What Is IUI?
IUI is short for intrauterine insemination. This is a fertility treatment designed to help women conceive who have not been able to via unprotected sex. Prior to the creation and refining of the IUI process, doctors would perform artificial insemination by placing sperm directly into the vagina. However, sperm still had to “swim” through the uterus and to the cervix. IUI is an improvement on this process because it involves a doctor placing sperm directly into the uterus where the sperm can ideally fertilize an egg and implant into the uterus.
What Does the IUI Process Involve?
The IUI process involves careful timing on the part of doctors and the participating couple. A doctor will frequently perform ultrasounds and/or blood testing to determine when a woman may be ovulating as this is the time that a woman can get pregnant. When a woman is ovulating, her partner will donate a sample of his sperm. The sperm are then taken to a laboratory where they are “washed” within an hour of a man’s ejaculation. The washing process involves applying chemicals that will separate the “best” sperm that have the greatest likelihood of fertilization. Also, while less common, it’s possible for a woman to be allergic to proteins in her partner’s sperm. This can cause great pain and discomfort when he ejaculates. Some couples may choose the washing process because it often removes the proteins associated with discomfort and a potential allergic reaction.
The sperm are then placed into a thin tube called a catheter. This catheter is inserted into the vagina, through the cervix (the passage between the vagina and uterus), and into the uterus. While this procedure takes a relatively short amount of time, most doctors will ask a woman to lie down for 15 to 45 minutes. This increases the likelihood the sperm will correctly meet with and fertilize an egg.
Often, a doctor may recommend several additional steps that could increase the likelihood a woman will become pregnant. One is to refrain from having sex two to five days before a man donates his sperm. This will increase the number of sperm present in the ejaculate. Another step a woman can take is to take fertility drugs. An example is the medicine clomiphene citrate (Clomid). This medication can stimulate hyperovulation, where a woman releases multiple eggs.
What Do Doctors Say About If the IUI Procedure Is Painful?
The IUI process should not be painful, but it may be uncomfortable. According to WebMD, many women describe the discomfort as being similar to that of having a Pap smear to test for abnormal cells in a woman’s cervix. However, some women do report side effects, such as cramping and/or light bleeding. This may last up to 48 hours after a woman undergoes the IUI procedure. Although a doctor may direct otherwise, most women can return to their regular activities after IUI.
Sometimes women may experience an infection after having IUI. This could potentially be painful as infection can cause irritation, fever, and discomfort. Because a doctor is inserting instruments into the vagina and onward, it’s possible that bacteria that cause infection could potentially be introduced. If a woman is taking fertility drugs to support ovulation, it is possible that she could experience a condition called hyperovulation syndrome, where the ovarian follicles will swell and cause pain. This side effect is not due to the IUI procedure, but instead due to the medications a woman may be taking prior to undergoing IUI.
Why Might a Couple Try IUI?
If a couple has not conceived within 6 to 12 months of having unprotected sex, a doctor may recommend trying IUI. Some women may try three to six rounds of IUI before they become pregnant. If they do not conceive after this, a doctor may recommend more invasive methods, such as in vitro fertilization. Both IUI and in vitro fertilization are associated with greater risks for multiple pregnancies due to medications given to stimulate hyperovulation and sometimes that multiple embryos are inserted into the uterus, in the case of in vitro fertilization.
Just as there are many reasons why a couple may not be able to conceive, there are many explanations as to why IUI may not be effective. Examples include:
- A woman being older. Traditionally, women older than age 35 may have more difficulty conceiving.
- Poor quality of eggs or sperm. Sometimes a doctor may recommend using donor sperm for the IUI process to increase the chances the procedure will be effective.
- History of Fallopian tube damage, such as from a severe pelvic infection. If a woman’s fertility concern is a blockage of her Fallopian tube, IUI will not typically work.
According to the American Pregnancy Association, the success rates for IUI are about 20 percent per cycle. The chances that the process will work depend upon many variables, especially if a doctor knows why a woman is experiencing fertility problems.
Conclusions: Is the IUI Procedure Painful?
While the IUI procedure may not be one that a woman wishes to undergo on a daily basis, it is not usually painful. A woman may find it temporarily uncomfortable. She may also experience some cramping and spotting after the procedure. This does not affect her chances of getting pregnant. However, the short duration of the procedure and the lack of invasiveness mean that it rarely causes severe pain. A woman should always immediately tell her doctor if she experiences a great degree of discomfort or pain during or after the IUI process.
Sometimes a doctor will have a woman come back the following day for a repeat IUI process. This may be associated with greater discomfort because of the tissues being disrupted more than once. An over-the-counter pain reliever is typically sufficient to help reduce any discomfort a subsequent IUI treatment may cause.
American Pregnancy: Intrauterine Insemination (IUI)
Human Fertilization & Embryology Authority: What Is Intrauterine Insemination and How Does It Work?
Mayo Clinic: Intrauterine Insemination (IUI)
WebMD: Infertility and Artificial Insemination
Intrauterine insemination (IUI) is an assisted reproductive technology that helps a woman become pregnant by placing the sperm directly into the uterus. The procedure does not require making incisions into the body and is not associated with severe side effects. However, any procedure can be associated with some degree of side effects. Examples of these side effects include cramping and/or some mild bleeding. These symptoms may last anywhere from 24 to 48 hours after the IUI process.
Side Effects of IUI and Fertility Drugs
Sometimes a doctor will prescribe fertility drugs before a round of IUI. This is to encourage a process known as hyper-ovulation, where a woman will release more than one egg during ovulation. Although this has the beneficial side effect of more eggs for sperm inserted into the uterus to fertilize, taking fertility drugs can cause a condition known as ovarian hyperstimulation syndrome. The condition causes the ovaries to become enlarged, which can result in a number of symptoms. Examples of these symptoms include:
- Ascites or fluid in the peritoneal cavity
- Decreased urine production
- Pleural effusions (buildup of liquid in the lungs)
Ovarian hyperstimulation can cause symptoms that range from mild to severe. Severe symptoms affect a woman’s ability to breathe, darkened urine, and severe abdominal pain. These symptoms should not be ignored. If a woman finds she is gaining weight very quickly, this can be a symptom of ovarian hyperstimulation.
Treatments for the condition include stopping taking the fertility medications as well as draining any excessive fluid that may have built up in the peritoneal cavity. Most commonly, the symptoms will subside when a person stops taking the medication and with time.
Multiple Pregnancy Risks
In addition to the health risks associated with IUI and taking fertility medications, a woman is also at greater risk for having multiple pregnancies. This is because fertility medications can lead to hyperovulation where a woman releases multiple eggs. Because the sperm injection contains multiple sperm, it’s possible the sperm could fertilize more than one egg, resulting in a multiples pregnancy. While multiples are not necessarily a problem, a multiples pregnancy is associated with greater risks for miscarriage. It’s important that a woman weigh these risks with her partners and doctor. Other potential risks associated with a multiples pregnancy include:
- Increased risk for gestational diabetes
- Greater risk for preeclampsia (high blood pressure in pregnancy)
- Greater likelihood for requiring bed rest during pregnancy
According to Attain Fertility, an estimated 10 percent of women who take drugs intended to stimulate ovulation will have a multiples pregnancy. An estimated 30 percent of women who take gonadotropins for fertility will become pregnant with multiples.
Risks the IUI Procedure May Not Work
One of the greatest risks associated with IUI is that it may not result in a pregnancy, which is the goal for treatment. According to RESOLVE, the National Infertility Association, the success rates of IUI couples with fertility drugs have improved pregnancy rates compared with women just undergoing IUI. Examples of these medications include Clomiphene, letrozole, or human menopausal gonadotropins.
Much of the success associated with IUI depends on a partner’s sperm quality and the woman’s age. For example, a fertility doctor will often recommend testing to ensure the man has sperm that have at least 5 percent normally shaped sperm. If a man does not, the likelihood of a successful pregnancy with IUI in a woman under age 35 is 7 percent. This number increases to 13 percent likelihood for conceiving if the man’s sperm morphology is greater than 5 percent and the woman is older than age 35.
According to Attain Fertility, the more IUI cycles a woman undergoes, the more likely she is to get pregnant. For example, between three and six IUI cycles is associated with pregnancy rates that near 80 percent. According to Attain Fertility, the likelihood for pregnancy for all women who undergo IUI is:
- 10 to 20 percent in women under age 35
- 10 percent in women between the ages of 35 and 40
- 2 to 5 percent in women ages 40 and above
If a woman has tried six IUI cycles, she should contact her fertility specialist or endocrinologist as she may need to try a different fertility treatment.
Unfortunately, the likelihood for IUI success in a woman who has had trouble conceiving and is older than age 35 is almost zero. Therefore, women may wish to try in vitro fertilization as an alternative to IUI due to the likelihood they won’t conceive. A woman should always discuss the individual likelihood she will conceive using fertility treatments with her doctor. While IUI is not as costly as in vitro fertilization treatments can be, it still represents a cost. If the treatment is unlikely to work, a woman may wish to direct the funds toward other treatments.
Understanding the IUI Process
IUI involves taking sperm from a man and “cleaning” them to ideally make them more effective in fertilizing an egg. The process will start by meeting with a fertility specialist or endocrinologist. This doctor will likely conduct testing that can determine the health of a man’s sperm and/or to identify the potential reasons why a woman may be experiencing infertility. If the doctor recommends moving forward, they may prescribe medications to enhance fertility. These medications are designed to stimulate a woman’s body to release more than one egg, thus enhancing her chances of success when ovulating.
A doctor will conduct blood tests, ultrasound scans, and even temperature monitoring to determine when a woman is ovulating or may start ovulating. This is important because the only time a woman can get pregnant is when she is ovulating.
When a woman is ovulating, her partner will be asked to donate a sperm sample. This is usually accomplished through masturbation. The sperm are then taken to a laboratory where they are prepared for the insemination process. The “washing” process involves exposing the sperm to special chemicals that are able to separate the stronger sperm from the weaker ones. This process also removes toxins from the sperm that are associated with potentially causing an allergic reaction that impairs pregnancy.
Once the sperm has been prepared, a woman returns to her doctor’s office for the insemination. The procedure is similar to a Pap smear. A doctor will insert an instrument called a speculum into the woman’s vagina. Using a small, thin tool called a catheter, the doctor will insert the semen through the vagina and cervix and into the uterus. A woman will usually be asked to sit in the treatment room for anywhere from 30 to 45 minutes. This allows the sperm to stay in position for a longer amount of time. Ideally, this will result in the sperm fertilizing the egg. The IUI procedure itself will typically take anywhere from 10 to 15 minutes and the process of waiting at the doctor’s office afterward will take about one hour.
Sometimes a doctor may recommend coming back to the office the following day for an additional IUI treatment. This can increase the likelihood that an IUI treatment will be effective.
Conclusions on IUI Side Effects
Fortunately, IUI side effects are considered very minimal. A woman may expect to experience some mild bleeding and cramping after the procedure. However, some women may experience side effects from taking medications to stimulate fertilization, such as gonadotropins. This includes ovarian hyperstimulation syndrome, which can cause severe effects from ovarian swelling in some instances.
If a woman has unanticipated effects after undergoing IUI, she should contact her doctor. Seeking treatment as quickly as possible is associated with having the greatest treatment results.
American Pregnancy: Intrauterine Insemination (IUI)
Human Fertilization & Embryology Authority: Intrauterine Insemination (IUI) – The Risks
Human Fertilization & Embryology Authority: What Is Intrauterine Insemination and How Does It Work?
Mayo Clinic: Intrauterine Insemination (IUI)
RESOLVE: Intrauterine Insemination: Will It Help Me Conceive?
WebMD: Infertility and Artificial Insemination
What Is In Vitro Vs. In Vivo Research?
When it comes to fertilization and conception, there are two terms that doctors commonly use: in vitro and in vivo. Each has a different meaning and implications for fertility. Understanding a couple’s options when it comes to conceiving can help.
In vitro and in vivo are both Latin terms. When translated, in vivo means “in life.” In vitro means “in glass.” While these terms apply to fertility treatments, they also apply to the scientific world in general. For example, when scientists perform an in vitro study, they are performing studies using test tubes, petri dishes, and other instruments. Scientists often using in vitro studies to isolate a small part of a larger organism. This could include specific types of cells. Other in vitro studies may focus on bacteria and viruses. While in vitro studies have many clinical applications, they don’t always translate perfectly into how a cell will respond or act when it is in a living person’s body. In vitro studies are important to clinical research, as are in vivo studies. In vivo studies involve experiments with humans and other animals. Many ethical concerns exist as to how to safely and effectively perform in vivo studies. Not all experiments can be performed if they have the potential to cause serious harm to people.
What Is In Vitro Vs. In Vivo When It Comes to Fertility?
In the field of reproductive medicine, the concepts of in vivo vs. in vitro are very important. In vivo fertilization refers to fertilization that occurs in the human body using sexually reproductive organs. Another name for this is “natural” reproduction. This is in contrast with in vitro fertilization, where fertilization occurs in a lab and outside of the human body.
While in vitro fertilization may not take place as a “natural” form of fertilization, it does involve using the same components as in vivo fertilization. During in vitro fertilization, a doctor prescribes fertility medications to a woman. She takes these medicines as a means to encourage her body to do what is called “superovulation.” This is when her Fallopian tubes release more than one egg in a fertility cycle. The effect is beneficial because a doctor will use a special technique that involves extracting the eggs using a needle. The eggs are then preserved in a special substance known as a “medium” that allows the eggs to be transferred to a laboratory. A man will then produce his sperm, usually via masturbation, that is also transferred to a laboratory.
A laboratory technician will combine the sperm and egg with the goal of fertilizing the egg. In about five days, the fertilized egg will ideally become an embryo. The embryo or embryos, in some instances, are then transferred to a woman’s uterus via a special technique performed in a doctor’s office. Ideally, the fertilized embryo will implant into the uterus and pregnancy will occur.
Chances of Getting Pregnant In Vivo Vs. In Vitro
According to “Parents” magazine, a women is born with all the eggs she will have across her lifetime. This number is somewhere between 1 and 2 million eggs. As she ages, a woman has fewer available eggs, and the eggs tend to be less healthy or viable. Regardless of an in vivo or an in vitro approach, a woman only has a slim period of time when she can get pregnant – about one week out of the month.
For women, age plays a great deal into whether or not they become pregnant. When doctors attempt to determine fertility, they will often take into account the age of the mother when predicting the likelihood that she will get pregnant. This is due to the decline in egg availability and quality. According to “Parents’ magazine, the likelihood that a woman will get pregnant if she attempts to conceive “in vivo” include:
- Early 20s: A woman is 96 percent likely to conceive in a year if she is trying on a monthly basis. At this age, if a woman’s partner is similar to how old she is, infertility is more likely to be due to a male-related factor.
- Ages 25 to 29: Women at this age have an 86 percent chance of conceiving within a year.
- Ages 30 to 34: Women have the same chance to conceive as their 25 to 29 counterparts at this age. However, there is a key difference in that they are at greater risk for miscarriage. Women at this age are 20 percent more likely to miscarry while women in their mid- to late-20s have a miscarriage risk of 10 percent.
- Ages 35 to 39: Women before age 37 have a higher chance of getting pregnant than their counterparts after age 37. At age 35, a woman has a 78 percent chance of conceiving within a year. However, it may take longer for a woman to conceive.
- Early 40’s: A woman in her early 40s faces challenges both in conceiving and in staying pregnant. A woman’s ovulation cycle is shorter and her uterine lining often is not as thick, which can make implantation into the uterus more difficult.
- Ages 45 and over: At this time, a woman’s chances to get pregnant are between 3 and 4 percent.
Most women do not seek in vitro fertilization unless they have already had difficulty conceiving, usually after they have been trying to get pregnant for a year. According to the American Pregnancy Association, the likelihood of a life birth rate with an IVF cycle includes:
- Less than 35: Between 41 and 41 percent
- Between 35 and 37: Between 33 and 36 percent
- Ages 38 to 40: Between 23 and 27 percent
- Older than age 40: Between 13 and 18 percent
However, a person should keep in mind these statistics are per IVF cycle and the earlier-mentioned statistics are for women trying to get pregnant over the course of a year.
Regardless of the chances for success related to age, a woman should always talk to her doctor about her individual chances for conceiving. A woman may have certain benefits and drawbacks that could impact her ability to conceive.
American Pregnancy Association: In Vitro Fertilization (IVF)
Parents: Up Your Chances of Getting Pregnant at Every Age
Reproduction: Early History of In Vitro Fertilization
Resolve: What Are My Chances of Success With IVF?
Santa Barbara Independent: In Vitro Fertilization, Part I: A Brief History
TechnoDoze: In Vivo and In Vitro Fertilization – What’s the Difference?
VeryWell: In Vitro Definition
As you’ve probably noticed, many cosmetic products contain a number of chemicals with names that are hard to pronounce. Although the Food and Drug Administration allows these products on the market, some studies suggest that certain ingredients in skin and hair products might be less than healthy, particularly during pregnancy.
Your skin is not an impermeable barrier. Your skin and scalp absorb a portion of the products you put on it and these chemicals can enter your bloodstream and cross the placenta. That’s why, just as with medications and supplements, think about what you’re putting on your skin and hair.
Are hair products unsafe to use during pregnancy? It depends on the ingredients. Here are some hair products you should probably avoid:
Chemical Hair Straighteners
Don’t be tempted by ads for Brazilian Blowout products. Some of these popular hair straighteners contain formaldehyde, a chemical that’s suspected of causing cancer. Not only that, formaldehyde exposure during pregnancy is associated with premature birth, birth defects, and spontaneous abortion. What about other chemical straighteners? Some are formulated with methylene glycol, a chemical that can turn into formaldehyde in the presence of heat. If possible, avoid using any chemical straightener on your hair while you’re pregnant. There’s plenty of time for that after you deliver!
While there’s no proof that chemicals used to perm your hair are harmful, there’s little research to support their safety either. Why take a chance? Perm solutions stay on your scalp for a sustained amount of time and that means more opportunity to absorb chemicals. If you must perm your hair, avoid using solutions that contain lye. There’s another reason to avoid perming during pregnancy. Perms typically don’t last as long. If you want curls or waves in your hair, use a curling iron or hot rollers. Chemical free curls are safer.
Hair Dyes During the First Trimester
Hair dyes contain a hodge-podge of chemicals, some of which may be harmful to a growing baby. The cells of a developing baby divide rapidly during the first trimester of pregnancy. During periods of rapid cell division is when fetuses are most susceptible to chemicals. While it’s safest to avoid dying your hair, if you do, wait until the second trimester to do it when the risk is lower. Even better, use henna or a vegetable-based dye as opposed to one that’s chemical based.
If you can’t resist the urge to touch up your roots while you’re pregnant, this will make you feel better. The esteemed Mayo Clinic points out that dyeing your hair during pregnancy, if you take appropriate precautions, is unlikely to be harmful to your baby. The most recent studies don’t show a link between the chemicals in hair dyes and an increased risk of childhood cancers or other health issues. If you do color your hair, wear gloves when applying the solution. Leave it on the least amount of time possible, and rinse thoroughly.
What About Shampoos and Conditioners?
Should you switch to an organic shampoo and conditioner? Some conditioners and shampoos, while free of formaldehyde, contain formaldehyde releasers. These chemicals emit small amounts of formaldehyde for protection against bacterial growth and a number of shampoos and conditions are formulated with them. Although the quantity of formaldehyde these products release is small, it’s best to limit your exposure to these chemicals. Choose a shampoo and conditioner that’s plant-based and free of petroleum and other chemicals.
The Bottom Line
Play it safe during pregnancy by limiting exposure to questionable chemicals during pregnancy. There’s plenty of time for that once your baby safely enters the world.
MCN Am J Matern Child Nurs. 2015 May-Jun;40(3):180-5.
What to Expect. “Hair Dye and Highlights During Pregnancy”
Mayo Clinic. “Is It Okay to Use Hair Dye During Pregnancy?”
Diet, medications, and cosmetics – there are more changes in pregnancy than just your growing belly. Because your baby doesn’t have the same protections that adults do, there are many products that could be potentially harmful to your baby if applied to your skin. The products are intended to penetrate your skin and have their desired activity on the skin. As a result, they can get into your bloodstream and potentially transmit to your baby. Here’s a list of ingredient no-no’s to avoid when you’re pregnant.
Retinoids are derivatives of vitamin A. These ingredients promote skin cell turnover, helping to reduce the appearance of wrinkles. High dosages of vitamin A and retinoids can be harmful to unborn babies. While there isn’t any study that says topical retinoids are harmful to babies, few research studies are conducted on pregnant women because of the potential harm to babies. Because doctors know oral forms of retinoids, like isotretinoin (Accutane) are harmful, they don’t recommend topical options either. Examples of topical retinoids or ingredients include:
- Differin (adapelene)
- Retin-A (tretinoin)
- Retinoic acid
- Retinyl linoleate
- Retinyl palmitate
Keep in mind that cosmetics brands also may add retinoids to their makeup products, such as powders. You’ll want to check the ingredients in your makeup products too.
Similar to retinoids, topical forms of salicylic acid haven’t been shown to cause birth defects. However, oral forms of salicylic acid, like high-dose aspirin, have been shown to cause birth defects as well as pregnancy complications. As a result, most doctors recommend avoiding salicyclic acid applied topically during pregnancy. This is especially true for stronger facial and body peels. Smaller amounts, such as spot treatments to reduce acne or toners to improve the skin’s appearance, may be safe. Just talk to your doctor first. Sometimes salicylic acid is labeled as beta hydroxyl acid or BHA.
Another option, benzoyl peroxide, is generally considered safe for use during pregnancy to treat acne blemishes. Look for a skincare product that is 5 percent benzoyl peroxide or less.
Hydroquinone is a compound that cosmetic manufacturers add to their skincare products to lighten their skin. This is helpful for women who may have moles or skincare discolorations due to sun exposure. While hydroquinone hasn’t been tested on pregnant animals or women, doctors generally recommend avoiding the ingredient as a safety precaution. Ingredients to avoid include:
- quinol/1-4 dihydroxyl benzene/1-4 hydroxy benzene
Exfoliation using alpha hydroxy acids may help to reduce the appearance of excess skin pigments while pregnant. After you have your little one and are done breastfeeding, you can go back to your previous treatments.
Ask your doctor if there are individual skincare products you should avoid given your health history. If you’re not sure if your product is safe, refrain from using it until you ask your doctor. When you do have your little one, keep in mind that ingredients in skincare products can affect your baby if you’re breastfeeding too.
Ultrasound technology has meant expectant parents can get a small glimpse into their baby’s appearance before the big due date arrives. You may notice when your doctor is looking at the ultrasound that they’re doing so very intently. This is because doctors are visualizing an ultrasound not only to see your baby’s movements and development, but also for several other key factors.
Each obstetrician may have different protocols as to how many ultrasounds are performed. Sometimes, a doctor will recommend an ultrasound with each visit or sometimes at least twice during a pregnancy.
A doctor will typically perform at least a first-trimester ultrasound somewhere between the 12 and 14 weeks of pregnancy. At this time, your doctor is looking at the baby for signs of nuchal translucency. This area at the back of the neck is where fluid can build up. In babies who have certain chromosome defects, such as Down’s syndrome, the nuchal area may have a significant collection of fluid buildup. However, the scan is only an estimate. If your doctor suspects your baby may have an abnormality, further testing is usually recommended.
It’s possible that your doctor could recommend an ultrasound at six to seven weeks into your pregnancy. This is often via a transvaginal ultrasound instead of putting the ultrasound wand over your belly. Your baby is not usually big enough this early in your pregnancy to be easily visualized via an abdominal ultrasound. However, your doctor may use an early ultrasound to ensure your baby has implanted into the right location in your uterus. Otherwise, the pregnancy could be an ectopic one and will not develop further.
At about 18 to 20 weeks into your pregnancy, your obstetrician will often perform a second ultrasound. This one is often significantly more involved as your doctor is checking for the valves in your baby’s heart, presence of healthy kidney development, normal facial growth, and the all-important gender of your baby, if you wish to know. Often, ultrasound is accompanied by listening to fetal heart tones to ensure your baby’s heartbeat is strong and steady.
During the third trimester, your doctor may perform another ultrasound to ensure all is well with your baby’s growth and positioning. At this time, a doctor may be looking at the amount of fluid surrounding your baby to ensure there isn’t too much (or not enough). Your doctor is also looking to see if your baby is head down or if their head is pointed toward your chest, which is known as a breach position. Because you cannot safely deliver a baby vaginally in breech position, it’s important for your doctor to know where your baby is at.
Utilizing New Ultrasound Technology
The advent of 3-D and 4-D ultrasound technology mean that expectant parents, friends, and family can see a baby in much finer detail than ever before. While some doctors have these higher-tech imaging capabilities, other people go to ultrasound facilities to see the images of their little ones. However, it’s important to remember if you do go to an ultrasound facility that the personnel there are not doctors. Therefore, it’s possible they may not see a defect or other irregularity that a doctor might.
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