Fertility and Sterility On Air - Unplugged: December 2025

In this month's Fertility & Sterility: Unplugged, we take a look at articles from F&S's sister journals! Topics this month include: x (2:41) a link between angiotension II and fibroid development (14:11), use of psychedelics in reproductive medicine (20:27) and an artificial intelligence tool for clinical decision making during stimulation (26:21).

F&S Reviews: https://www.fertstertreviews.org/article/S2666-5719(25)00009-X/abstract
F&S Science: https://www.fertstertscience.org/article/S2666-335X(25)00091-6/abstract
Consider this: https://www.fertstert.org/news-do/psychedelic-medicine-revisited-advances-and-reproductive-health-implications
F&S Reports: https://www.fertstertreports.org/article/S2666-3341(25)00017-0/fulltext

Welcome to Fertility and Sterility Unplugged, the podcast where you can stay current on the latest global research in the field of reproductive medicine. This podcast brings you an overview of this month's journal, in-depth discussions with authors and other special features. Fertility and Sterility Unplugged is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine and is hosted by Dr. Molly Kornfield, Dr. Blake Evans, Dr. Daylon James, and Dr. Pietro Bortoletto.

Hello everyone and welcome to another episode of FNS Unplugged. I'm your co-host Pietro Bortoletto, joined by the ever present, ever dashing, ever interesting Daylon James, Dr. Blake Evans, and special guest, Dr. Elena Hogan-Esch. Hi, Elena.

Hi, thanks for having me. For the untrained listener, Elena is the reason we sound as good as we do. She has been producing the podcast in the background this entire time and has really done yeoman's work on the editing floor to make this trio look as good as we do.

Elena, you're a second year fellow at UCSF. How do you find time to do this? Well, first of all, it's not that much work. You guys aren't so bad, but it's been really fun and a good way to learn and keep up to date with the podcast.

So I've been having a good time doing it. I'm always humbled by how many fellows listen to us, which is really cool. It really is.

And we really appreciate all of your work, Elena. I'm sure it's not that easy of a task to filter through all the ridiculous things that we say, because what we say that comes on the podcast is a lot less than what actually happens. There's a lot of takes and pauses.

And please edit that out, comments throughout the recording. So we appreciate you going through all of that. Big time.

My pleasure. Well, you're probably wondering where Molly is. Molly's out this month, which is why we've invited Elena to pitch, hit and help us present articles from FNS Reports.

Blake, we never really start with you, mostly because I don't like the look of your face. But today I think we should start with FNS Reviews. Tell us what you got from the journal.

Well, it's hard to follow that comment. I don't really know how to take that. But thank you.

Happy holidays. Anyways, I'm going to start us off. I'm sure Elena is going to have to edit out me crying for a bit.

But the article I'm going to talk about is entitled Fertility Considerations in Individuals Affected by HIV, Human Immunodeficiency Virus, a scoping review by first author Anisha Chadha and senior author Heather Hipp out of Emory. So a little bit of background here on this review. Over the last 40 years, HIV has transitioned from a terminal illness to now fortunately a very manageable chronic condition, particularly among reproductive age individuals.

And so in this review, they wanted to investigate the impact of HIV and its sequelae, involving comorbidities of having the virus itself, and also taking antiretroviral treatment on infertility for both men and women. So the review included 59 studies, 9 of which were prospective, 14 were retrospective, and 35 of which were observational. The studies analyzed various aspects of fertility in both men and women, as I mentioned.

So we're going to first start off with male infertility and its implications. So in summary, HIV positive men often experience abnormal semen parameters. This could include reduced motility, reduced concentration, morphology, or combination of all of these things.

However, I will note that the generalizability of the results make the findings limited because there's a wide range of clinical disease states in patients with HIV. So how severe is it, what's their viral load, CD4 count, etc. So the more severe the virus, the more severe implications in regarding the sperm parameters.

And then of course, how controlled is the disease as well? So severe disease states and antiretroviral treatment can exacerbate these issues. But there are studies in this review that indicate that there's no significant difference in pregnancy outcomes for serodiscordant couples undergoing intrauterine insemination or IVF, for example. So that's the reassuring or a reassuring finding here.

Shifting to female infertility, women with HIV are at a higher risk for oligomenorrhea, so menstrual abnormalities, even amenorrhea, not even having a period at all. That's what that means, Pietro. Especially if you have a really low CD4 count.

And so similarly to the sperm parameters, the more severe the condition and the more severe the HIV, the more abnormalities that women are having in their menstrual cycles. Also, similarly, a notable impact on ovarian reserve. So more severe disease had led to more severe implications in regards to ovarian reserve.

Decreased AMH, decreased, or excuse me, increased menstrual irregularities. As well. So women with HIV may face decreased pregnancy rates as well and increased miscarriage as well.

So in general, when they look at antiretroviral treatment, the review emphasizes that while ART certainly improves maternal health, reduce perinatal HIV transmission, there are certain treatments, particularly the NRTIs or the nucleoside reverse transcriptase inhibitors that may adversely affect gamete health due to mitochondrial toxicity. Of note, there was a study in 2011 out of London. They examined several discordant couples, around 300 couples, and found that HIV positive men taking the ART treatment, so upwards of about three out of four, experienced significantly impaired sperm counts, including motility, morphology, and concentration, compared to those not taking medication.

However, their parameters were still sufficient for IUI versus IVF. So it's unlikely that these men that are taking these medications are going to be able to successfully conceive naturally. Basically, a very large majority of these men are going to need to have ART treatments or some help.

So kind of wrapping up their findings, patients with controlled HIV, so on ART medications, with lower undetectable viral loads tend to have favorable fertility outcomes. That's no surprise there. HIV affects fertility in both men and women, with treatment complexities that require careful management.

So to optimize these outcomes, the authors discuss a multidisciplinary approach, how important this is, and also in terms of us, when we are talking with these patients for preconception planning. So talking to these patients about implications of being on these medications, how they're likely going to need infertility treatments as well. So I found this review helpful, eye-opening.

We don't see this a whole lot. I imagine, do you guys see a lot of HIV patients in your center? I would imagine the number just in general across the board is pretty low, but do you guys take care of these patients? So in New England, there is a place that's been doing lots of work on this topic for quite some time, primarily looking at how to sperm wash in such a way where you can reduce viral load sufficiently for IUI and not have to utilize IVF-XE to help decrease viral transmission. I think these patients are still pretty rare.

They're very few and far between. I think in the era of antiretrovirals, we have so many patients who are undetectable and are just having sex the old-fashioned way at home and getting pregnant, which is really cool. So I can recall maybe one or two couples that I cared for in New York City that were serodiscordant, but haven't really cared for a whole lot here in Massachusetts.

Let me ask though, my takeaway that there is, you're saying part of the upshot here is that you need to cancel patients as you're putting them on antiretroviral therapies that their semen parameters may need ART. It's a lot of ART, ART. We got to find a separate acronym to run in here because the redundancy is confusing me.

But to ask the question again, not to say you didn't answer the question, Pietro, you did say they're very rare. But that is my question is, do you get a lot of patients who, are there studies showing that patients who are undetectable are having some kind of iatrogenic infertility? Got them. Yeah.

Not that I know of, honestly. But I think it's a spot where I don't have a ton of experience with. Here at UCSF, you probably see more serodiscordant couples than the average podcast host.

What's your experience been like in San Francisco? I mean, I can't say that I actually can recall any serodiscordant couples that I've cared for since being in San Francisco. I do wonder if access to care is an issue for some of these patients. So perhaps there is an element that antiretroviral therapy is affecting semen parameters, but this might also be a population that has trouble affording IVF in states that don't have mandated coverage.

Yeah. In addition to that, a lot of IVF centers can't actually take care of these couples. They'll have to go to certain centers that have labs that are equipped to take care of patients who have HIV.

So I know you have to have a complete separate hood, for example, whenever you're manipulating the gametes. And so not all centers are going to have that. So I recall at one point in time actually looking up these different centers.

I know one of which is Emory, which of course they put this review out. But I know that they're few and far between in terms of centers that will actually be able to take care of HIV positive patients. So having to travel to go to those centers, or that's another barrier as well.

So yeah, maybe that's the elephant in the room here is that there's just not a lot of infrastructure out there to take care of this patient group. And the demographic oftentimes maybe that's not the first thing on their mind. Yeah, for sure.

Well, big shout out to the team at Emory for sharing their clinical expertise in FNS reviews. Daylon, what's going on in FNS science these days? Well, it's different, a little bit different. There's always something different in FNS science.

That's why I love it. And if I'm honest, it sometimes feels like the only thing we talk about on this podcast is IVF, ART, not antiretroviral therapy in this case, assisted reproductive technologies. And I'm not throwing stones here.

I might be the worst offender. And in our defense, I mean, the podcast is from the Fertility and Sterility Family Journal. So apropos, right? But there's so many dimensions to infertility and to human reproductive biology at large.

And I wanna highlight one of those facets today with a study out of FNS science that's focused on uterine leiomyoma, otherwise known as fibroids. My favorite, big leiomyoma guy. I did it for you, Pietro.

I did it for you. You can talk about all the leiomyomas you cut out. Now there's for sure a well-established relationship, right, between fibroids and infertility.

But the uninitiated, which is pretty much just me most of the time, leiomyomas are benign uterine smooth muscle tumors that are very common in reproductive age women. And it doesn't take a great leap of imagination to make that link, right, between inflammation, tissue remodeling, and the other things, and the failure to successfully conceive and or carry, right? But the nature of that link is subtle and nuanced, right, guys? Pietro, I mean, or any of you guys. You have some kernels to offer either from your review of the literature or experience and practice that guides your action.

Like what do you do? What's your thresholds for patients with fibroids in terms of go, no-go? I start by telling them that fibroids are not a death sentence for fertility. There are so many people with all kinds of crazy fibroid burdens who have totally uneventful tries at conception, pregnancies, deliveries, particularly outside of the United States where I think we probably over-treat fibroids. In a lot of the developing world, Latin America, Sub-Saharan Africa, fibroids are just part of living.

And yes, it causes quality of life issues, but it doesn't always cause fertility issues. But when the patient's in front of us, the fertility doctor, and they're struggling to become pregnant, then we do focus on the number, the location, the size, and try to risk-reduce by typically talking about surgery, but more and more having some medical and non-extirpative options for fibroids, which I think are really cool. And yeah, I use the word extirpative.

Very good. Um, yes, well, you know, this, as I said, this isn't a story about infertility per se. And like many aspects of reproductive biology, particularly in females, the biology of fibroids is actually all tied up with the function of organ systems outside of the reproductive axis.

For example, emerging evidence suggests that fibroids participate in this renin-angiotensin signaling axis, which is a well-defined lever in the pathogenesis of hypertension. Fibroids are increasingly found to be associated not with just infertility, but also hypertension, preeclampsia. Indeed, the group of authors of the study that I'm talking about today, they previously showed that in a prospective cohort study that women with fibroids, if you surgically remove or extirpate, the fibroid, is that right? Did I do it right? You can significantly, or it results in a significant reduction in systolic blood pressure and serum angiotensin levels.

So here, the same group, which is led by Mustapha Barahi at Johns Hopkins, utilized a cell-based model, all right? No mice here, guys. It's cell-based, it's not in a patient, sure. But we got human material in this in vitro model that mechanistically deconstructs the relationship between renin-angiotensin signaling and fibroid growth, right? So quick review, again, probably just for me and those like me, renin-angiotensin, what's that about? Well, the system is activated to raise blood pressure by increasing blood volume and constricting blood vessels, right? In response to low blood flow to the kidneys, those kidneys release renin, which converts liver-based angiotensin to angiotensin 1, which is in turn converted in the lungs by ACE, angiotensin converting enzyme, to this more potent form, angiotensin 2, which then constricts vessels, stimulates aldosterone, thereby increasing thirst by modulating the salt balance.

So review over, and the study design here, the authors here, they short-circuited that whole pathway, right? By directly adding that more potent angiotensin 2 to primary and immortalized leiomyoma and smooth muscle cells. There were a couple of major takeaways. I invite you to look at the data and all the rationale around it, really, which I thought was really good read for me.

But the major takeaways were two for me. One is that angiotensin 2 increased the proliferation, also the extracellular matrix deposition in those immortalized cells. So it seemed to be a link between the receipt of angiotensin 2 signaling activation, and they grow, and they put down a lot of matrix.

The second thing is that they, in addition to this immortalized cell line, they had two patients from which they got primary cells, right, right? And what was cool, I guess, by design or maybe by accident, either way, N equals 1 is not that compelling, but nevertheless, they had one of those patients that was hypertensive, and the other was not. And while both sets of primary cells showed expression of the angiotensin receptor, only the cells from the hypertensive patients showed that growth phenotype. I don't know.

Like I said, you need to scale up the N to see if that's a real result or not. That's actually really cool. That's like a really interesting finding.

Yes, that's what I'm saying. Yes, I got him! Damn it, I didn't want to like the article, but I did, I did. It's happening.

We got him. We got him. It's happening right before our eyes, right before our ears.

I mean, listen, I'll be honest. This raised a lot of questions for me. First, there's this other link, right? So removing fibroids reduces serum angiotensin, reduces systolic pressure, suggesting that the fibroid tissue itself is contributing to the elevated angiotensin in SQLA.

But here, it's also suggested the fibroid is on the receiving end of that signaling. So sure, there's a lot of questions for follow-up. But here, I think the thing I appreciate the most about this study is it's a reflection of the scientific zeitgeist.

I'm always using these studies, which are relatively small scale, to kind of illustrate the way the wind's blowing. Nowadays, the use of these in vitro cellular models has become increasingly sophisticated, incorporating both primary and even like stem cell derived materials to generate these avatars of disease that are sometimes even patient-specific. While there may be more questions and answers following from this study, I think it's a great demonstration of how deeply penetrative the tool set is now and how we can really ask a lot more questions with today's model system.

So guys, get out there in the tissue culture. Get your primary cells cooking because you're gonna be the engine solving the world's problems in the future, aren't you? Especially you, Elena. I just wanna know if we should all be on ACE inhibitors.

Yeah, I thought it was an interesting study because I'm really curious if both fibroids and perhaps essential hypertension are manifestations of microvascular changes that are happening. And those are sort of the sequelae of some process that we're not yet seeing at an earlier phase. Yeah, no need for ACE inhibitors.

Just do myomectomy now, Pietro. Extirpate. Extirpate.

There's so much sun setting behind me. Does it look like I'm dead like in heaven right now? Or maybe I'm a Christmas angel. I mean, it is Christmas time, but I feel like I look like that of an angel right now on screen.

I'm sorry that- A cherub. A cherub, yeah. This is what we get, guys.

This is what we get. We go one of two ways. We got Pietro who's on the hook, now loves FNS science.

And Blake is fantasizing about imminent death. I'm ascending into heaven. Ascent.

Listen, I'm going to take this a step further and I'm going to hit you with my consider this article. We're talking about psychedelic medicine. Wow.

Nice segway. Visited colon advances and reproductive health implications. This comes out of the good folks out at Beaverton, Oregon at OHSU, primary author Clayton Edenfield, senior author Adam Crossland.

But leave it to the Pacific Northwesterners to think about psychedelics in reproductive medicine. There's a joke in there somewhere. But basically what this really nice consider this piece is trying to talk about is that maybe we have missed an opportunity to use psychedelics in reproductive age patients.

But there are some important things that we should keep in mind. The reason why I think this is timely is there's actually been several psychedelic compounds that have received FDA breakthrough therapy designation for mental health conditions, including psilocybin for treatment resistant depression and MDMA for PTSD. And as you can imagine, these are mostly studies that have been done in men, men in the military, veterans.

And we have left behind certainly women in a lot of this research, but duh, we've left behind reproductive age women. But there's some important nuances here as we kind of think about this as a potential therapeutic opportunity for our patients. There are some notable sex differences in users who take psychedelics.

For example, estrogen interacts with serotonin 5HT2A receptors, the same receptors that psychedelics target. So have to be a little cautious there for our patients. You have to be cautious about menstrual cycle effects.

There's both anecdotal and in literature reported differences in patients with their menstrual cycle at different potencies and dosages. There are actually even case reports of reversal of amenorrhea following psychedelic use. Probably warrants a little bit further investigation, but it's kind of cool.

And I think probably the thing that I think this article does the best job at highlighting is that there's a bunch of potential therapeutic applications for our patients. Premenstrual symptoms, sexual dysfunction, chronic pelvic pain, perimenopause transition, postpartum depression, a bunch of potential benefits that our patients may yield from these medications. What we don't know, of course, is safety in and around the time of pregnancy.

We know very little about most medications in pregnancy. We know even less about things like psilocybin, LSD, in and around pregnancy, in and around breastfeeding. So definitely some caution to proceed with on this topic and some informed decision-making.

But I think the bottom line here is there is a growing body of data for use in other mental health conditions. And women shouldn't miss out on the opportunity to benefit from these medications because we're all kind of chicken about studying these meds in women, particularly in reproductive age women, in and around pregnancy. Daylon, you've been a burning man.

What do you think? I haven't, actually. My brother, he went every year and then he had kids and that got shut down. But you know what interests me about these studies and the pivot on psychoactive drugs, I think specifically, because unlike so many other FDA-approved drugs, I mean, there are some drugs where you just need the trial.

You just need the results. You need to show benefit. But like the mechanism is really quite elusive and inscrutable in these psychoactive drugs, particularly like the link between, you know, a psychoactive drug and your reproductive access.

But like then again, of course, there's now a whole raft of studies that link stress and just state of mind. So like, I get it. I get it.

But I feel like that I hate to evoke the fears of the conservative right from years ago. But like they talked about that slippery slope and like it was like, yeah, PTSD and, you know, talking about soldiers coming from war and treatment as a depression. And now suddenly, you know, anything and everything.

We're slip and sliding, baby. Yes, I mean, but hey, I guess that's the point. We're trying to get high to get low, right? So I got to say, I have my doubts about the scientific grounding, but I'm not trying to get in the way.

Hey, get out there, go to Burning Man. Enjoy, have a baby. Did you guys see in the news that there was a baby delivered at this year's Burning Man? That was all over like CNN and the New York Times.

And there actually happened to be an obstetrician who was there. My former co-fellow. Get out, tell us more.

What do you know? A shout out to Dr. Jacob Christ. He was- I know Jacob. Yeah, he was the physician who delivered the placenta, I believe.

You can read about it in the New York Times. So you mean to tell me that J Christ delivered a baby at Burning Man? That's the top line headline here, Elena? J Christ brought a life into the world at Burning Man. Well, now we know where the Garden of Eden is.

That makes sense, checks out. Yeah. Wow, it all makes sense now.

Yeah, Elena, you have the unenviable task of going last. Not because you are the least among us, but because you are the newest amongst us. What do you have on behalf of Molly and the kind folks at FNS Reports to share with us? Well, I'm going to disappoint Daylon because we're going back to IVF, I'm sorry to say.

But as we all know, as we all know, artificial intelligence is certainly a hot topic in reproductive medicine. And there's been a particular interest in implementing this technology in areas such as embryo assessment, outcome prediction, and now ovarian stimulation. So today I'll be reviewing an original research article from FNS Reports, Real World Use of an Artificial Intelligence Powered Clinical Decision Support Tool for Ovarian Stimulation by authors Cameron J. Bixby and Bradley Miller.

So this was a retrospective cohort study that looked at the impact of using an adjunctive AI tool to assist physicians in selecting the starting dose of follicle stimulating hormone or FSH, as well as identifying when to trigger during stimulation. The study included two groups. The first cohort was composed of 292 patients undergoing ovarian stimulation at a single fertility center in which physicians use this AI program to assist in clinical decision-making during the IVF cycles.

To create the comparison cohort, the authors matched 292 historical controls who had undergone autologous ovarian stimulation at the same clinic with the same group of treating physicians a few years prior, but without the use of this AI tool. The AI program consisted of two components, the starting dose tool and the trigger tool, which were trained on roughly 18,000 and 30,000 IVF cycles respectively. The first component, the starting dose tool, was used prior to stimulation to aid physicians in determining the appropriate initial dose of FSH.

This tool works by taking into account a patient's baseline antimalarian hormone or AMH, the antral follicle count and BMI to create a dose response curve for the starting dose of FSH and the predicted number of metaphase 2 or M2O sites retrieved. The second component, the trigger tool, is used throughout the stimulation cycle to predict the number of M2s that would be retrieved if planning to trigger that day, the next day or in two days. Predictions are made based on linear regression models which take into account the latest estradiol level and follicle measurements.

The primary outcomes that they looked at were the starting FSH dose, the total FSH dose and the number of M2O sites retrieved at the end of stimulation. They also looked at the peak estradiol level on the day of trigger between the two groups. The authors reported that after matching the treatment and control cohorts had no significant differences in age, AMH, antral follicle count or BMI.

The average starting FSH dose was significantly higher in the control group compared to the AI cohort, 443 units for the controls versus 397 units for the AI cohort. Similarly, the average total FSH dose was significantly higher in the control group compared to the AI cohort. This was about 4,600 units versus 4,100 units.

However, there was no significant difference in the number of M2O sites retrieved, 11.25 in the control group and 11.18 in the treatment group. The authors then stratified their analysis by age group comparing these outcomes among those less than 35, 35 to 40 and greater than 40 years of age. They report that in the two younger groups, the associations remained with the control group having a significantly greater average starting FSH dose and total FSH dose, but no significant difference in the number of M2s retrieved.

However, in the patients age 40 and up, the difference in starting and total FSH dose was not different between the two groups. Lastly, the authors report the estradiol levels did not differ significantly between either control or AI group. And they note that there were no cases of severe OHSS in either group.

I thought this was a really interesting and novel paper as much of the existing literature around the use of AI and reproductive medicine has focused on the training of machine learning algorithms using prior cycles with of course known outcomes. In contrast, this study makes the jump to the performance of an AI tool in a prospective clinical setting. Of course, there were some limitations to this study including the retrospective control group.

I would certainly be curious to see how this tool compares head-to-head in a randomized control trial. I'm also curious to know how often clinicians actually followed the AI recommendations and if physician agreement with the recommendations differed based on physician experience or perhaps even physician age. I'd be curious to hear what you guys think.

Full disclosure, I am a medical advisor for Alife, the company that developed this tool. So just need to say that out loud. I wanna drill down on the actual difference.

I know that they came up with a statistically significant difference in total gonadotropin dose. But if you actually do a little math, 4,654 minus 4,181, we're talking like a 300 pen of gonalef difference or Follistim, pick your poison. Clinically different, clinically meaningful, financially meaningful for the patient.

What do you guys think? Yeah, I was thinking the same thing. And then I'm trying to find the number you'd mentioned difference in oocyte number was like 0.1 of an egg. Yeah, basically no difference.

A 10th of an oocyte. So basically that means the same in my mind. But yeah, I mean, having tools to help us be more efficient in the clinic and always welcome.

And I would be interested to see more of the data on this, but tools to help us improve outcomes, be more efficient in clinics, see more patients move on more quickly, always gonna be helpful. I will say me personally, it doesn't take me a significant amount of time to figure out what dose I'm gonna put a patient on. But so, you know, if this is gonna cost, I don't know what PHR is charging for this or will charge for this.

But. I know you can't afford it. Yeah, yeah.

So I'm just not even gonna ask. And then also I was trying to find this, correct me if I'm wrong, but I didn't see in here where it takes into consideration if you're doing fresh first frozen transfer. I like if you are doing a fresh transfer, basically.

So if you're doing a trigger shot and with the intent to not even do a transfer, then that's gonna change a lot of this decision, I feel like in terms of the, what is the estradiol value, what type of trigger shot, how much HCG to give. So since that's not taken into account and for us folks in Oklahoma that do a fresh transfers a lot, that's certainly something that's on the forefront of my mind. So just some thoughts that I had.

As someone who doesn't practice, so take this with a 10th of a grain of salt. I'm not saying you're missing the point, but the point that I'm taking away from this is that there is a meaningful, significant difference that is conferred using the AI. And I think the implication there is that, one, that can only get better with a larger training set.

And two, if it works for this, let's see what else it can work for. And I think that we all are looking down the barrel of a society that's incorporating AI into probably most things. I think this is a kind of a good fit, whether or not it's practical now, I think is less the point than, I mean, not to be cynical, but to pump the stock, so to speak.

This is a validation of the approach, the rationale, and the training set, I think, because everyone always says with AI, garbage in, garbage out. So they're saying not garbage, a 10th of an oocyte ain't garbage. I mean, despite you poo-pooing it, Blake, I'll take a 10th of an oocyte.

What is it? A couple of cells in the zona pellucida? Is that what we're calling it? Yes. I'll take just a fragment of zona. Yummy.

Wait, Elena, closing your article out, comments on comments? I just think, I agree that I think it would be interesting to see a cost-effectiveness analysis. And I think something that needs to be factored in, in addition to the cost of the medications, which I agree, I don't think that is going to be a huge difference at the place it is now for this AI technology is also the cost of implementing the AI technology. I think that is something that in a lot of the excitement around AI, certainly here in the Bay Area, we're very familiar with that, is something that often gets overlooked.

And so I would be curious to see how that gets factored in, if at all, into future cost-effectiveness analyses. Elena, what a fabulous substitution for Molly. Molly, it's not like we're going to kick you to the curb, but we know we have a worthy replacement should you fall ill or just need a month off.

Elena, thanks for representing FNS Reports. I'm taking a month off, partner. You have to go double duty.

When am I up? You're going to have to find a suitable replacement. Good luck. Not a deep bench.

She can't do for me. We need more ovaries on this show, partners. Ain't that the truth.

Listeners, thanks for being with us again. It's always nice to see Daylon's face. Blake, it is nice to see your face.

And Elena, thanks again for joining us on the podcast this month. That's all the time we have for today. Until next time, bye-bye.

This concludes our episode of Fertility and Sterility Unplugged, brought to you by Fertility and Sterility in conjunction with the American Society for Reproductive Medicine. This podcast is produced by Dr. Molly Cornfield, Dr. Adriana Wong, Dr. Elena Huganesh, Dr. Selena Park, Dr. Carissa Pinkey, and Dr. Nicholas Raha. This podcast was developed by Fertility and Sterility and the American Society for Reproductive Medicine as an educational resource in service to its members and other practicing clinicians.

While the podcast reflects the views of the authors and the host, it is not intended to be the only approved standard of practice or to direct an exclusive course of treatment. The opinions expressed are those of the discussants and do not reflect Fertility and Sterility or the American Society for Reproductive Medicine.