The title of today’s show is The Endometrial Function Test and Everything You Need to Know from Implantation Onwards. We have the most well-known physician scientist here today to talk to us about that.
Dr. Harvey Kliman holds an MD and PhD in cellular biochemistry from the University of Chicago. He is currently a research scientist in the department of OBGYN, Yale University School of Medicine, and the director of the reproductive and placental research unit with a special interest in infertility and pregnancy complication. In addition to his research and teaching activities at Yale, he also consults with doctors and patients to evaluate complicated cases of unexplained infertility, pregnancy loss, and poor pregnancy outcomes.
He has over 10 patents, including the patent for the Endometrial Function Test®, or EFT® test, that we’ll talk about today, which is “the soil test for the endometrium” and method and system for determining placental volume.
His contributions in the field of placental research include the development of the “Kliman” method of trophoblast purification, research into the mechanisms of trophoblast differentiation and invasion, the role and genesis of syncytial knots, the discovery of placental fetal fibronectin, and more recently, the clinical utility of abnormalities in placental villous growth patterns, especially trophoblast invaginations and inclusions, to diagnose genetic abnormalities in pregnancy, including autism.
Dr. Aimee: Thank you for all of the work and research you’re doing to move this field forward. Tell us about how you became interested in fertility medicine and pregnancy complications.
Dr. Harvey Kliman: As usual, serendipity. I certainly wasn’t planning on this. I’m an MD PhD physician scientist, as you said. During my pathology residency at University of Pennsylvania, I realized that I really wanted to focus on obstetrical issues and pregnancy issues. I started working and did what’s called a post-doctoral research fellowship in the laboratory of Jerry Strauss, and I started working on the placenta there.
That’s actually where I met Bruce Lessey, who I know you had as a guest here recently. Bruce and I are friends. Chris Coutifaris and Bruce and I were all one group, we were in the same class together, if you will. While they worked on their things, Bruce starting the Beta-3 integrin test, I was looking at the placenta. I was interested in the basic cell biology of the placenta, how it works, the cell that basically makes all of the other cell types. We by chance discovered a special glue protein that keeps the placenta attached to the endometrium, to the lining of the uterus. This is critical for keeping the placenta attached during pregnancy.
That discovery led to my interest in the endometrium. They’re two halves to the pair. You have the placenta and then you have it joining the endometrium. So, I said, “Gee, what’s the endometrium doing here? Does the endometrium need to be specialized and differentiated and prepared for implantation?”
As I tell my students, the endometrium is not a piece of Scotch tape. Basically, it doesn’t allow attachment except for one little small window, just a few days. The earliest work we did on this is that we took the cells of the placenta and incubated them with pieces of endometrium from hysterectomy specimens — patients after their hysterectomies let us take these little pieces and study them in a laboratory. We saw that only on day 19 of the cycle did these pieces of trophoblast, these cells which were sort of like a little blastocyst mimicking implantation, stick to the surface.
I was thinking, “Wow, that’s really specialized. How does the endometrium stay closed to attachment and what opens up that door?” So, I became interested in the biology of the endometrium and how it changes through the menstrual cycle and how it controls this process. That’s what led to my interest in the endometrium. I still maintain a lot of interest in the placenta, but I added the endometrium to my portfolio, if you will, of research.
Dr. Aimee: What role does the endometrium play in supporting a healthy pregnancy?
Dr. Harvey Kliman: The first job really is to facilitate implantation. What’s amazing about the endometrium is that it’s a really unique tissue in our species. Only females have it. It’s the only tissue that cycles every month and grows and then gets ready for implantation and then differentiates. If there isn’t an embryo that’s attaching, it sloughs and regrows again every month. There is no other tissue that does that, so that’s very unique.
It’s controlled by hormones that are coming from outside of the uterus, from the ovary, and that’s being controlled by other hormones that are coming from the pituitary, so it’s a very complex system. On top of it, what makes it even more complicated is that it’s a mixture of two cell types. I call it the fruitcake model. That’s what I teach my students and it’s useful for them to think about it.
You can think of the fruitcake as a cake itself, and that’s the stroma, and the glands are like the little pieces of fruit inside of the fruitcake. They communicate with each other, so the signals from the outside world, from the mother’s body, come and affect the stroma, the cake part, and then they send signals to the glands to cause them to grow and differentiate.
So, it’s a very complex system. Complexity allows for loss of control. It also, unfortunately, allows for a lot of problems to appear. Outside things like inflammation, infection, even stress in the woman herself can impinge on this complex system and basically derail it and make it not work correctly.
Dr. Aimee: I was going to ask, but you answered it perfectly, what can cause an unhealthy endometrium. Things that a woman can do, her environment, the environment of her body can affect the lining of the uterus.
Dr. Harvey Kliman: Absolutely. I think we anecdotally know this. Of course, this rule doesn’t work, if you don’t want to get pregnant, then usually it works pretty well. It’s when you really want to get pregnant, and you put a lot of energy into trying to get pregnant, that sometimes can be difficult. There are a lot of things that can interfere with that. For example, just inflammation in the pelvis around the uterus.
One of the most common in our society is endometriosis. Endometriosis is basically the backflow of menstrual debris into the pelvic cavity. It’s sort of like weeds that are growing where they shouldn’t grow and their growth every cycle, they still continue to cycle, they don’t know that they’re outside of the uterus. It causes inflammation and scarring. That inflammation can go back and affect the normal endometrium.
There can be inflammation or infection in the fallopian tubes. There can actually be bacteria that come up into the uterine cavity that interferes with the development. Finally, there’s a whole field of work that looks at stress in a patient herself and that can cause it. The other thing I’ve found is that women with either very low BMIs who are too thin or too obese can also have dysregulation of the endometrium and its development.
Dr. Aimee: How did you discover and create the Endometrial Function Test?
Dr. Harvey Kliman: Again, it was completely by chance. We discovered something that appeared in the endometrium, we thought it was the linker protein that attached the blastocyst to the endometrium. We just assumed that every patient would have it. We started looking at specimens at University of Pennsylvania, again at the same time Bruce Lessey was there. We were sort of all interested in the idea of endometrial development and control and infertility. We found that some women didn’t have these markers and some women did, and it seemed to be related to their fertility status, if you will.
The first marker was called MAG. The problem with that marker is it only works in blood group A patients. My father was an engineer, and I look at things from an engineer’s point of view, so I said if it’s a developmental system, if I break it down and I ask myself what’s really happening, the endometrium goes through a stage of proliferation, cell growth and getting more cells to be there, that’s in response to estrogen. Then right before ovulation, on day 13, the evening before ovulation, the ovary starts to make progesterone. That progesterone induces differentiation, that’s actually getting the endometrium ready for pregnancy.
I said to myself if it’s a system of proliferation and differentiation, instead of looking at these complex markers that I and other people were looking at, why don’t we just look at the underlying machinery, which is the proliferation system?
So, we looked at something called cyclins, which are the machines that cause cells to divide. You can think of this as the gas pedal and the brake. In the first half of the cycle, the gas pedal should be on. Then you take your foot off the gas pedal and you start applying the brake. Cyclin E turned out to be the gas pedal and p27 is the brake.
We simply looked at the expression of these two compounds, cyclin E and p27, and found that in normal women the cyclin E was present where estrogen and when estrogen was there, and when ovulation started, it started to go away and then p27, the brake, appeared. Women who were infertile kept on having the gas pedal basically turned on. Even on day 24, their endometrium was still proliferating. It’s as if their engine was still running and the gas pedal was on. You can’t have implantation if the gas pedal is still on, so that became the critical basis to make this test.
Dr. Aimee: At what point should a fertility patient be doing this test? Is it after a transfer that doesn’t work? Is this for women who are having recurrent pregnancy loss or who have been given the diagnosis of unexplained infertility? Who should be asking their doctor for the EFT?
Dr. Harvey Kliman: That’s a great question. In a review that we wrote a few years ago, in 2019, in Fertility and Sterility, we ended it with a sort of cost-benefit analysis, in the sense that the fewer embryos that a patient has the more critical it is to know that the endometrium is optimized. We can’t guarantee it, of course, but we have made it the most optimal conditions possible given how precious those embryos are.
If this is the first time and we have a lot of embryos in this couple’s future, then it is not critical to do the Endometrial Function Test. Insurance doesn’t pay for it and they have to pay out of pocket, so it’s expensive, and let’s not do a test that isn’t necessary. Given the success rates of most infertility doctors, REIs, I would say patients should go through routine procedures of getting oocytes made, embryos made, having frozen embryo transfers, fresh transfers, whatever is decided by them and their doctor.
As Einstein said, stupidity is repeating something over and over again and expecting a new result if you do the same thing. Again, this is the cost-benefit analysis. Let’s say you have a $15,000 Japanese maple tree that you want to put in your front yard, and I say to you, “You can plant that tree and you can see how it goes, or you can do a soil test. I will test the soil for the right sort of components and things like that.” It costs $600 to do that test. If it’s abnormal, it’s basically saying to you don’t plant the tree, you should fix the soil first. Maybe at some point you have to decide is it worth spending that $600 to save the $15,000. I think that’s where you should think about it.
Certainly, in a donor oocyte transfer, that’s very expensive. The success is very high. If a patient is not successful in a donor embryo transfer and everything is optimized as best the doctor can do, I think you should stop and say maybe we need to really make sure that the stimulation we just did on that patient is optimal for her.
I think this is an important point. We’re not, hopefully, Midas muffler technicians. It’s not like a car comes in and makes noise and we replace the whole muffler system. As physicians, what we should be doing is figuring out what’s going on with our particular patient, diagnosing the problem as best we can, and then treating that patient based on what we learn. Not every patient responds the same way to what we do. There isn’t one treatment that is optimal for everybody.
The point of the Endometrial Function Test is to see given what you have just done to your patient, did her endometrium actually develop normally. That’s really what it’s designed to do. As the embryos become more precious and it becomes more expensive to do the transfer, like in a donor cycle, then I think it becomes more cost effective to think about doing it.
Dr. Aimee: If someone receives abnormal results, what kinds of changes can they make to make the results more normal and favorable for a future transfer?
Dr. Harvey Kliman: I think that’s a really great question. I’m going to draw another analogy that I think will help the listeners understand what we’re talking about, because it’s not helpful if I say do this, this, and this. Let’s look at the endometrium and the development and what the EFT is doing and think of it as a plane at the end of a runway.
There’s the plane, it’s a little Cessna single-engine plane, it’s at the end of the runway. We step on the throttle, we give it the gas, that’s the estrogen. We’re tooling down the run, we’re going faster and faster, and then right near the end of the runway we have to pull back on the stick to go up, otherwise we crash into the trees at the end of the runway. The stick is the progesterone. I think everybody can imagine that if you’re going really fast down the runway and if you pull back on the stick really hard, the plane is going to go straight up, and then stall, and crash. That’s often what happens.
We have a lot of women who are what we call hyperestrogenic, they have already too much estrogen. Estrogen upregulates the progesterone receptor. They’re already moving fast, we’re giving them more gas, they’re moving really quickly, and that stick that we pull back is so sensitive that even if we give a little bit progesterone, even if we pull back on the stick a little bit, it’s as if we’ve jammed it back.
So, a lot of what we do with the EFT is we look at the end of the runway and we look just as the plane is coming off the end of the runway, that’s the day 15 biopsy. We can see how fast it’s going, how much the estrogenic stimulation is. We can see how much progesterone receptor has been made, that shows the response of the estrogen to the endometrium. We can see the response of the progesterone on the endometrium, how fast that stick was pulled back. Then day 24 we ask the question, “Is the plane up in the air and flying level where it should be?”
There are a lot of patients who literally crash at the end of the runway and the plane is not the air. We look back and say, “Let’s analyze this plane.” First of all, it was going too fast down the runway, so we need to give less estrogen, more gradual, and we need to pull back on the stick much less firmly, so we need to give progesterone in a gradual slope.
If you look at the natural normal menstrual cycle, it turns out nature designed it to give a very little blip of progesterone the evening of day 13, that’s the evening before ovulation. Ovulation is on day 14 in an idealized cycle. Then gradually increases progesterone until about day 21 or 22, where it levels off. There are many doctors who give a bolus of progesterone, they might even give Crinone vaginally, they give so much progesterone that it’s yanking the stick back tremendously.
So, a lot of times when I look at the results I will talk to the doctor. I think it’s important for people to understand that a patient can’t call me up and say, “I want to do the EFT.” I don’t and can’t deal directly with patients. This is too complicated. I work with doctors who are taking care of patients who have infertility issues. It’s only a doctor who is dedicated to doing the test and then looking at the results. I actually have rounds with my doctors all the time, I have calls with them, they page me or they text me, or whatever when they want to talk about the results, because let’s work through this, let’s see what’s going on.
There’s a whole class of patients who have an abnormal result because of the stimulation. I try to take the results and optimize the stimulation with the doctor. Then there are a whole bunch of patients, and you can only see this if you look under the microscope at the tissue itself, who have inflammation. They have macrophages in their gland lumens, that’s a sign of inflammation in their pelvis. They have neutrophils, which are a sign of a bacterial infection.
I had a patient recently who the entire stroma, the cake part of the endometrium, was filled with tuberculosis. Trust me, she will never get pregnant with tuberculosis in her endometrium. If you do other tests that simply are molecular tests that look at the dating of the endometrium, they will not see that. Then you’ll have a woman who might even have a normal result on those tests and have transfer after transfer and never get pregnant. One, the fertility treatment won’t work. Two, we need to treat her for tuberculosis.
We have women I see who have what’s called hyperplasia, where they’re actually moving in the direction of a precancerous state. As much as I think it’s important to have a family, I want to save the woman’s life first. Let’s make sure is safe and sound.
That is the reason why the EFT, unlike the other tests that are available, is a combination of molecular markers the cyclin E and p27, and me as a trained pathologist who actually looks at the endometrium to make sure that there are no problems. I think that’s really an important distinction and people should understand the difference between this test and the other tests that are available because of that.
Dr. Aimee: If someone wants to do your test and the other tests, can they somehow combine them so that you’re doing one biopsy and sending it to you to analyze and to the other companies? Is there a way to make it efficient so that people can still learn from the data that you can generate?
Dr. Harvey Kliman: I wish that were true, but it’s not true. Because the ERA Test, the Endometrial Receptivity Analysis Test, is a molecular test that’s basically a dating test. The purpose of it is to use molecular markers to determine the dating, where in the cycle it is. They’ve designed their test to optimize, I think, on day 20, based on progesterone start date. We need to do biopsy on day 15 and 24, so the answer is no.
I think that if you do too many biopsies in one cycle, you’re going to get just artifacts of having too many biopsies. I’m sure, as you probably know, the patients wouldn’t be that happy to have three biopsies in one cycle. You would agree with me on that?
Dr. Aimee: I totally agree. But I think people might see value in maybe doing an EFT cycle perhaps first, getting some information. A lot of patients have done the ERA already and still don’t have answers, then they can come and do an EFT cycle.
Dr. Harvey Kliman: Right. The ERA, I don’t know if you were explicitly going to ask about it, but one of the issues that I have, and we wrote about this in our review — if anybody is interested, please go to our website at Yale and take a look at our review, because we, I think in a fair way, review the three major tests that are available at this point — the ReceptivaDX Test that Bruce Lessey developed, the EFT that we developed, and the ERA Test.
The ERA Test, as I said, is a very cool concept, which is to say instead of looking under the microscope to figure out which day of the cycle we are, we’re going to use molecular markers. The problem is that in 2004, Coutifaris, who was actually the first author of a very large study, showed that dating by itself does not predict fertility status. So, even back in 2004 we understood that it’s too simple just to look at the timing of the endometrium, because of these other factors.
Most of what determines timing is the stroma, but the glands in the stroma, as I said at the beginning, are disconnected. I’m going to give another analogy. You’re in California, so this will be real for you guys. Surfing. We don’t surf in Connecticut that much. Think of the wave as the stroma going through the cycle, right from the beginning to the end. The waves are coming, so there’s a surfer out there. The surfer is the gland. The glands are riding on the wave of the stroma. Unless the gland paddles quickly enough to get to the slope of that wave, he or she is going to be left behind.
It turns out the ERA Test looks at the wave. The waves come in and they’re regular, they come in and they keep on going. The Endometrial Function Test looks at the surfer. We actually analyze that the surfer missed the wave, and that’s the critical part in terms of implantation. So, you can be deceived and get a normal result or a slightly abnormal result with the wave, the stroma, but still not understand what’s happening with the glands themselves.
That’s the reason why I think that the Endometrial Function Test gives us more information. We also date the endometrium, so we actually answer that question as part of it, and we look for pathologies that are there also. I think everything is wrapped up into one test pretty nicely.
Dr. Aimee: You did touch on the difference between the three tests. I appreciate that, because I think a lot of people hear about the tests, maybe from their doctors, and not as much as they could about the EFT. I’m glad we’re bringing more attention to the importance of the surfer.
Dr. Harvey Kliman: It’s just Harvey Kliman and my research assistant who runs my lab. We’re not a company and we don’t have salespeople. It’s a much more academic test, I would say. I’m personally very grateful for the people who use it because I feel that it actually does help these patients achieve what they want, which is to become pregnant.
Dr. Aimee: What do doctors need to know about these tests? If there’s a doctor listening, how do they get in touch with you to be on your rounds, so to speak? I’ve definitely benefitted from that and you’ve given me such valuable information about my dear patients, and I think that’s really important for doctors to know how available you are and how helpful your guidance is.
Dr. Harvey Kliman: First of all, it’s my pleasure to do it. It really is an honor to be part of a team of people that help these couples achieve their goals. I’m always available, and I will as long as I’m able to, of course. My website at Yale is very simple. You could certainly Google ‘Kliman Yale’ and find me, but it’s klimanlabs.yale.edu, and there’s a whole section on infertility there.
I would say the most important thing for a physician to do it is that if the goal of the doctor doing infertility treatment is to do cycles and put patients through their protocols, and that isn’t necessarily bad, but doesn’t have the time nor energy or inclination to actually sit down and try to figure out why a particular patient isn’t pregnant, then that person probably will not benefit. The people who benefit to do this test and to talk to me are those that have made a personal decision that I want to break out of the mold here, I want to actually figure out why this patient isn’t getting pregnant, and start from the beginning and just break it down.
The basics of what we do as physicians is to diagnose things. It takes time. It takes extra time to do it. To ask a patient to go through a mock cycle when they’re anxious to get pregnant, it takes a lot. Plus, without being covered by insurance — I wish it was, but it isn’t — there is a burden for the physicians to convince their patients. So, I do understand that. As I said, I would only push this when the cost-benefit ratio gets to the point where I get so many calls from doctors saying, “I have a patient, this is her last embryo, this is her last chance to try to get pregnant.” Then I say we need to do everything we can before we launch the shuttle, we push the button for launch, to make sure that everything is right on that rocket before we push the go button.
Dr. Aimee: You have contributed greatly to placental research. When I was reading your bio, we talked about the development of the ‘Kliman method.”
What is the estimated placental volume, or EPV? Can you talk to us a little bit about that and how it can improve patients’ prenatal care and outcomes?
Dr. Harvey Kliman: Absolutely. I will give just an overview about pregnancy loss in general. We’re just actually finishing writing up a large series of the consults that I’ve had for the last many years, there are over 1,200 patients that we’re writing about. We started from 4 weeks all the way to 43 weeks. It turns out the number one cause for miscarriages, which is defined as pregnancy losses before 20 weeks, is genetic, 90% are genetic. I’m not going to talk about this in detail, but the ways that we look at the placenta can figure out that the placenta has grown abnormally and the basis for the loss is a genetic loss.
I think people have appreciated that, they understand that. What’s important is to help a couple understand that they didn’t do something wrong. This was not caused by the mother stepping on the brake too hard while she was driving. Really, someone said that to me. Her shoes were too tight. She bent over one day and thought that she might have been crushing her baby and that’s what led to the loss. Just to have them understand it’s not their fault and give a tangible reason is very important, I think.
That takes care of the miscarriages, and there are 1,000,000 a year in our country. That’s a big number. There are 5,000,000 pregnancies; 1,000,000 miscarriages, 4,000,000 deliveries. That’s a big number. That means in 1 in 4, 25% of all women will have one of these miscarriages. I think it’s important to bring closure to them for that.
For stillbirths, which is defined as losses at 20 weeks or greater, the number one cause is a small placenta. Since we know the number one cause is a small placenta, and I had these cases bombarding me about 15 years ago, I’m not that fast, but after three cases in a row of a small placenta and a stillbirth, I went to my colleagues at Yale, where I have been for the last 30 years, and they’re very good MFMs there, maternal fetal medicine specialists, and I said, “Why aren’t you measuring the placenta?” They said, “Well, it’s just too hard.” It’s this curve, it’s like a yarmulke, it’s this curved shape, it’s hard to get it, it’s not like a diameter, it’s not like the length of an arm or the circumference of the abdomen, which are easier to measure, it’s complicated.
I grew up with a father who was an engineer who gave me math problems all the time. Really, he didn’t play ball with me, he gave me math problems. I called him up and said, “Dad, you gave me problems all my life. I have one for you. Imagine this spherical cap like a yarmulke, I cut it right down the middle, and I’m just going to give you the width, the height, and the thickness of this sickle short of spherical cap shaped thing. What is the equation that explains the volume of that?”
He developed the equation. We tested it and we looked at women just before they were delivering, like 12 hours before. I did this with one of the maternal fetal medicine fellows at Yale. Then we weighed the placentas, and we compared the estimated placental volume measurement to the weight, and found they were very close. I said cool, we now have a tool.
The next thing we had to do is what’s called normative curves. In other words, I can’t ask doctors to do this, they would say to me, “What’s normal? What’s not normal?” Fine, we’ll go back to the drawing board. We started developing normative curves. We did a set at Yale, we did a set at Cornell, I had one of my Yale students from Senegal actually do it in Senegal for a year, so we have now almost 2,000 data points, we have normative curves.
I wanted to make it easy for people. I’m an Apple fan, so we made an iPhone app for it. It’s actually named after my father, it’s called Merwin’s Calculator. There’s an Android version now, too. Really, there’s nothing preventing doctors from using this.
The problem now, I feel like this is the Wizard of Oz. Dorothy goes to the wizard and says, “Can you bring me back to Kansas?” The wizard can’t really do that, so he says, “Why don’t you get the broomstick of the Wicked Witch of the West? That’s what I need you to do,” and he figures that he won’t see her anymore. That’s what I feel I’m being treated like by my fellow clinicians. They say, “Harvey, thanks for the normative curves, but you haven’t proven that doing the EPV will save baby’s lives.”
That’s the next phase that we’re doing now. It’s challenging to develop studies for something that’s actually not as common as miscarriages. Six per thousand stillbirths, that’s less than 1%. One-third of them, even though the most common cause is a small placenta, it’s one-third, so that means two out of 1,000. That takes a lot of ultrasounds and pregnancies to follow before you find one of these cases. But I have a bunch of dedicated colleagues and collaborators who are helping me, and I hope eventually we’ll have the studies that will validate its clinical utility.
Dr. Aimee: How do you spell your dad’s name?
Dr. Harvey Kliman: Merwin.
Dr. Aimee: I’ll be downloading that app. I think that’s really a special story.
Dr. Harvey Kliman: Please do it. You can start at six weeks. You could do it as an REI right now.
Dr. Aimee: I’m going to take a look right after today. I think that’s great. Thank you again for just being you and just being so kind and compassionate, and just asking these great research questions and doing the work to answer them for us. I know that all of my patients who have had miscarriage, and especially stillbirths, I know they appreciate knowing that there is someone like you that is going to help give us all answers.
Thank you from the bottom of my heart. I met you when I was in medical school, I remember at a conference. I have continuously just been so impressed by how dedicated you are to your life’s work, and you just continue to move the field forward. Thank you.
Dr. Harvey Kliman: Aimee, that’s so sweet of you. Too sweet, really. Thank you for everything that you do and how you communicate with your patients also.
Dr. Aimee: Is there anything else that you would like to add for our listeners?
Dr. Harvey Kliman: Patients should know that there are tools out there to help them if they’re not able to get pregnant. If it hasn’t worked for several times, they should reach out and help their doctor, if their doctor isn’t doing one of these tests, including the Endometrial Function Test. Please email me and I will send information to their doctor and try to teach them how to do it.
For the loss patients, I just really want an important message out there; it’s not your fault, you did not cause this loss. The first step for healing is to be able to understand why it happened. Then, hopefully, with that understanding, know what you can do in terms of improving your chances for a successful pregnancy.
Dr. Aimee: I appreciate you saying that because that’s my style too. I do a lot of second opinion consults (and third, fourth, fifth,) and I suggest certain tests. Then they go back to their doctor and their doctor says, “I don’t believe in that test.” I always say it just means they don’t have any experience with that test, they haven’t done it yet to see how it can improve their patients’ outcomes, so please just let me talk to them about it. Hopefully, by talking to them about my experiences with it and showing them the papers, maybe they will add it to the practice. But you’re right, we can’t convince everyone to do it.
Dr. Harvey Kliman: Absolutely. But we try. The bottom line is we try. Every case, one at a time, as best we can.
Dr. Aimee: Thank you, Harvey, for your time today. Thank you for being on The Egg Whisperer Show. Thank you for being so amazing.
Dr. Harvey Kliman: Thank you for asking me to be on, Aimee. Take care.
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