PCOS & Pregnancy: Navigating The Possibilities

Jennifer Roelands, MD, ABOIM

Thank you. I’m honored to be here. PCOS is my favorite subject to talk about, so I can’t wait to dive in.

Aumatma Simmons, ND, FABNE, MS

How does PCOS contribute to infertility? What is it about PCOS that has anything to do with fertility?

Jennifer Roelands, MD, ABOIM

It’s generally a lack of ovulation. When you’re not ovulating, you can’t get pregnant. You need to. You need to get pregnant. PCOS is a very common cause of lack of ovulation, or anovulation, in the medical term. So women with PCOS consistently are not ovulating, and therefore their chances of getting pregnant every month are lower and lower, depending on how consistent that is.

Aumatma Simmons, ND, FABNE, MS

So, anovulation is the biggest driver. Let’s talk a little bit about anovulation. What in the PCOS picture contributes to that?

Jennifer Roelands, MD, ABOIM

Both pieces of the PCOS picture contribute. the insulin resistance picture that happens related to PCOS and also the high androgen. The high androgens certainly contribute to the lack of ovulation. So some schools of thought say it’s the high androgens that then cause the blood sugar dysregulation, which causes the lack of ovulation. Or is it the blood sugar issue that causes the androgen issue, which then causes ovulation? Either way, both of those two pieces are contributing to the problem of anovulation. When you have a lack of ovulation, that’s when getting pregnant is more difficult for women with PCOS.

Aumatma Simmons, ND, FABNE, MS

It’s like a chicken and egg scenario, and they both kind of feed each other. If insulin resistance is present, then it feeds the androgen excess, and vice versa. accumulating and making each other worse.

Jennifer Roelands, MD, ABOIM

That vicious cycle is related to PCOS. We have insulin resistance, which causes high androgens, inflammation, and other parts of the body, which then causes more androgens, which cause more insulin resistance. It’s just that vicious cycle that keeps repeating itself.

Aumatma Simmons, ND, FABNE, MS

Women with PCOS, are they this end of the ovulatory pitcher and the hormones that are contributing to it, or are we just doomed if we’ve been diagnosed with PCOS and want to have a child?

Jennifer Roelands, MD, ABOIM

No, there are so many options. First of all, some women want to do it more naturally.  So when they want to feel more natural, I focus on, Do you have insulin resistance? Do you have high androgens? Do you have gut issues? What are those pieces of the puzzle that are making up your PCOS diagnosis? If you start to break that vicious cycle and you fix insulin resistance, if that’s what’s part of your PCOS, or if you lower your androgens, then you will be able to cycle naturally and potentially ovulate as well, which will improve your fertility as well. There are different reasons why some women want to try things a little bit more naturally. Some women are open to ovulation medications like Clomid, Femara, or even injectable medications. Some women want to ultimately do things like IVF. There are a lot of options, for sure. It’s not a diagnosis that says you’ll never have children, by any means. I can tell you from a personal standpoint that I have PCOS and I have four children. it’s not a it’s not a no for sure.

Aumatma Simmons, ND, FABNE, MS

I often say, at least from what I’ve seen, that 99 to 100% of our people with PCOS get pregnant. So I believe that there’s a hidden gift of PCOS, and I like to frame it that way because, like, everything just seems so doom and gloomy, especially when you’ve been struggling with something for so long and people say you just need to be on birth control. I’m like, You go; the last thing I want to do is get pregnant. I’m going to agree too. It’s fun to see them transform, be able to start ovulating, and eventually get pregnant. But the fact that they have lots of extra follicles in their ovaries is the hidden gift that they have the potential to access.

Jennifer Roelands, MD, ABOIM

I love that. I love to focus too. PCOS is being a PCOS warrior. There are some serious benefits to having PCOS like women with PCOS have good-quality eggs. They tend to have a lot of them, as opposed to someone who might have hypothalamic amenorrhea or might just have low shear. They have great eggs—good-quality eggs. It’s just that they have to get them kicked out of the ovary and PCOS warriors with testosterone are good at athletics. If you look at Olympians, there was a cool study done a couple of years ago that said there’s a high percentage of Olympian athletes who have PCOS because the stronger testosterone that is present is very good for muscle building and very good for strong endurance. It’s just been the concept of PCOS. If you’re a hardcore warrior, you’re not like you. There are so many benefits and some ways that you can do things that other women cannot. It’s about hacking your biology and understanding how you can then make it work for you if it’s fertility that’s the question or if it’s just the question, like, how do you maximize your biology?

Aumatma Simmons, ND, FABNE, MS

What can women do to help support conception with PCOS?

Jennifer Roelands, MD, ABOIM

Make sure that they get those labs done by their discos who look at the metabolic side of PCOS. What happens often when people go to a standard OB-GYN, is they say, here’s your estrogen and progesterone and testosterone. Here, you have PCOS. You want to try to get pregnant, try for six months, and then come back. when you’re at this point. But truly to give them a real chance at trying, you have to understand, do they have any metabolic dysfunction that comes with it? You need to be tested for inflammation. You need to be tested for insulin resistance and gut health issues. You need to be tested for this metabolic picture because it doesn’t matter if someone’s trying for six months if they have pre-diabetes for the health of their pregnancy. They need to optimize this. If you wanted to go, how would I make my body ready for this? Make sure you understand what is driving your PCOS symptoms. What is driving that diagnosis for you? Because it could be very different than the woman next to you having PCOS, and throughout your lifetime, it has changed. making sure you’re always on top of getting that metabolic workout. Then I’m a big component of using supplements too that help optimize nutrition because we’re learning more and more is being known, but like getting out there about how important nutrition is for fertility and not only just to make sex hormones, but ultimately for quality and to improve your overall health. I’m a big component of looking at what you’re eating. Are you able to eat to get the maximum number of nutrients that you need, or should you consider supplementation because you just can’t get them in your diet? The other important thing that happens a lot is women get what I’m going to do I’m not going to put myself we’re going to get exposure, any toxins and I’m not going to go anywhere and I’m going to work out crazy hard. I feel like they sometimes get a little bit overly invested in this sort of journey, and it can contribute to their cortisol being off because you have these sorts of feelings, like my friend got pregnant because she does cardio four days a week. I should do cardio. That doesn’t necessarily work for you. It might stress you out if you hate cardio.

Aumatma Simmons, ND, FABNE, MS

Or it must have been too much.

Jennifer Roelands, MD, ABOIM

It’s a very personal journey. You have to put that part of it into the way that you go through; it is going to be different than your friend. I notice a lot of times when women are considering having a baby, they often put themselves on a very regimented lifestyle. You have to be able to also be comfortable on that journey. If you’re doing something like you hate Zumba and you sign up for Zumba classes, it’s going to be a disaster for you hormonally.

Aumatma Simmons, ND, FABNE, MS

Do whatever you like and please don’t force yourself within reason. Even food sometimes becomes so regimented, and in some people’s cases, it needs to be. But in other cases, it’s like you can’t overregulate, you can’t oversupply, or overexercise is your way to conception. that toning it down and finding that balance in everything that you’re doing supports that journey in a more useful way.

Jennifer Roelands, MD, ABOIM

It’s important to find somebody, a provider who meets the needs of what you’re looking for, because there are patients who’re with doing natural up until, say, Clomid, but they won’t do IVF or they won’t do they have sort of their ethical boundaries or what they’re comfortable with. Starting that journey with the right provider that’s going to be in line with what you want to do is important because you don’t want to show up and say, I’m, I don’t feel IVF is the right thing for me and the providers like IVF.

Aumatma Simmons, ND, FABNE, MS

The providers; that’s what we do here.

Jennifer Roelands, MD, ABOIM

That balance to where it meets your values.

Aumatma Simmons, ND, FABNE, MS

You mentioned that I want to go back to a couple of things that you said earlier. You mentioned inflammation as one of the possible underlying things that we might find in a metabolic workup in terms of someone who maybe doesn’t know they have PCOS and you suspected or someone that is diagnosed with PCOS and you’re like, What else is going on? What kind of testing do you think is necessary for you to get that big-picture metabolic-functional perspective on that person in front of you?

Jennifer Roelands, MD, ABOIM

If they have PCOS, I want to test them for PCOS. I want to know first of all: do they have irregular periods? Because you need that for the diagnosis, and do they have levels of androgens that are elevated? You’re going to do DHEA; you’re going to test total testosterone and free testosterone. You’re going to be looking for those androgens that are elevated because you need them to make a diagnosis. Now, if someone came into me and they had irregular periods and they have evidence of hearsay, to some, they have hair on their belly or they have chin hair. They’ve already met the criteria. It could be physical signs or it could be bloodwork that defines the high androgens. then I will test them for those metabolic labs like we were referring to. Let’s say it comes back as negative for PCOS and they still have high inflammation. They’re going to start looking into what they eat, what they put on their bodies, and what chemicals they may be exposed to. What if they may have had lyme or mold ten years ago? What is going on in the environment? focusing on the environment for that patient to figure out what this inflammation is. Inflammation can also be cortisol dysfunction. It could also be that of the patient who’s maybe trying to lose weight, exercising seven days a week, and eating two carrots like this. Some of that contributes to inflammation as well. understanding that if they’re not a PCOS patient, they may just have metabolic dysfunction and therefore have to look at those parameters as well.

Aumatma Simmons, ND, FABNE, MS

Then, in terms of the metabolic panel, what would you like to test on there? Let’s get into the nitty-gritty.

Jennifer Roelands, MD, ABOIM

CRP, which is the measure of inflammation. I do fasting and leptin levels, and. look at those two kinds of leptin and insulin parameters that have to do with blood sugar balance. I like the cardio IQ, which is a more advanced lipid profile, to understand what someone’s cardiovascular disease is because we know that PCOS has a higher chance of cardiovascular disease as we age, and we don’t want to just be 20 years old. Just because you’re 20 doesn’t mean you don’t need to have that checked.

Aumatma Simmons, ND, FABNE, MS

Like preventing. 

Jennifer Roelands, MD, ABOIM

On every PCOS patient. Sometimes I dive into things like testosterone because that can contribute to the metabolic dysfunction of someone, and everyone will do things like growth hormone. It just depends on the age of the patient as well.

Aumatma Simmons, ND, FABNE, MS

In terms of supporting someone to have a healthy pregnancy with PCOS, what do you think is the most important? We’ve touched a little bit on all of it, like diet supplements or exercise-like lifestyle pieces. But if we were to get granular with it, what are the key things that people should pay attention to, specifically with PCOS? That is, it may be necessary for women with other fertility challenges.

Jennifer Roelands, MD, ABOIM

Understanding that it’s a metabolic concern, then, while you’re pregnant, you’re at increased risk for hypertension in pregnancy, and diabetes in pregnancy. Understanding that you’ll be watching those more carefully. If you already have blood sugar problems earlier, like pre-diabetes, then I would, as an OB provider, be checking someone for gestational diabetes earlier in pregnancy than 20 weeks. I’d be monitoring them; maybe even do it in the first trimester, but certainly by 20 weeks and by 28 weeks. To look for insulin resistance to turn into gestational diabetes, I would be more conscious of their blood pressure. Could they develop preeclampsia? I would be more conscious of mood issues too, because with PCOS, you do have some issues related to mood, and pregnancy can be hard for people. It can be a hard time, too. Not everybody likes walking around. This is the best thing that ever happened to me. Some people have a hard pregnancy, and so if they have depression or anxiety on top of that, does that patient need to be treated for their depression or anxiety knowing that we also need to support their gut during pregnancy? Because that’s important for the mood as well. then trying to understand, if are there any other components of their PCOS that we would need to be conscious of during pregnancy. For example, there is a higher chance of thyroid disease in PCOS women. Untreated hypothyroidism is bad for a fetus. We need to be on top of that as well as understand that we need to look for thyroid disease. So understanding those things that co-morbidities or the things that can occur while someone is PCOS and the complications related to pregnancy is important for a good provider to say, we don’t need to just do our standard see you in four weeks or see you in 20 weeks, we need to be looking at that and checking things that are a little bit more appropriate. Check vitamin D levels because vitamin D deficiency is very common in PCOS. It’s amazing when you start checking people’s pregnancies to see if they’re right. That baby’s taken quite a bit. I always check vitamin D levels in PCOS patients while they’re pregnant, just to make sure that they’re getting enough for themselves and that they’re growing bones in the baby.

Aumatma Simmons, ND, FABNE, MS

Needed for fertility and pregnancy. Vitamin D has a lot of research coming out about how it supports critical and quality implantation, sperm health, and how there are just so many ways in which it’s impacting fertility. If you are already pregnant, it is important, and if you’re not pregnant yet, don’t get your vitamin D checked.

Jennifer Roelands, MD, ABOIM

Check it every once in a year once you’re not pregnant. Once you’re done having a baby, it’s important to be on top of those, like I said. Part of this I should have mentioned in the metabolic labs as well. But it is important to have these series of labs once a year at your annual.

Aumatma Simmons, ND, FABNE, MS

It blows my mind how many times people come from doctors and they’re like, I go for my checkup every year, and I’m like, How come we don’t have any data? How come you have a CBC and CMP? And that’s it. Sorry,  I went to the doctor, Lingo. It is a comprehensive metabolic panel, and CBC is just like the red blood cells, white blood cells, and all of that. Commonly, people aren’t being checked, and with the, like you’ve been saying, metabolic issues—the blood sugar, insulin, and leptin—are the things that have a very big impact. When someone has PCOS, it’s important to check regularly. then cardiovascular health, of course, is very important.

Jennifer Roelands, MD, ABOIM

The reason they do that is because the standard says that below 40, you don’t need to do this sort of metabolic workout.  That’s also because Western medicine sees PCOS as a problem when it should be considered an ongoing metabolic and endocrine problem. Until it categorizes that, they’re going to keep missing the fact that these women need prevention, not waiting until they have a 50% chance of diabetes at 40. Half of them end up diabetic. It makes no sense to me. This is why I love integrative medicine because it’s about the prevention of disease and reversal of disease, not waiting till our hemoglobin A1C hits.

Aumatma Simmons, ND, FABNE, MS

It’s like we’re on the edge for a lot longer than we were before getting diagnosed.

Jennifer Roelands, MD, ABOIM

That’s why I love using things like technology. I use CGM as a continuous glucose monitor and a lot with PCOS patients to help them understand blood sugar balance. I use sleep aids. It could be like an Oura ring, an Apple Watch, a Whoop, or whatever it is—a device to help understand these metabolic parameters. Because if you learn what works for you and the secret to me like I can have sweet potatoes, but sweet potatoes with olive oil and green, I can understand why what works for me.

Aumatma Simmons, ND, FABNE, MS

Can you talk a little bit about the CGM? That’s very interesting in terms of how people can help understand their metabolic pattern, their blood sugar, or stuff like that. How do you guide people in, like, figuring out what their body feels good and not good with?

Jennifer Roelands, MD, ABOIM

Continuous glucose monitors, you just put them on the back of your arm. They’re little. They look like little white patches. There is a needle attached to them, so you wear them for 14 days. The one monitor lasts about 14 days. When I talk to patients about starting them, I say, Just eat what you normally eat in the first seven days, and it’s going to start tracking it. It can be tracked on your desktop, on your phone, and the app, and you can start seeing what my waking-up blood glucose level is, what my glucose level is after I eat breakfast, and what my glucose level is when I go to work out. What is my glucose level when I’m in the middle of a meeting with my boss? What are my breakfast levels? You’re looking for not only how high it is rising from the baseline but also how long it remains elevated. Everybody’s going to go up when you eat, but is it going up sky high or is it the same persistently up for two, three, or four hours? Those are those concerns where you start going. What’s the thing I did that’s correlating with this? For the first few days, I just tell people to track it.

We’ll take a look at the data. Let’s see where we can start making some changes because sometimes it’s about, for example, the sweet potato example I gave you. That’s my example. When I wore a CGM with glasses, I had a sweet potato, and it shot up to 220 in my blood glucose, and it was there for three hours. It just slowly went down, and the next time I had a sweet potato, I decided to put olive oil in it and greens, and I didn’t have that giant spike. I had a nice gradual up, and it came back down within two hours. I combined it with some fat, and I combined it with some greens. For me, that slowed the absorption of the glucose. It was a little bit of a better option for me who loves sweet potatoes. Surprisingly enough, it was better than Oreos. I had to go to a Trader Joe’s Oreos multiple times apart so I could see if it was just a fluke and it didn’t go up as high as sweet potatoes. 

Aumatma Simmons, ND, FABNE, MS

Oreos are better than sweet potatoes.

Jennifer Roelands, MD, ABOIM

I use that information more than you understand. Maybe someone’s waking up blood sugar is elevated; maybe it’s their breakfast choices. Maybe it’s that. They’re eating too late at night. Maybe. It gives some data, and if you’re a data person, that helps you make changes because you understand what’s happening to your body. It’s useful for those patients to go, maybe next time I have oatmeal, I should have oatmeal with chia seeds and berries because it seems to go a little better for me for blood glucose levels than just oatmeal or making these changes that might happen. I like it for people who want to slow the timeframe down on how I figure out what I can est. Doing it on your own, where you would be journaling. If you decided to do it on your own, you’d be like writing down what you eat, what symptoms you had, and how you felt. Were you having shaky episodes? What’s going on with those symptoms? Slowly figuring out how to eat more for insulin resistance, for example, which can take some time. I like CGM because it gives you real-time data, and I’m not a big fan of using them forever. I don’t think everybody should be wearing them nonstop, because I was a bit neurotic about that.

Aumatma Simmons, ND, FABNE, MS

That was going to be my next question.

Jennifer Roelands, MD, ABOIM

It could help patients, and I feel like I’m doing everything right. What is the problem here? Where’s the gap? I find them very useful for my patients in my practice especially those women who may also be perimenopausal, and blood and insulin resistance and blood sugar dysregulation are very common as you age as estrogen goes down. I find it helpful if you have a PCOS or perimenopause lady; it’s a great tool for them.

Aumatma Simmons, ND, FABNE, MS

Now for the favorite part that everyone loves to talk about, let’s talk about supplements for PCOS. If we were trying to get pregnant, what are your favorite ones? Who are they helpful for? I always like to emphasize the who because a lot of people will hear these lists and just go out and get everything, and we as providers know that’s not the way to do it. We can dive into the supplement piece and just talk about what are the ones that you found the most success with. Then who or what kinds of things were happening that they were most helpful for?

Jennifer Roelands, MD, ABOIM

Part of what I recommend for supplementation is certainly related to whether they have insulin resistance, inflammation, or other issues. Do they have the other components? Because across the board, I would say I almost always suggest inositol, because inositol hasn’t a lot of downsides. We know that the data supports that there’s a good egg or improved egg quality, as well as ovulation related to inositol. I don’t have a problem saying to every PCOS woman who’s who wants to conceive, go for inositol at least two grams. You need to at least get two grams. There are very few side effects—maybe some gas pain or some digestive discomfort—but very few side effects. Inositol has always been a favorite of mine. I also always suggest that women, no matter what’s driving their PCOS, get an omega-3. If you’re not someone who eats a lot of omega-3 fats, make sure because that will also help with inflammation, which almost everybody has in their body in the world we live in. Omega-3s like fish oil or flaxseed, whichever you prefer from an ethical standpoint, are fine, but I certainly think omega-3s are very valuable. If you have any nutrition issues, like you don’t eat them very well on a diet, then you should be taking your prenatal anyway. Prenatal can often help with overall balancing any nutritional gaps you may have because it’ll give you some vitamin D, but it may also be folic acid, and it’ll give you some of those other vitamins that are useful as well. A multivitamin is also very helpful. then B-Complex is almost always a very important option too, because most people need these for both sex hormones and neurotransmitters. B-Complex is always a very valuable one as well. Unless you’re just somebody who just eats a ton of bell peppers and kills them in the B vitamin department. It could be helpful, too. Then the rest of the supplements are tailored to that specific person. We can certainly talk about NAC, and we can certainly talk about vitamin D. Let’s say, as we said, that if you’re vitamin D deficient, you better just be on vitamin D. That’s just for sure, but the specific supplements are geared towards where you are. Do you have a metabolic issue? What are some other components that may be related to your PCOS? Those, I suggest, are more personal based on the patient’s specifics.

Aumatma Simmons, ND, FABNE, MS

In terms of the specifics, NAC, says that there’s a lot of research on NAC and PCOS; there’s research on anything as just a high-quality antioxidant or anything else. How do you tailor this to people deciding whether they need it or not?

Jennifer Roelands, MD, ABOIM

If they have other metabolic issues, say high blood pressure or maybe pre-diabetic or other metabolic dysfunction, we know that their mitochondria take a hit. They have some serious mitochondrial health issues. I have a very low threshold for adding NAC to that. If you’re a little older and trying to have a baby, that’s also very helpful because just oxidative stress helps our bodies keep up with energy requirements. I’m also a big fan of NAC.  There’s more for those who have other metabolic issues, and certainly, if your CRP is high, this is a very useful supplement as well. Also, some would argue against it, but some people just put it on. They do it anyway for all fertility patients. Is there a downside to it? Probably not. NAC is pretty well tolerated. It’s amino acids right there. Amino acids are proteins that we eat. Is it one that you’re going to likely get into hard? Probably not.

Aumatma Simmons, ND, FABNE, MS

I feel like supplements are tricky. You can take a lot and it’s supportive, and then you can take a lot and it’s working against you. I read a paper recently that said that the number of supplements that people take has been shown to cause oxidative stress and deplete egg quality. There’s that threshold of, yes, this is the right thing for us, and it’ll be amazing for you. Then, no, let’s drop that off just for the sake of not adding stuff that your body has to deal with.  I feel fine. Like, where’s the balance? Like, always trying to weigh the scale of whether this is the right thing? Do we need it, is it desirable, or is it not a necessity? Try to weigh that out regularly for people.

Jennifer Roelands, MD, ABOIM

Where I find the concern is that patients will often take, say, ten supplements, but the supplement they’re taking doesn’t have enough of the ingredient that is used. For example, there are a lot of hormone balance supplements over the counter, and they have Chaste Berry, but it’s like Chaste Berry 50 milligrams. That’s nothing. That’s can not do anything. I find that when I start going to people’s supplements, I’m like, Yes, Chaste Berry is Fantastic but it doesn’t do anything at 50 milligrams; if you have a headache, it might give you a quarter of one tablet of ibuprofen. You’re going to be like, My headache didn’t go away. It’s not a therapeutic dose. I’m more where I see it from a clinical standpoint; I just see a lot of people who are like, I saw this on Instagram. I’m taking this one; I see this one; I take this one; I’m taking this one. They don’t realize that they’re not even getting enough of the active ingredient to do anything. So you may not need ten. You might need four good ones.

Aumatma Simmons, ND, FABNE, MS

Yes, exactly, tailoring in it.  Are there any other supplements or herbs that you’re a fan of? You mentioned Vitex, which tends to be a potentially good herb for people with PCOS. What’s your what’s your take on it?

Jennifer Roelands, MD, ABOIM

I often use Vitex for people who are trying to get it in regular cycles. They don’t want to take an ovulation medication. They want to continue just having regular cycles. It may be that, ultimately, their progesterone is the issue. We’re using Vitex or Chaste Berry for that, and supplements for things like fertility, you can go down; there are a lot of different options. We could talk about vitamin E; we could talk about there’s a lot of herbal options. You can even talk about Schisandra, from an Arabic medicine perspective, there are a lot of different sorts of ones, but it becomes more personal to that person, and it’s important to make sure that, as I said, supplements supplement nutrition, so it doesn’t make sense to take if you’re eating something and getting it to appropriate levels. Now, one thing to mention is that you could get nutrient testing, which is often covered by insurance with companies like Genova, and I don’t work for them for anything, just throwing it out there for people. But you could also get nutrient testing, which I sometimes do with fertility patients, to understand that maybe they’re thinking they’re getting enough amino acids, but they’re not, or they’re not getting enough vitamin B, or they’re not getting certain nutrients that they think they’re getting. Therefore, this is the perfect example of supplementation. 

Through your OB, whoever you’re going to see for your pregnancy is on board, because there are sometimes some obese people who are a little less open-minded to being on NAC and probably need to make sure that you also run it by your provider to say, this is what I want to try, see if it improves my ovulation, egg equality, and overall health. Are you with me in continuing this regimen when I get pregnant?

Aumatma Simmons, ND, FABNE, MS

You want to find the right team that is understanding of what it is that you’re doing and how it’s supporting you or not, and you want to be able to have those conversations because, as a lot of people struggle with, my OB is not on board or already said to stop all my supplements, and sometimes that’s necessary and sometimes that’s not the best thing for them. Always finding that team that is going to support you with your vision and your goal is helpful.

Jennifer Roelands, MD, ABOIM

Yes.

Aumatma Simmons, ND, FABNE, MS

Well, thank you so much for being with us today, Dr. Roelands. It’s always lovely to chat with you and hear all of your wisdom and what you’re doing in your practice. Thank you for being with us today.

Jennifer Roelands, MD, ABOIM

Thank you so much for having me. It’s been a pleasure.