy my whole part of, you know, my job. I feel like I’m very lucky. Family is very important to me. I grew up in a very close knit family. I have a younger brother, younger sister, close to my uncles and aunts and cousins. So I understand family and I have a daughter, a son, and I'm very close to my family. So I recognize how important family is, and I really is that all patients that I'm seeing, they're trying to build a family, and for me to be able to take part in helping them build the family, you know, it means a lot to me. I understand, you know, it's I’m very lucky to be able to partake in trying to help create their family unit. It says
Dara: How nice is that? Your patients are so lucky.
Rena: So lucky and I know you're someone you're a doctor who calls seven days a week, even though you're juggling, you know, your own kids, your own family and you're really someone who works all the time because you genuinely care. And I think it's so obvious in your work with patients
Dara: So nice. So we know that you specialize in something in BRCA. Can you let everyone know what that is? And how also you got in to that specialty?
Dr. Matthew Lederman: Well, so my interest in BRCA the B-R-C-A gene starts out with my family. So my mother-in-law, you know due to her family history decided to get tested and it turns out she was a BRCA2 carrier, and we found out that she was a carrier a few weeks after we had my son. And I remember that day sitting on my couch you know when she told us that she was a carrier and she was gonna have prophylactic surgery from
Dara: Let's let's explain what the BRCA gene is also just in case of people…
Dr. Matthew Lederman: So the BRCA gene it's a genetic mutation that carries a risk of hereditary cancer and, most commonly think of breast and ovarian cancer and breast cancer it is a lifetime risk of up to 80% of breast cancer for both BRCA1 and BRCA2 carriers.
Rena: And what’s the difference between BRCA1 and BRCA2?
Dr. Matthew Lederman: So BRCA1 BRCA2 they’re similar, but they carry different risk factors for certain cancers. It's usually more ovarian cancer, so they both have a very high lifetime risk of breast cancer. Where ovarian cancer, BRCA1 has about a 40 to 60% risk of ovarian cancer and the BRCA2 is a little, a little bit less maybe like 20 to 30% so still high, but less than the you know BRCA1. And it's not just that they have risk of breast and ovarian cancer, but it’s at a younger age of onset. And that could be in the twenties and the thirties in the forties, a lot of it depends on the family history, but it's lifetime increased risk of breast ovarian but at a much earlier age. And there's also other risk of certain cancers, such as pancreatic cancer, breast cancer in men, prostate cancer and melanoma.
Rena: Wow.
Dara: I had no idea.
Rena: I know and it's so crazy that we have the technology now to see if someone’s a carrier for that and see okay, you're now at an increased risk for all these cancers. I think that's wild.
Dara: I didn't realize that, You know, usually the screening I always thought was for women, but perhaps..
Dr. Matthew Lederman: No men are at a much lesser risk for the cancer. You know the big ones to the female breast and ovarian.
Rena: I feel like those are the stories we hear in the news. Celebrities speaking out about getting double mastectomies. Angelina Jolie I know was a big advocate for getting tested and shared her story with the world. So ok so you got so you got involved because your mother-in-law.
Dr. Matthew Lederman: So she was a carrier, she had prophylactic surgery so my wife, obviously needed to get tested because the way the gene works is 50% of your offspring will be affected.
Rena: Wow.
Dr. Matthew Lederman: So there was a 50% chance my wife would have the gene. She got tested and turns out she was a carrier. And you know she had a prophylactic mastectomy reconstruction and then I had my two kids at the time and we weren't sure at the time you know were we going to go for the third? One of the recommendations is if somebody’s a BRCA carrier, because the risk of ovarian cancer is is to take out their ovaries and tubes when they're done having kids.
Dara: When they're done having kids.
Dr. Matthew Lederman: Or by the age of about 40. So she was 40. We decide we're content with our family and you know so she had a prophylactic removal of fallopian tubes and ovaries called BS or bilateral salpingoophorectomy fancy medical terms. And so that's where my interests got interested you know where I started to get involved. And you know, a lot of that’s related to what I do. So because of my personal family history that led me more and more getting involved in the BRCA community and the hereditary cancer community. And there’s not a lot of information out there and support for that community. Yes you hear about the Angelina Jolie's who's bringing some attention. But there's a lot of lack of education among the general public and even physicians and why it's important to me is that you know my kids have a 50% chance of inheriting the gene. Rena: So now that’s what I was gonna ask so now have you kids been tested?
Dr. Matthew Lederman: So it’s a little tricky. There's no clear cut recommendations when to do it. Generally, it's sometime in the early twenties when they could consent to undergo You know, the testing and remove the risk of the cancer. Not it's not in the teens, right? So you know there's no clear cut guidelines, but it’s usually in the early twenties, when they can consent to it and they have a 50% chance of inheriting the genes and the risk associated with it.
Rena: Huh. And so now Dara and I if we wanted to get tested, I mean is that something we should do? I don't know about Dara, but I don't, it’s not in my family history. Is that still something I should go get tested for just to kind of know?
Dara: That’s a good question like should all women?
Rena: Is this a simple blood test I mean how does that work?
Dr. Matthew Lederman: It’s a tricky question because there are someone who ends up testing up opens a whole can of worms. What do you do with that information? And everyone reacts differently to that information. You know, someone who is a carrier when it comes to breast screening that they you know the recommendation is to start undergoing imaging of the breasts around age 25 and clinical brest exams. And obviously there’s that option of having a prophylactic mastectomy, which is removing the breasts and reconstruction obviously to prevent it. When it comes to ovarian cancer, there's no great surveillance for that. So breast cancer you could you know there's options in terms of surveillance imaging. For ovarian cancer, unfortunately, you know there's not much to do. There's a blood test called the Ca125 and women could have an ultrasound. When they do that, alternate every six months with that. But the problem is when they looked at studies to see improved detecting it and improve mortality it didn't show any benefit. So it's one of those things that we can do but really doesn't do anything. So there's not great screening for you know, ovarian cancer.
Rena: So you would just have to do the surgery to really?
Dr. Matthew Lederman: Well the only way you know to obviously prevent ovarian cancer obviously, the only way to do that is removal of the fallopian tubes and ovaries, and obviously that affects one’s ability to get pregnant. That's why the recommendation is to take it out when you know you’re done having kids or around age 40. But back to the question, you know, should everyone be screened for that? And so for those reasons, it's, you know, there's a lot that's involved, and a lot of it depends on family history. And it's not just for the BRCA gene, because they’re other hereditary cancer genes that also are associated with hereditary cancer another one that some are more familiar with is Lynch syndrome, which is a risk factor for colon cancer. Both in men and women. Big risk of colon cancer. And the recommendation someone who has the gene to undergo frequent colonoscopies of every year in their thirties or it depends on the family history.
Dara: Ok
Dr. Matthew Lederman: And women are at risk for endometrial cancer and also ovarian cancer. So that's another one that has a high risk. And there are other genetic mutations too that's associated with cancer. But it depends on the gene depends on the risk depends on the cancer, and now, you know, usually I suggest someone who has a family history, which we'll get into a little bit when they're going to be evaluated by a cancer geneticist they undergo now a extended cancer panel. So it's not just the BRCA gene. You know some of the panels are 30, 60, 80, you know they're growing
Rena: Oh wow.
Dara: They’re much more thorough which is great to see.
Rena: Yeah.
Dara: And I know I mean back to in terms of, like the screening and then a genetic component about it. I know I've done some of those like 23 me and and then you can, like, send it to a special place and they can give you all but is that a good way of doing it?
Dr. Matthew Lederman: So fortunately I've seen a lot of patients come to me I did 23 and me. I thought it was negative I was fine.
Dara: Yeah
Dr. Matthew Lederman: That's false reassurance. The BRCA gene is on 23 and me, but they only have 3 mutations. So it's it's not an extensive evaluation for the BRCA.
Rena: So you should really go say I want to be tested for the BRCA gene?
Dr. Matthew Lederman: Yeah. So when it comes to screening, who should be screened a lot of it depends on the family history. So if they have a history of having breast cancer at an earlier age, ovarian cancer, pancreatic cancer, metastatic prostate cancer, colon cancer. So they're certain cancers that are linked and they tend to cluster within families. So a lot of it depends on the family history, someone’s who's had cancer, say breast cancer. Now they’re recommending anyone who has diagnosed with breast cancer or ovarian cancer or pancreatic to have genetic screening for that. Also, the BRCA gene is found in about 1 in 40 Ashkenazi Jews, which is pretty high.
Rena: Wow.
Dr. Matthew Lederman: You know and you know that population. So there's some people out there who think that all Ashkenazi Jews should be screened. The verdict's not out yet on that, but that's pretty high.
Dara: We don't screen here for that?
Dr. Matthew Lederman: So usually here if someone has a significant history for cancer in the family, we’ll refer them to Mount Sinai Cancer Genetics program or any other cancer genetics program to be evaluated to have the appropriate pretest counseling and post test counseling because it's not just you have it. What could you do moving forward in terms of screening preventions and then also it affects we’re very interested in is how it affects building one's family, because there's a lot of things that affect that right. There's options. So, for example, someone who has the gene they have the option if they so choose where they could do IVF biopsy the embryo see if the embryo has that gene and then transfer an embryo that's unaffected with a gene so basically ending the cycle.
Dara: That's unbelievable that we can do that in this day and age.
Rena: So it seems like IVF is a great choice for someone that has the gene because they can weed out any embryos that aren’t carriers.
Dr. Matthew Lederman: It's a great option, but that's not for everyone. Not everyone wants to do that, and that's okay.
Rena: I’m sure not everyone wants to know, right?
Dara: But the fact that there is an option.
Dr. Matthew Lederman: Yeah not everyone wants to know, number one, that they necessarily have it or if they have, remember, it's a risk factor it doesn’t guarantee.
Dara: Yeah
Dr. Matthew Lederman: But there are many women and men who will make choose to do IVF to screen that out and lotta that time depends on their family history where they had a relative who passed away at an earlier age or significant history or a friend who's gone through that. A lot may choose to do that, but also some may choose not to do that. And so for someone who knows that they want to eliminate that gene to me it makes the most sense to take advantage and do these treatments at an earlier age because age plays such a role in the ability to have success.
Rena: Now do you see a lot of patients who may have been able to conceive naturally, but because they're carriers for BRCA, they choose to come and do IVF because they want to end the cycle?
Dr. Matthew Lederman: Well, yes, I see some for that who do IVF purely for genetic reason to prevent transferring that you know that gene. And we do that for all genetic mutations that such as like cystic say you have two cystic fibrosis carriers with they have a one in four chance of having a child at risk for cystic fibrosis or someone who is a BRCA carrier, a Lynch carrier who have a 50% chance of passing that gene on to their offspring. And the other interesting thing with BRCA is that some studies have also suggested that BRCA carriers’ ovaries may act a little older, where they don't do as well with IVF, they get less eggs or embryos. They have lower AMH levels which are anti Dr. Matthew Ledermanarian hormone, which is a mark of one's fertility potential. So some have suggested that there's an egg factor, and that's more BRCA1 compared to BRCA2. And there are studies that have not found that association. But I do believe that there's a subset, no matter how young they are that have and egg component and that affects their ability to have success. The other thing is, you know, someone who may choose to take out their ovaries because of the risk of ovarian cancer as a risk reducing strategy, if they haven't started a family, they do nothing. They're not gonna be able to get pregnant. So someone in that situation who's single they could freeze eggs before removing their tubes and ovaries. They could freeze embryos before removing their tubes and ovaries. And interestingly, a lot of women don't realize that they could still get pregnant without having ovaries. We could give them hormones to support early pregnancy,
Rena: Huh. So that, can you expand on that a little bit? I think. So, women can get pregnant without having ovaries?
Dr. Matthew Lederman: So just like someone who's in menopause could get pregnant using a donor egg, someone else's eggs, because we could give them hormones same kind of concept. So as long as we have their eggs or we have embryos and if they don't have ovaries we could give them estrogen and progesterone to get everything ready get the uterus the lining ready to carry her pregnancy. And then eventually the placenta takes over.
Rena: Wow.
Dara: Unbelievable.
Rena: So unbelievable.
Dara: So interesting.
Rena: So now where do you see kind of the future in this? Do you see what kind of new research is coming out? Where do you think in five years is this gonna be changed at all? Where do you think this is going
Dara: And where? And are we doing research here on this? This is
Dr. Matthew Lederman: So a lot has changed in the world of fertility over the last few years. And what has changed that is the ability to make IVF better. How’ve we made IVF better? Well, we’re biopsying the embryo at what we call the blastocyst stage, which is an advanced stage embryo. And we're taking cells from the outside the embryo, which cells destined become the placenta, so it’s not harmful to the embryo. We then freeze the embryo and send the cells to a special agent X laboratory to screen for chromosomal abnormalities things like down syndrome.
Rena: This testing you’re talking about is what we refer to as PGS testing, correct?
Dr. Matthew Lederman: Or it used to be referred to the PGS preimplantation genetic screening. The new is PGT.
Dara: PGT
Rena: PGT
Dr. Matthew Lederman: And that's preimplantation genetic testing and so it’s PGT-A which is for aneuploidy which it means chromosomes so you’re testing the chromosomes.
Rena: Ok
Dara: But this is interesting because I always thought also that you took the embryo, but it's only taking some cells surrounding it?
Dr. Matthew Lederman: Correct, you’re taking some cells from the outside.
Dara: So it doesn't harm the actual embryo
Dr. Matthew Lederman: Yeah and get those are the cells that are destined to become the placenta and then the embryo’s frozen. The cells are sent to a special laboratory the chromosome abnorDr. Matthew Ledermanities things like, you know, Down Syndrome which you know is trisomy 21 as well as various numerous chromosomal abnormalities. And when you have a chromosomally normal embryo in our program, it will implant about 60 to 70% of the time.
Dara: Wow
Dr. Matthew Lederman: So it allows us to transfer one embryo with much higher confidence instead of putting back an embryo that’s never gonna work from the start. We don't tran, obviously transfer that or one that's destined to miscarry. Even though it doesn't completely eliminate it, it greatly reduces it. So the ability to screen the embryo has resulted in a much higher success for our patients, and we don't even see twins anymore. So now we just see twins with patients who are, say, doing IUIs with say clomid letrozole. And rarely, you can see a twin when you put back whenever it splits. So our goal for all our patients is a singleton pregnancy. Why? It's a healthier, safer pregnancy.
Dara: Lower risk
Rena: For the mother and the baby?
Dr. Matthew Lederman: Yeah for both the Mother, the baby. It's a much you know safer, practically I mean a lot of twins do fine, but a lot of them don't, and you can't predict who's gonna have the twins, who 's gonna have the really difficult, risky pregnancy.
Dara: But that's changed just more recently. When I was a patient here, this was almost 10 years ago we were putting back I had three embryos put back in with one and two embryos put back in with another. When did this change? Was this more the last 3,4,5 years?
Dr. Matthew Lederman: This has been around for a while, but the way we’ve done it has changed, and you know in the beginning the techniques were as good. Now, the way these embryos are being analyzed it's called NGS, which is next generation sequencing so that embryos are being sequenced and that's the
Rena: Wait what does that mean?
Dr. Matthew Lederman: It’s you know so the platforms have changed over the years in terms of how do you analyze it and basically you're sequencing the embryos to look at the chromosomes is the best way to look at it. You know you're breaking down looking at it can even pick up what's called deletions or duplications where there's genetic material missing.
Rena: Wow.
Dr. Matthew Lederman: You know, even though the number of chromosomes are norDr. Matthew Lederman or it has an extra area of some you know, genetic material.
Dara: So you can really analyze the DNA?
Dr. Matthew Lederman: So the whole genetics and that's where I'm getting at is the relevance to fertility is has gone up exponentially in the last few years, and so we've been screening the embryo, you know, for a while, but the number of patients who are going through it now over I think 90% of patients who do IVF were screening the embryos, because we do it better now. So that's where IVF is going. The whole genetics and genomic revolution and its role in the infertility world that's where you know where we were able to better identify the embryo we’re able to present prevent disease, whether it's the BRCA, whether it's Lynch, whether it's cystic fibrosis or you know other mutations and a lot of our patients before they go through any process they undergo expanded carrier screening for, like the cystic fibrosis, the Tay Sachs and the pound that we use currently is over 280 mutations.
Rena: Wow I had no idea there was even that many mutations.
Dr. Matthew Lederman: And that panel is only going up so the more we’re able to detect the more we’re able to prevent disease. And also, I think, what's gonna happen to why does a screened embryo only implant in the best case scenario up to 70% of the time? We don’t know the answer. You know, we think it's something about the embryo we just can't detect yet. And I think with our ability, the genetics revolution, we're gonna better able to attack the best embryo to therefore than transfer and further increase the pregnancy rate.
Dara: That's so exciting.
Rena: It's so fascinating. And you know this came up in another podcast we did where I wonder, you know, with all of this testing and the changes in genetics’ ability to screen and then weed out you know, all of these diseases. Do you think that's really gonna change kind of our overall, the look of our population? You know, and how that looks and and sort of eliminate people born with things we’re screening out for you know do you think overall, we're going to have a generally healthier population?
Dr. Matthew Lederman: Well, I don’t think we’re going to have a perfectly healthy population because there’s always an influence of genetics and environment, right? You're not gonna be completely able to eliminate everything right, but we'll be able to prevent certain, you know, these diseases that are debilitating, You know where the newborn or the child you know have, you know, these disabilities related to the underlying genetics. So I think we’re better able to prevent those. I think we’re doing a better job now and in the future even, you know, lower that rate, but obviously not gonna completely eliminate everything
Rena: I think it’s fascinating.
Dara: So fascinating. So how we usually end our sessions we ask two questions, one of which is nothing to do with work, what do you do in your spare time?
Dr. Matthew Lederman: So as I mentioned earlier, you know, family is very important to me, so I spend a lot of time with my family. You know, my son is very sporty, so I go to his base now it’s baseball season. So it's lots of baseball games or basketball. My daughter, she's been you know she used to ride horses. And now she's swimming and tennis. So, she has different interest more than individual sports. She’s changed a lot so I like go enjoy watching them or watching a movie with them or just, you know, hanging out. I like food. I like to cook, although I don't cook as much as I used to. So I like to go to nice restaurants. So I’m kind of simple
Dara: No you’re busy! A simple, busy man.
Rena: Very busy.
Dr. Matthew Lederman: I'm a sports fan, I like watching you know I’m a big sports fan
Rena: Ok
Dr. Matthew Lederman: The Mets, Knicks, Jets and Michigan Wolverine fan so I like watching their basketball and football games. So I'm fortunately used to misery because my teams don't do so well.
Dara: This could be the year.
Rena: Never know.
Dara: And then the last thing that we like to ask all of our speakers is what they're grateful for at this moment today or in general, so it sounds like for sure, family.
Dr. Matthew Lederman: Yeah. Probably the most I’m grateful for is my family. I'm very lucky I have a great job and I have a great family.
Rena: So positive, I love it so much.
Dara: Your patients really are so lucky
Rena: Yeah so lucky. Dara? What is your gratitude?
Dara: I was gonna actually say family because you know speaking about your kids, I am grateful for my family. And I'm grateful for my RMA family who helped me create my own family.
Rena: That is so beautiful.
Dara: What about you, Rena?
Rena: I guess I need to you know be the third person here to say family. You know my daughter who you know, is an IVF baby and and my family and my parents were so supportive. Definitely takes a village to raise a child, that's for sure.
Dara: And then some.
Rena: Yes. Totally so family also
Dara: Family day. Well, thank you so much, Dr Lederman for coming on here and really educating us about genetics, about the world of fertility and a little bit about your life. Thank you.
Dr. Matthew Lederman: My pleasure. Thank you for having me.
Dara: Thank you so much for listening today. And always remember: practice gratitude, give a little love to someone else and yourself and remember you are not alone. Find us on Instagram @fertility_forward. And if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.

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