Artificial wombs, memetics, and genetics. Such a fascinating futuristic topic. Let's think about it like creation. So, with humans, the sperm meets the egg and it begins gestating inside of the woman. And that's how we procreate. That's how we've been able to evolve such a complex civilization over millions of years. But even all other biological evolution is also experiencing some sort of creation where they also go through a process of reproductive cycles. So all of the species are here due to reproductive cycles over the span of billions of years. This is a key aspect of evolutionary biology and the reason why we are here with as much success as we are. That we procreate and we pass our wisdom down generationally to the next ones. That's why the generations born today have access to internet, computers, electricity, food, water, shelter, all of these things so abundantly. So let's talk a little bit more about when people in the past used to have children. Well, the way that hierarchies were structured in the past, it made it so that you really wanted to have children. You needed to have children early. You was almost as though the earlier you had children, the earlier you had an additional asset. This asset being even five children that would be able to help you with your day-to-day for survival, whether that be farming for food, whether that be going and hunting, whether that be going and identifying other tools or inventing, innovating new things for people to do, new sort of ways for us to live more optimally and more creatively and more harmoniously with nature. So people were constantly procreating earlier in their lives. And yes, do largely also to the fact that lifespans used to be a lot shorter as well. But this necessity to procreate for this additional asset as a human was crucial. And one could even talk about how the amount of children that you have gave you more likelihood to have super intelligent children. And also that gave you likelihood to have children that were born with some sort of genetic deficits as well. So we have to remember that having children is actually, especially in the past, was a critical asset to our evolution. And people used to have those children earlier in their lives. So now we have what's called exponential technology. We have information technology that is so abundantly at our fingertips that can be communicated across the planet to eight billion of us. So it went from maybe just a couple million people on the planet and focusing on genetics was really important to now my ability, your ability to focus on memetics, spreading memes, spreading ideas through cultural information transfer is becoming more and more important. Like I can impact millions of people, you can impact millions if not all eight billion people by spreading knowledge and information wisdom across the world. And so people are focusing more on that like this video transmission instead of me being out at a museum or some sort of a spiritual gathering, some sort of art exhibit or some sort of a scientific discovery process where I could potentially meet some sort of a partner that could then I could endeavor into having children with and focus my time on just the child versus focusing my time on disseminating this content. People are starting to live longer too. By living longer, you can focus more of your 20s and even more of your 30s on memetics, on climbing your way up a hierarchy in order for you to then, yes, spread your memes further but also be able to procure greater genetic offspring.  But as you climb up that hierarchy, more and more mates, both women and men, identify you as competent that you've climbed up that hierarchy and you get better and better choices for offspring as well. So back in the day, this hierarchical climb was important because you wanted to also get better mates and better offspring but now you have eight billion people to choose from for your offspring. Of course, brought that down a couple not just four billion are of the opposite sex and brought that down again a couple not just for your age group and brought down a couple not just for your preference. So maybe there's only actually somewhere closer to a couple million people that are in the most ideal potential for your candidates and then again, you can focus more of your time on spreading memes to climb up that hierarchy now with information technologies and then more and more likely to gain ideal mate plus more ideal offspring. So this is a massive aspect to this conversational point is now we live longer, now we focus more on memes and now we're able to go from one to eight billion in terms of communicating memes instead of one to one child which is communicating genes through genetics. How much actualization does someone get from having a child or having two children or five children? A lot of the time they get a lot of actualization there's a lot of profound aspects to having children and it's critical to do the so. At the same time, how much profound self-actualization does someone get from spreading memes? So now this has become a new thing. It was becoming a newer and newer thing with our ability to write on stone, to paint on stone, to be able to write on papyrus, to be able to then have the era of the printing press and spread out more of our books of wisdom across the world. So this has been evolving really fast but especially the information technology as an exponential technology has accelerated it faster. We're gonna get to some really crazy things with artificial wombs in a little bit as well because that's the next futuristic step. So here's crazy way to look at this as well. When you're, I'm almost 27 years old and what happens around this time is that your biology is basically screaming at you and saying find a partner and procreate.  And that's one of the things that people have to figure out in their lives is, okay, well when I'm around my early 20s to my late 20s what am I focusing on? Am I focusing on my career, my hierarchical climb or am I focused on finding a mate and having children? Because even at my age of almost 27 I already have friends that have children that are like eight years old already or they have children that are two years old or they're married now, right? All of these different things.  They're 35 and they're focused heavily on their careers and climbing up the hierarchy as well. So that this innate evolutionary biology pressure that we have around this time period to be like have children focus on that now because your genes want to pass themselves on is such a critical way to perceive reality because that in so many ways is exactly what is happening within us at even a subconscious level that we're not always aware of. Your genes want to pass themselves on. So you're being urged to procreate around this age. And this is a really important aspect of understanding it too is that this is a combinatoric that you're running. You identifying one of those 10 million potentially more better identified partners for you is a combinatoric. So if you procreate with one of those out of those 10 million you're gonna have a different offspring than if you do with another one. So you're basically trying to optimize your genes by having another partner that has really strong genes. So you want them to be very sexually attractive. You want them to be very smart, very intelligent. And you want them to have other very good characteristics. Like you want them to have a strong metabolism. You don't want them to be brought down by lots of disease and that type of stuff. So you have this subconscious program going on within you to identify the most optimal mate and do a combinatoric with them to produce an offspring. And this is crucial for that child's life outcome. The stronger you pick a partner the better the child's life outcome is gonna be. And this is a serious deal. Having children is a serious deal. In so many ways we have tons and tons of children being born into the world that don't have financially stable parents, that have parents that are too young and not ready to have children but they had accidents. We need to be way more serious about the importance of bringing children into the world and being really ready for bringing those children into the world financially, emotionally, intellectually, spiritually ready to bring another child into the world. And to give them the right tools that they need for their roots to get nutrients and for them to be able to blossom and bring their gifts to the world. We talked about this as well a little bit earlier but it's so important that within this hierarchical climb that we're all going on when are you going to identify the right time for you to have those children? So many people see these as bifurcating moments in their life trajectory. Am I going to spend the next four hours going out to this event where I know there are going to be single men or women there and I'm going to be able to see if maybe some of them are the right mate for me? Or do I spend the next four hours working on spreading memes? Do I work on continuing to grow my career and climb up the hierarchy? Which one and at what time? I'm almost 27 but what about when you're almost 32 or what about when you're 21 or what about when you're 42? All these different age points as well, when do you invest more time into going and seeking a mate and having offspring or when do you focus more time on your genetic processes? Or your memetic processes? So again, are you focusing more time on your genetic processes or your memetic processes based on what age you are in your life trajectory and also where you are within the hierarchy as well of competence? Okay, so some really crazy things are happening around the world with what is known as these artificial wombs or this designer baby era that we are approaching and so if you're not familiar with that think about it this way. Right now, some of the richest people in the world are taking their sperm and their partner's eggs and they're running combinatorics but only with two people with one partnership and they're running combinatorics in the sense that they begin the fertilization process with the sperm and the egg. Maybe let's just give a number of 16 times. So they start making 16 little babies for themselves and this is all really beginning to happen in vitro usually. So we're talking about even outside of a human, even not in vivo but in vitro and you can start doing things like you can start seeing, because you make an environment for the cells, for the sperm and the egg to be able to divide and start making two, start making four cells, start making eight cells and you can then get to a point where you can start screening at a certain point you can start screening these little clumps of 16 cells, 32 cells as they exponentially grow. You can start screening them for their genetics. So you have 16 of these little combinatoric experiments happening and then you screen them for their most optimal genetic states. So for example, if you're wealthy enough you can do something like this. It's already happening around the world. Out of the 16, maybe a couple of them actually have genetic issues that have evolved. So we just toss those to the side. We don't wanna deal with those. Then there's genetic engineering where you could say, oh those with the issues we can actually edit out the issues and we can actually then do the next step with the crazy process which is you can bring in enhancements. So you can find the most optimal of the 16, let's say and be like, wow, that's the best one we genetically screen. That one has the most optimal intelligence, metabolism, life outcome scenarios, all this type of stuff. But next is you can do things like be like, okay, well, why don't we figure out, because this is really hard stuff, we're still figuring this out with genetic engineering but figuring out how to bring their intelligence up another notch, how to bring their metabolism up another notch, how to bring their physical strength up another notch. And then you can add those edits to the process of making your child's life outcome even better. And so this is the era of the designer babies where you're literally able to create the most advanced version of your child possible and run all of these permutations, all of these combinatorics to figure out exactly how to make that best child. We all want a healthiest, smartest child that's a majorly important part of our lives. And we also want in the case of knowing if there's a genetic issue to knock out that genetic issue and to produce a healthy child. We don't want a child that has a significant genetic disease. And I have an interesting example here, which is trisomy. Trisomy is having three copies of a chromosome instead of two. And I'm interested to know if, is this biology trying to permutate and find a new combination? Well, some people say that it is the case and also that it's extremely harmful because when you have a child that has three copies of chromosome instead of two, you can get things like Down syndrome. You can get significant mental and physical disabilities that prevent people from their North stars. But could there be a biological permutation that's happening inside of us as we keep trying to have more and more kids where there's some sort of a crazy biological advancement that's trying to combine and say, well, what if a child does have three chromosomes and they become extremely intelligent? Who knows, is that possible? Is it possible for any of these biological permutations to happen where a child becomes significantly more intelligent? And maybe that's one of the things that we try to identify as a biological enhancement. There's a lot of single point mutations and even multi point mutations that are causing severe illnesses, sickle cell anemia. There's a lot of these that we're currently figuring out how to knock out and actually make it so that people don't have to suffer from those. But also this is going to be really difficult to figure out what actually makes for an intelligent child and then try and figure out how to edit a genome for intelligence. But that is totally future we're going in. So you can take this process that literally used to be the fertilization of the new child being gestated inside of a woman, literally inside of a woman for nine months has been the process that it's been since the dawn of time for us. And now instead of it having to be in a woman and literally that woman in a sense, it's a gorgeous and beautiful process for the woman to take on the nutritional, the process of distributing nutrients to the child and growing this child within her. It's a very beautiful process and actually men around the world can get better at empathizing with women about that process and just being better stewards and better companions for the child that's growing with them and for the woman itself or them to be going through this process, I think. But now instead of needing to always have the child gestating within them, we have artificial wombs now where the child can gestate outside of the woman. Okay, interesting. Well, what about the spirit, right? This is a great question. Well, what happens to the spirit isn't the fact that the gestation is happening within the woman that there's something that's happening with the spirit forming of the child in that scenario. Could a child born outside of the womb potentially have issues with spirit or potentially have issues with the soul or the seat of consciousness, right? So these are interesting questions as well. Is there a specific aspect to gestating here that creates a seat of consciousness when it happens inside of the body versus outside of the body in an artificial womb? And so when you take this example with these, let's say these different permutations that you're trying to run of like 16 potential candidates for a sperm meeting an egg and trying to evolve a child, right? That you can take the most optimal one and you can plant that in an artificial womb and you don't even need to be a part of the further development of that child, the evolution of that child in terms of the next nine months and the next nine months the child's taken care of, completely taken care of by that artificial womb and you yourself don't necessarily need to spend that much time taking care of it, which is very interesting versus having to literally carry it within you and be very vigilant about it.  So literally things that are already happening like having our first trillionaires around the planet, these types of things. And when that happens then, what's gonna happen? The best, the most wealthy are going to get the best genetic augmentations for their children fastest. And then is there going to be a speed of change that's just too fast where it's just the children have the best physical, the best metabolism, the best intelligence characteristics that enable them to completely outpace the other eight billion people. And then what does that actually end up then doing for the overall societal wealth trajectory and the species trajectory? Because in many ways, people that already fly on private jets and have five or 10 homes and that spend time on luxury yachts and that own trillion dollar businesses that these types of people already live just vastly completely different lives than the rest of us do. But now we're talking about them birthing children in completely different ways to augment their intelligences and make it so that their children are even more superior than just having access to the best teachers and the best curriculums and the best learning styles and the best travel experiences and whatnot. So we have to be very vigilant about what artificial wombs and the focus on memetics as you climb up hierarchies are going to do to civilizations future. So that's why we had this conversation, this episode on artificial wombs, on memetics versus genetics and what the future is gonna be like with all of these things. So I greatly appreciate you tuning in. Thank you. I would love to hear your thoughts in the comments below on the episode. I would also love to hear more people talk to your, more of you guys talk to your friends, your families, coworkers, people online about these subjects, about artificial wombs, about wealth inequality, about genetic augmentations, about memetics versus genetics. Really have more convos about this subject. It's a fascinating one to talk about everyone. Also, support the artist, the entrepreneurs, the spiritual leaders, the organizations around the world that you believe in support simulation. Our links are below and you can do cool things like design, cool merch and get paid. You can also join us on PayPal, Patreon, cryptocurrency, all that stuff's below. And go and build the future everyone. Manifest your dreams into the world. I love you very much. Thank you for tuning in. And I've been really enjoying this sun. And even the bugs, these insects that are around me, because you got to practice that zen, that spirituality. Life is a blessing. One's buzzing in my ear right now. It just landed. Very grateful for you all. Very grateful for life. Let's build a bright future together. I love you very much. Thank you for tuning in. We'll see you soon.


What is going on guys welcome back to channel critical overload here's to my Jurassic Park in his view to here again today more specifically the upcoming Six entry I believe Jurassic World Dominion the third entry and what was originally I believe thought to be the conclusion for this franchise But it's actually just going to be the conclusion of the Jurassic era as we know It has been teased by the marketing campaign with the with the latest poster and the latest trailer We got also one of the producers a few months ago Frank Marshall revealed in an interview with slash film That this would not be the end for the franchise. He said that he thinks the millions going to wrap up this trilogy But we're not resting on laurels. We're going to sit down and we're going to see what the future is So he also continued on to to note that they have that wonderful series camp Cramp Cretaceous on Netflix We obviously want to make quality good movies with great storytelling great writers and directors But we're definitely looking to do more in the Jurassic world now I'll touch on what I think they might do if they expand beyond just six movies if I thought there's gonna be the final chapter But it's not so Also previously or recently in a new interview this month Collin Travaro who was the one who was the director and co-writer revealed in a new interview with Empire some details about a Entity that's returning that's been around since the original film Biosyn who we know is the competitor to engine trying to keep up with them in the cloney technology as it relates to dinosaurs And you know how Dennis Nedry factored in with the embryo Espionage I was supposed to go down in the original film which ultimately led to the part getting shut down and you know all that good stuff So his comments about biosyns factoring into this into this latest movie because they seem like they're gonna be the main villain apparently So biosyn got the contract to house the dinosaurs that have been captured around the world via various governments and They claim it's a research facility where they can study the pharmaceutical values of the animals, but there's other stuff going on so They seem to be dealing with maybe black market type of stuff with dinosaurs and I know that as it stands with this movie With biosyn being back in a more prominent role than ever before it seems my only Fear is that what they'll do here is Unite all of these characters because we know we have the the legacy characters of Ian Malcolm Allen Grant and then we also have the newer characters with Chris Pratt's character and Bryce Dallas Howard's character of Owen and Claire and Having all six of them come together like that. My gripe here is that With the biosyn focus, are they going to then give us a lot of retcons? Where biosyn has been pulling the strings since day one and what I mean is biosyn is responsible somewhat for what went down in the 2015 film biosyn is responsible somewhat for what went down in Fallen Kingdom and now biosyn will be directly involved of course with what went down in Dominion I mean To make matters worse what they take it as far back as to say that Biosyn has been doing a lot going as far back as the lost world and just connecting all those movies like like this Through biosyn and having biosyns mastermind I guess narrative far exceed what it should which would then create a lot of a Lot of retcons it can make your narrative come off as you're trying to Switch up a lot of what we had already had established to make your lackluster writing work And then they already have too many characters. I know they're gonna try to juggle We'll see if that even comes off well on screen The movie no doubt is gonna be entertaining but going beyond this in a world where dinosaurs are completely just roaming the earth and It's gonna be basically a test to see who comes out on top humans or dinosaurs My money's gonna be on dinosaurs of course So I don't really know what they could do going forward They could explore some details about biosyn in future future films Maybe they take a planet of the apes approach and get get the planet of the apes director involved Maybe they just I mean honestly I would rather you just decide to not make another Jurassic Park movie versus just constantly exploring these Movies in this universe to the point where you're gonna have to keep on doing things that we already knew to be true and then shifting them to make your narrative work and You know the I think the the strongest aspect of this new trilogy compared to the one from the 90s that led into the early 2000s is the fact that there was a start and an end there were plans along the way With the original trilogy it felt very much so that they were going off of Like a wait-and-see type of thing without having many plans in place prior to anything being a success or not They were just like oh well that one was a success. We're gonna make another one. Okay, let's start writing and come up with ideas They didn't have any ideas brainstorming with Jurassic World. It seems like there was a clear Start point and a clear end point out to say that the path along the way has been the most of Successful or anything like that has been the most compelling It's just that there was a plan here for this trilogy as opposed to the original Jurassic Park trilogy So if they just start doing random narratives for future films, I mean, maybe you lose a few people there it's probably gonna come off more as a Retread of the bad things we start to see with the second and third Jurassic Park movies now being explored once again Unfortunately in a potential 7th 8th 9th Who knows how many films if they're trying to produce as many films as the fast and furious franchise, but It's a planet of the apes approach isn't out of the out of the ramble possibility And honestly, that's probably what they would do. Maybe they go in the more horror Aspect where I'm sure this movie will have a lot of horror aspects anywhere We have stalking scenes a lot of tension building scenes chase sequences And if you do anything beyond dominion, do you bring back dr. Grant? Do you bring back Ian Malcolm assuming they make it out of this movie alive? I don't think that they should just be here for one and done if you're just gonna keep exploring this universe Sure, you could explore other characters within the world and tell a lot of I guess like walking dead like narratives a Quiet place type of thing. So, you know, there's there's like a quiet place spin-off coming It feels like maybe we're leaning into apocalypse type of movies not Complete apocalypse, but that's how it could come across with the fact that humans are being forced to live amongst dinosaurs We're seeing civilization destroyed humanity as they as they once knew it is no longer the same They have to live with these dinosaurs. I don't know if movies like that can necessarily work Maybe if you tap more into the horror aspect, they will but we'll see what happens with Jurassic World to mean if it's a success What do you think it happened in the future with this franchise? Let me know all that down in the comment section below if you haven't already of course make sure you subscribe Turn on post occasion and miss video in the description. I've links my social media accounts on Facebook Twitter and Instagram You can message me there, of course the limiters in the movies news or views like me to cover in the future with all that in mind Guys, I will see you in the next video


President of the United States Please sit down and thank you and good morning and welcome to the White House There's good news for the American people in the paper this morning Tax reform is a live and well and kicking What's that I heard about lame duckery Well Congratulations are due to all of those in the house who worked so long and hard to bring us to this point We can now look forward to a lot more hard work, but today America can feel Almost the true tax reformers within its grasp We must not disappoint the American people We must move forward from here with all deliberate speed To pass a tax reform bill that will spur economic growth Create jobs and give America's families the long overdue tax relief that they deserve In this last week We've begun to put into place a solid pro-growth framework of Lord marginal tax rates and spending restraints And together they promise to make our economy fit and trim and competitive for the future now Phil Warren and Fritz You who have given your names to Graham Rudman Hollings bill also deserve our congratulations from now on when the public hears the names Graham Rudman or Hollings they'll think deficit reduction and Connie Mack and Dick Cheney Who followed quite quickly in the house you deserve our thanks all of you here today Who have given so much time and hard work to this bill have earned your country's thanks The government gargantua has been gorging on taxpayer dollars for too long We plan to get a slim down into shape at the end of the decade For years. We've been warning that the growing deficit reflects a dangerous increase in the size of government polls to demonstrate public concern Now Graham Rudman Hollings locks in a long-term commitment To lowering and eventually eliminating deficits It's my hope that history will record last week as the time when the relentless expansion of the federal government was finally halted and Put into reverse But we can't afford to be complacent It's going to take a lot more hard work and many more difficult decisions if we're to live up to the promise of this moment The law now puts a time limit on governmental overspending it mandates a balanced budget But while Graham Rudman Hollings gives us some guidelines and directions. It doesn't take us to our destination It's essential as we embark on this journey toward a balanced budget that we keep a clear sense of our priorities and Hold our first purposes firmly in mind We must not allow Graham Rudman Hollings to become an excuse to avoid the tough decisions entailed in cutting back on runaway domestic spending we will not only be held responsible for Cutting the depths of it deficit ultimately we will be judged on how we reduce the deficit While will we for instance continue to fund welfare for the rich Will we continue to insist that low-income taxpayers? Subsidize programs for people who make ten or eleven times as much money as they do Will we fund wasteful pork barrel programs at the expense of essential defense requirements?  Graham Rudman Hollings won't make our decisions any easier, but it will make our choices crystal clear for all to see Last year for instance, we said the United States government had no business running a railroad and running it by the way hundreds of millions of dollars in the red We proposed eliminating federal subsidies to Amtrak, but intense Lobbying pressure kept money flowing Next time around no program will get a free ride We can abide by the letter of the Graham Rudman Hollings law and still violated spirit If we try to accomplish deficit reduction by tax increases or through just deep cuts in defense that endanger our national security We will have failed in our paramount duty to the American people the duty of good and responsible government Raising taxes in order to reduce the deficit is robbing Peter to pay Paul and Peter went bankrupt a long time ago Whether excess spending is financed through taxes or borrowing it puts a heavy burden on the private economy and slows the engines of prosperity In fact by slowing economic growth the tax increase might well make the deficit bigger not smaller And I want you all to know that When I sat at my desk in the Oval Office and signed Graham Rudman Hollings. I kept my veto pen ready In the top drawer. It's sitting there right now waiting for any tax increase That might come my way We should also remember that when we passed Graham Rudman Hollings. We didn't absolve ourselves of our first responsibility As the elected representatives of this country to provide for the national defense The last thing we want to do is return our country to the weakened vulnerable state in which we found it in 1980 It was a stronger and reinvigorated national defense That allowed the United States to move swiftly and confidently liberating Grenada from communism and bringing the terrorist murderers of Leon Klinghofer to justice It was this renewed sense of purpose and commitment that gave confidence to friends and allies around the globe and particularly to those struggling for freedom against Soviet imposed regimes and It was our determination to proceed with the modernization of nuclear our nuclear deterrent that Through Geneva has improved the prospects for real arms reduction Maintaining a strong national defense is not only our obligation to America It's our duty as the last best hope of mankind to the cause of human freedom. I Feel confident that if Congress abides by its already established agreement for real growth and defense We can meet our national security requirements We will meet the Graham-Rudman Hollings targets in the budgets that we submit to Congress and We'll do it the right way by cutting or eliminating wasteful and unnecessary programs. I hope that each of us Will pledge to follow through in the spirit of Graham-Rudman Hollings to see that government does only that which it must do and No more and I hope that we'll all work together To secure the deficit-cutting gains that we make by adopting a balanced budget amendment to the Constitution So as I said the real work of controlling federal spending is only just begun We've taken a dramatic step forward Let's keep the momentum going Thank you all for coming down here. God bless you all


Next speaker is James Kirkpatrick. He's an assistant professor of medicine and medical ethics and health policy at the University of Pennsylvania. One of the few ethics-trained cardiologists in the country, and he directs Ethics and Professionalism Education for the Penn Cardiovascular Medicine Fellowship and Training Program. Does ethics consults and coordinates ethics educational outreach initiatives and serves in the Ethics Committee of the Hospital of the University of Pennsylvania? Jim? All right, thanks so much, Dan. And thank you so much to Mark and the McClain's, I really appreciate all the input that they've had into my career and the careers of everyone else that is in this room practically. Mark, I wanted to let you know that I still hand out Pasquale's major, Pasquale's wager, on rounds when I'm with cardiology fellows and residents and that sort of thing. It's a wonderful piece if you haven't read it. Here is my disclosure slides. I don't have any industry affiliations, and actually a lot of these things are old in particular out of the Greenwell Foundation grant. But my biggest disclosure is that I'm a cardiologist. And that is a disclosure because we have traditionally proven difficult in interacting with terminally ill patients. We tend to withhold information from patients. We tend to have lower awareness of poor prognosis. And we tend to initiate CPR and ventilation for patients with severe chronic diseases and marginal prognosis because, I mean, it's just a fact. Our patients do not die of cardiac disease. And this is part of the reason. Mark spoke earlier about the dramatic improvements that we've had in preserving patients' life and that sort of thing, and we have a lot to do with that. We've actually bent the curve since about the mid-1980s so that now heart disease mortality is decreasing, and we think we're pretty hot stuff. But the problem is that despite all of our wonderful technology, and here we're going to focus particularly on some of the implantable devices that we have here, and just over here we can see a left ventricular assist device in the upper left-hand side, a defibrillator in the right-hand side, pacemakers in the left lower, biventricular pacemaker in the right lower, and right in the middle is one of the newer left ventricular assist device that literally fits in the palm of your hand, and we actually have another one coming out that's going to support the circulation of a feeling heart, and it's the size of a AA battery. Amazing stuff, but even heart transplant, which is our gold standard treatment for cardiovascular disease, carries with it a five-year, 20% mortality, and 40% of patients, almost half of them are dead by 10 years out. If a loss of a young person gets transplanted, they're going to need another heart before they die, unless they die before that. And this is how heart failure patients in particular live. This is work that was developed by Sarah Goodland, who's now out at Oregon Health Sciences University, and she basically described this. It needs to be a bit updated with some of the advances in our devices, but essentially, number one, you're coming with heart failure. You get on the right medicines, you get stabilized, you enter a plateau phase. This plateau phase is very difficult to predict how long it's going to be, but eventually things start getting worse.  At any of these points, the dashed lines there, where it says sudden death event, you could just die, even despite defibrillator therapy.  Then you go back on that plateau, but then you just do the same thing all over again. You end up down at number five, even with our new technology. And these patients suffer. We normally think of heart failure patients being short of breath and having chest pain maybe, and being volume overloaded and being really tired. But they have all of these other things too, because heart patients tend to be older. And they have a lot of psychospiritual comorbidities as well and social and functional abnormalities. And this is all well documented in the heart failure literature. There's a very interesting study a few years ago, and there have been subsequent ones that show the same sort of thing. Looking at end of life preferences in patients with advanced heart failure, and one of the interesting things is that patient preferences correlated very poorly with quality of life scores. And although it wasn't statistically significant in this study, there was a trend towards patients with the worst quality of life wanting more aggressive treatment. This doesn't make any sense in our sort of oncology dominated paradigms, which if you're feeling poorly, the last thing you want is more chemotherapy that's going to make you feel even worse. But it doesn't work that way in heart failure patients. And our devices are also different than giving chemotherapy. Our pacemakers improve quality of life, they improve symptoms, and they can also prolong your life, depending on what your underlying rhythm disturbance is. Implantable cardioverted defibrillators can improve your long length of life when they're appropriately put in, but they actually may make your life worse if you get shocked all the time. And it's difficult to predict where the benefit in the burden is going to lie on this. And this is a very powerful and poignant article that was in The New York Times magazine a few years ago. This academic was talking about the suffering that her family went through when essentially a pacemaker was forced on her demented father.  If we did nothing as pacemaker would not stop for years like the tireless, charmed brooms in Disney's Fantasia would prompt my father's heart to beat after he became too demented to speak, sit up, or eat. And in fact, that actually happened. ICDs are implanted about 100,000 a year in the United States. And as you know, they are basically put in in order to terminate lethal arrhythmias. And sometimes they do it by delivering a shock. Sometimes they can just pace the heart out of a bad rhythm. That's generally not an uncomfortable procedure. And they're put in for both primary and secondary prevention. Primary prevention, you have not had a cardiac arrest. Secondary prevention, you've had one already. And this is essentially what happens, if you think about it. But there's a downside. Defibrillator shock has been described as feeling like you're getting kicked in the chest by a horse. And this obviously can lead to anxiety, depression, post traumatic stress disorder, and obviously raises emergency department resource utilization when those things happen. So we actually are in the process of writing up a study we did. We surveyed electrophysiology practitioners. These are the people who put in the devices and maintain them from an email database from the Heart Rhythm Society. And we said, in your opinion, how would we think about a pacemaker in a pacemaker dependent patient? And these are basically the answers that we got. But about 50% of them said, well, it's kind of like constitutive therapy. It's something that just keeps you alive, like, say, dialysis. Well, contrast that when we asked the same question about implantable cardioverted defibrillators, nearly half of them said, it's not like anything else. And it's certainly not like constitutive therapy. So the nature of these devices is complicated and complex, especially among those who put them in a no best. Well, let's move on briefly to ventricular assist devices. These devices are essentially heart bypass machines that get implanted inside the patient. They were initially developed for a number of indications of the heart failing acutely and suddenly, like after cardiac surgery. It happens sometimes. If you get a heart infection, the heart muscle itself gets either infected or inflamed, and the heart fails, or a massive heart attack. And then they begin to be used increasingly to stabilize patients until they can get transplanted. And now we have this concept called bridges. We have a bridge to transplant. We have a bridge to recovery if the heart's going to get better. But we also have this bridge to the rest of someone's life, which we call destination therapy.  That's the problem with. So this is what they look like. They generally consist of a cannula that's stuck into the apex of the left ventricle, and it sucks blood out. And it goes into the pump, and that puts it out into the aorta, and it's implanted. So it has a driveline that comes out through the skin. And that goes to a controller that's kind of worn on the belt area, and that is connected up to at least two batteries. And this is basically what it looks like on the inside.  And they actually work. They make people not only live longer, but actually feel much better. All of these things are standard measurements of how patients do and how they feel, and they were much better when the ventricular cyst device patients than those who didn't have. And they actually improved over time from baseline to six months out in this particular study. So it's led some people to conclude that there are no mathematical dilemmas in regards to these things. The technology has proved these patients have short, wretched lives. Why would we not implant them in everyone? Well, I would disagree with that. And in part, due to a study that we're in the middle of doing right now, we're interviewing caregivers and patients who have ventricular cyst devices. And this is one of the more poignant quotes that we got out of that study. This caregiver said for her husband who had a ventricular cyst device, he's verbalized many times he wished he'd never had it done. He said that if he knew that this is what was going to happen, he would never have had it done, because he's basically an invalid now. And he's really tried hard to make it back. So in essence, a lot of these cardiac devices put us into a classic principle of double effect. As you remember, a principle of double effect describes an action that causes serious harm. But because this harm is unintended, may even be foreseen, but it's unintended. It's a side effect, essentially. If it is performed in order to do something good, then it's OK. And so this is kind of a depiction of what happens. Your action can lead to good effect and evil effect together. And I think when we talk about implantable cardiac therapies, we intend to prolong a good quality of life, but we may end up prolonging suffering in some cases. This is a great quote. This was actually talking about treating coronary artery disease, but it applies even more to cardiac devices. We rescue people from a relatively sudden death from myocardial infarction, only to inflict on them a more prolonged death from progressive heart failure. And I worry that's what we do a lot. Vices like this, particularly ICDs, have been described in a number of different ways. Bio fixtures is one way to think about it. So it becomes part of the body. You can't really deactivate it, because now it's like an organ. Dr. Somasi has, I think, given us a much more helpful way of looking at this in describing therapies either substitutive therapy or replacement therapy. A substitutive therapy does some of the same things that the normal organ would do, but it's not the same thing as completely replacing it. So a ventricular assist device is not the same thing as a heart transplant. And we found in our study of these caregivers and patients that they looked at these devices, these ventricular assist devices, very interestingly. The anthropomorphize the device. They gave names to the device, like Vadi. And one person even called his Timothy. And we're not sure why that happened, but it's interesting. And essentially, they had to kind of figure out how to live with this device to come up with basically a new normal and what it meant to be someone, whether you think of yourself as a bionic person or whether you're just thinking of yourself as an invalid or somebody who has a new lease on life. There are identity issues that are all wrapped up in this. There are some inherent problems with caregiver, conflict here. If you think about it, there is a lot of stress in having a patient who has this device and it requires constant monitoring. You can't really leave them alone. You've got to make sure that the batteries don't run out. And this can lead to a lot of stress on the part of the caregiver, which may be even worse than the stress that the patient is experiencing. And because caregivers are also usually the designated surrogate decision makers and they're experiencing all this stress, perhaps there's some ambivalence that they're also experiencing. Perhaps there's a conflict of interest. And perhaps there's even moral distress that they're having to face. And there are very few programs that have caregiver support networks for ventricular assist device patients. Well, let's move on and talk briefly about advanced directives and cardiac patients. I think a lot of us would agree with this one. My advanced directives for you not to show up. When we, a few years ago, when I was at the University of Chicago, we actually, Savi Fedsen and I did a study looking at patients in the cardiac care unit. And we just wanted to find out what was their rate of advanced directives for the most part. And we found out that consistent with other studies, it was pretty low. So the light blue lines here are the number of subjects and the number with advanced directives, either living will and dark blue or durable power of attorney for healthcare and the teal are showed there. And these are across different types of heart disease, congestive heart failure, arrhythmic disease like ventricular tachycardia, coronary artery disease, heart transplant, stroke, cardiac arrest or pulmonary arterial hypertension across the board. It was pretty low. And when we asked them, the patients who said they did not have an advanced directive, did they want more information? We were surprised. A lot of them did. A great number actually wanted to. And interestingly, one third of them had been hospitalized before that and presumably had been asked about advanced directives because that's a requirement from the federal government, didn't even remember that they'd ever been asked about it. So clearly we weren't doing very good in addressing this with them. After going to Penn, we instituted a study looking at end of life issues related to deactivation of a plantable cardiac defibrillator. So we called up all the patients in our database who had defibrillators and talked to them on the phone. And of 278 patients we had had in this study, they'd had their devices for about five years. One third said they had received shocks, which is actually quite a large percentage. And they'd have an average of five shocks per patient, which is a little hard to believe. Half of them had actually had advanced directives, which was great, but only three had actually talked about their ICD in their advanced directive. And we asked them a number of questions. One of them was what should be done with an ICD in an end of life situation? Have you thought about this? Most of them had not, and even fewer had actually discussed it with their medical provider. Who should be the one responsible for discussing these advanced directives with you? And I thought they were pretty good about this. They said the primary care physician may not know a whole lot about it. So we should have the cardiologists and electrophysiologists do it. But guess what other research has said about this? Who doesn't want to talk about this? What should be done with an ICU if you are an end of life DNR? A lot of them said deactivate it, but look at the percentage that said keep it on. Doesn't make a whole lot of sense. How about hospice? If you go to hospice, what should be done with it? Again, a large percentage said keep it going. And this I think gets to their relationship with the device, which is not always so clear.  Only 30%.  Only 40%. If you were getting daily shocks, only half of them would want it turned off. And between 10 and 40% would never want it turned off. This is a complicated issue. Interestingly, when they actually looked at patients who had the pacemaker function deactivated along with their ICD versus not deactivated, there was no difference in when these people died. In other words, it didn't seem to matter if you kept the backup pacemaker function going or if you deactivated a pacemaker, if you also deactivated the ICD in it. It raises this question about these two devices. Deactivating them is not the same thing. Are you gonna deactivate the shocking or just the backup pacing? Are you gonna, does it matter? And whether you have a DNR, should that be an automatic sort of thing? If you're gonna deactivate the pacemaker, does it depend on your symptom relief? Are you gonna deactivate it if you have a biventricator pacemaker? You practically need electrophysiology consult just to make this decision. It's very, very complicated.  All of these patients have ventricular assist devices in. They're all dependent on a machine. I'm not sure that if they would've thought about it, they would've said the same thing. So it raises the question, if along with the pulse forms we're thinking about this, do we need a device-specific advanced directive? Now, I don't particularly wanna be ordering off a menu with what you do and what you don't do. That doesn't seem to be the way to go. But we do need to talk about the different options that are available, depending on the different types of devices that patients have. This is being done actually at the Mayo Clinic. They developed this thing called the Preparedness Plan. You expect some bad things that could happen and you go from there. And I'll skip this issue of cardiac patients and hospice, but there are a lot of questions that are still to be left with that. So hopefully I left you with more questions than answers in talking about these different things. And I thank you for your attention.


Okay, good afternoon and thank you for joining us today for listen to your gut living well with IBD. Today's topics are focused on women's health and IBD. I am Grace Purse with the University of Maryland Medical Center. Presenting today is Dr. Lauren George, assistant professor of medicine at University of Maryland School of Medicine. She will present Beyond Pregnancy, Women's Health and IBD. Dr. Seema Patil, associate professor of medicine at University of Maryland School of Medicine will be presenting Birds and the IBD's Sex, Fertility and Pregnancy in IBD. Before we begin, I have a few housekeeping items. Please submit your questions during the presentation and the physician will answer them at the end of the presentation. This seminar is being recorded and an email with this recording will be sent out next week. Thank you everybody for tuning in. I will now turn this over to Dr. George. Thank you Grace and welcome everybody. I'm going to start this webinar off by talking about everything except pregnancy. There's a lot of things that happen in a woman's life and we should be aware of each stage and how IBD affects that stage of life. So this is just an overview of what I'm going to talk about today. We're going to go through a little impuberty and menstruation and then menopause as well as some important preventative health measures that are specific to women and especially our women who are on immunosuppressants. And then we'll talk about some conditions that can occur with IBD that more commonly affect women and need to be addressed at your medical appointment. So as we know puberty is the start of a woman's reproductive life cycle and it occurs in the early teen years. And there's not much known about puberty in IBD as the majority of patients are diagnosed beyond the age of puberty. However, we do know in our pediatric patients who have IBD if their disease is poorly controlled it can delay the onset of menstruation. And this certainly can be from multiple factors. If you have poorly controlled disease and you're underweight or have failure to thrive, if these girls are on steroids, if they're having active flares and diarrhea and having poor eating habits or if they have nutritional deficiencies, all of these can delay the onset of menstruation and puberty. However, we do know that once disease is controlled and inflammation is controlled, girls will undergo a normal menstruation. And then the menstrual cycle itself, many women will have changes in their symptoms during the menstrual cycle and indeed many healthy women without IBD will have GI symptoms or changes in their GI health during their menstrual cycle. Many women will complain of looser vows or more frequent vows at the time that they're having experiencing menstruation. And specifically in women with IBD they can also have these cyclical changes in their IBD symptoms. And it has been shown in some studies that women with IBD do have this more frequently than women without IBD. And unfortunately changes in bowel habits can always be mistaken for active disease flares. And these women can have unnecessary prescriptions of steroids, unnecessary changes in therapy or symptoms that are due to hormonal changes and not truly active inflammation. This is a little bit of controversial, but sometimes if a woman with IBD is having significant cyclical GI symptoms, they can be managed with hormonal contraception. 20% of the time these can be managed with an estrogen-containing contraception in another study about 50% of the time an IUD was successful in managing these cyclical symptoms. And so there is an option and some treatment decisions to be made if you know you're experiencing a large change in your bowel habits during your menstrual cycle. Additionally, about 25% of women with IBD can have changes in their menstrual cycle itself. So they can have a longer or shorter cycle or they can have change in the amount of days between cycles. And so it's not completely unexpected if you notice that since you've been diagnosed with IBD, you have had some differences in your cycle. And then go into the other end of the spectrum with our reproductive life cycle is menopause where women undergo hormonal changes that lead to the cessation or the stoppage of the menstrual cycle. This is defined if you haven't had a menstrual cycle in about a year. You're considered to be in menopause. The good news is there's no difference in the age of onset of menopause. Women with IBD and without IBD tend to experience this at the same time, which averages late forties to early fifties. Again, somewhat controversial, but women with IBD who are on hormone replacement therapy after they undergo menopause may have less disease flares than those not on hormone replacement therapy. And there was some promise for this previously. However, in a larger national study, we've learned that hormonal replacement therapy does carry its own risks, including blood clot, heart disease, breast cancer, and stroke. So I'm certainly not saying this is a treatment option for your IBD, but it has been examined in the past. I think most importantly with women's health, we need to be considered of the special health maintenance that we must undergo as females.  As we know, all females should be undergoing screening for cervical cancer throughout their life cycle with a gynecologist. And cervical cancer is caused by a virus in the majority of the time, the human papilloma virus or HPV, which you may have all heard about. And about 70% of all cervical cancers in all women are due to two specific types of HPV, type 16 and type 18. And we can easily identify these on a traditional pap smear. And a pap smear is a scraping of the cervical tissue performed by a gynecologist on a pelvic exam. And this is how we screen for cervical cancer. Now, this is extremely important in our IBD population because we do know that women with IBD do have higher rates of abnormal pap smear compared to women without IBD. And this can be anywhere from three to six times the risk of having an abnormal pap smear. And once you have an abnormal pap smear, there's further testing and procedures that must be done to determine if there are pre-cancerous changes. Women with IBD are also at risk of having more severe lesions. Again, there's a whole grading system for cervical cancer and our patients tend to have higher grade lesions or more significant lesions. This is increased even more if you're a smoker. So again, another plug for working on stopping smoking if you have IBD. And in these studies that show that our patients have increased rates of abnormal pap smears, all the patients had these two strains of HPV 16 or 18. So it's really imperative that we're following with a gynecologist and identifying these strains of HPV and abnormal pap so that you can have the appropriate follow-up and care to prevent a cervical cancer down the road. Additionally, many of our patients are on immunosuppressive therapy and immunosuppressive therapies include Remicade, Humera, Simsia, Stalara, Antivio, all of these steroids, all of these medications, can increase your risk of developing these abnormal lesions in the cervix. So it's more important that you visit a gynecologist regularly and we would recommend usually, annually, you should be seeing a gynecologist and being screened for cervical cancer if you're on one of these medications. And that gets me to screening. So normal screening for cervical cancer in women without IBD or healthy women is to start with pap smears at age 21. And then based on the results of those pap smears will determine how often you need a repeat, similar to how we perform colonoscopies and look at polyps. However, in women who are immunocompromised, which again includes any of our biologic medications, it is recommended by both the American College of Obstetrics and Gynecology and the American College of Gastroenterology to start at age 21 but give annual pap smears. Additionally, all women should be avoided to counsel to avoid tobacco. And all women should be counseled on safe sex practices with a barrier contraception since we do know that HPV can be sexually transmitted. We also have another option for our younger patients and that includes vaccination. We do have a vaccine called Gardasil that works against HPV. It is safe and effective. It has been on the market for a few years now. And it prevents nine types of HPV virus including those types 16 and 18 that I talked about on earlier slides. And it targets the types of HPV that can most commonly cause not just cervical cancer but also oral and anal cancers. So this is an important vaccine in our armamentarium. The Advisory Committee on Immunization Practices, which gives guidelines and recommendations on vaccinations, currently recommends the HPV vaccination in all females between the age of 9 and 26. And more recently, societies have come out and recommended using a shared decision-making process, which means having a discussion with your doctor to determine if you should be vaccinated for HPV if you are between the ages of 27 and 45. And during this conversation, your doctor would talk to you about your risk factors. Are you a smoker? Do you have one of these types of HPV already? And what type of clinical scenario you have on to help make a decision on should you be vaccinated? There are multiple series of the vaccination. There's two shots or three shots. If you are on a biologic medication and immunosuppressed, you should receive the three dose series. And moving on to another important topic in women's health is bone health. As we know, women in general are at increased risk of having osteoporosis, which is low bone mass or low bone density. And that can lead to fractures or broken bones, hip fractures, spinal fractures. And a lot of complications as we age. And in addition to that, patients with inflammatory bowel disease are known to have increased risk of having reduced bone mineral density or osteoporosis. In certain studies anywhere between 14 to 42% of patients with IBD have osteoporosis. We know that certain patients are at increased risk. These include females. If patients are underweight or have a low normal BMI or weight, patients on steroids are at very high risk for it to their bone health. If you have uncontrolled inflammation and active disease, if you have a low calcium or low vitamin D, and if you have malnutrition, if you haven't been eating, if you've been losing a lot of weight. So in general, when a patient comes to an IBD center or our clinic, we assess a vitamin D level in all patients. And we give you vitamin D to replenish you if needed. And traditionally all women over the age of 65 should undergo a bone density scan or a DEXA scan, which is a radiology test that screens for osteoporosis. Additionally, many patients who come through our clinic who have been on chronic steroids or are underweight or have malnutrition, we will also perform a screening bone density scan. And this helps us identify if you either have osteoporosis or if you are starting to have low bone density, which may lead to osteoporosis in the future and allow us to make appropriate recommendations and referrals. So multiple conditions can occur in patients with IBD that are not related to inflammation and can cause similar symptoms. And a lot of these can happen more predominantly in females. So many patients with IBD, even when their inflammation is controlled will continue to experience abdominal pain or diarrhea or constipation changes to their bowel habits. And patients with IBD can be up to four times more likely to develop these chronic symptoms than someone in the general population. Within IBD, women are more likely to experience ongoing GI symptoms. And this is true in a general population as well where women are more at risk to develop irritable bowel syndrome. And certainly women who have existing anxiety or depression are at increased risk as well. An important take home point from this talk is that if you have a history of trauma or PTSD or anxiety or depression, you are at increased risk for developing irritable bowel syndrome overlap. And you should be talking to your doctor about these issues in addition to your inflammation. And we know that there's a strong connection between the nerves that supply the brain and the nerves that supply the bowels. This is called the mind-gut connection. And many symptoms that continue after your inflammation is controlled on a medication for IBD is due to this connection of the nerves. And when you have anxiety or depression, you can have even more sensitization of these nerves. So it's really important to identify these triggers. And we know that patients who have irritable bowel syndrome in addition to their IBD, again, present with symptoms and have increased use of steroids or narcotics. They get more imaging scans or go to the emergency room. And this has a huge impact on utilization of resources, but also quality of life for the patient. And so it is always important for your doctor to perform studies to make sure you don't have inflammation and that can include labs, stool tests, imaging or colonoscopy. But then it's also important to recognize that if these studies are negative, a treatment focus should be moved to treating irritable bowel syndrome. And there's multiple different options for irritable bowel syndrome. There's dietary therapies. There's a strong connection with the use of psychological therapy, such as cognitive behavioral therapy or hypnotherapy. And there's also multiple medications, including antibiotics or antidepressants or things that control the input of the nervous system that can be used to improve symptoms not due to inflammation. And finally, another condition that commonly occurs in females and especially females with IBD is fecal incontinence. And the pelvic floor refers to the muscles that make up your pelvis and are involved in having bowel movements, urination, childbirth. It's a large connection of muscles. And when you have a disorder of your pelvic floor or a problem with these muscles, you can develop multiple symptoms, including fecal incontinence, which is the loss of the ability to control your bowel movements. And this is common in IBD. Up to 75% of patients with IBD will have experienced fecal incontinence in the past. And sometimes certainly this is due to inflammation, but at other times it can be due to a pelvic floor disorder. And it's certainly under reported because our patients feel discomfort and embarrassment telling their doctor that they've had an episode of fecal incontinence. This is increased in women, and especially as women age, it is more common. And there's many other causes that are not related to your IBD. If you've had trauma from childbirth, if you've had inflammation in the past, if you've ever had a surgery involving the anus or the rectal area, certain medications, and just overall physical conditioning, because these are muscles. And patients with fecal incontinence have decreased quality of life. So again, just like having irritable bowel syndrome overlap, the first step is always to investigate for inflammation. But once inflammation has been ruled out, it's important to really test that pelvic floor and do further evaluations for the structure of the muscles, the sensation, the function. And there are again, alternate therapies. There's dietary therapies. We use ways to bulk up the stool, and there's actually a type of physical therapy called biofeedback that can strengthen the pelvic floor. And all of these are really important for providing a comprehensive evaluation and treatment of these incontinence disorders. And with that, I hope that was a nice overview of some conditions and concerns that affect women throughout their life with IBD. I look forward to a great presentation from Dr. Patil next about pregnancy, but I'm happy to take any questions you have at this time. Thank you. We'll go ahead and give everybody a minute to get their questions in. Okay. The first question we have might have two parts to it. So the question is, sometimes it's difficult to find information regarding women first diagnosed with Crohn's after age 65. So first I was going to stop there. If there's any beyond the doctor, is there any recommendations you have or finding more information or should women really head to their doctor's office? Do you have any comments on that certain group? Yeah. So that's a great question. There have certainly been an increasing rates of diagnosis of IBD in general in our older patients, and we are seeing that trend. And so it's definitely a group of interest. I would say that the most common age is still younger and a lot of our information is related to that. But you can certainly, I would recommend ask your doctor questions. Again, as we age, the more important things that we're going to think about are going to be things like bone health, maintaining immune health and what the right medication is for someone as they age based on if they have other medical conditions or how healthy they are or what kind of immune status they have. And so I think it is a special population and I think going to your doctor is important. I also think the Crohn's and Colitis Foundation has great patient resources and a great network of peer support. And so certainly always going on their website or reaching out can help you find others who have been diagnosed over the age of 65 as well. But I would say, you know, your doctor is still going to be the primary resource. Great. The next question is, my gynecologist says, I don't need a pap smear yearly. I have panohistorectomy. Is this correct? Should I insist on this? So that is another great question. I will give the best answer I can. I'm not a gynecologist, but I believe, you know, the hysterectomy itself and the details of the hysterectomy are important.  And if that's the case, there's really no cervix left. I know there are instances where part of the cervix can be left. And I would say I would definitely trust your gynecologist that they would make the right recommendation. And it may be that you no longer have a cervix, in which case that is true. You do not need annual pap smears. This question is looking for information. For women with IBD, are rates of colorectal cancer different for men? Or if you could just speak to colorectal cancer and IBD in that relationship? Yeah, no, another great question. So certainly in general, our patients with IBD and specifically inflammation of the colon, so either Crohn's colitis or ulcerative colitis are at increased rates or increased risk of having colon cancer. And that's why as you'll know that as you get further and further into your diagnosis, we're going to start doing more frequent colonoscopies. To my knowledge, there's no significant difference between men and women with IBD of the colon in the rates of colon cancer. And you should still be screened as per our recommendations, which is usually every one to two years after a certain time period since your symptoms or diagnosis. Thank you. One more minute. If there's any last questions, hand it over to Dr. Patil. Okay. So I am going to start with just welcoming everybody as well. Glad you could be here. Dr. George gave us a great background on many different topics of women's health and IBD. And so I'm going to focus on the so-called birds and the bees, sex, fertility and pregnancy and IBD.  There's often the term sexual dysfunction used. I feel the word dysfunction can sometimes be a loaded term, but we'll use them interchangeably. But sexual dysfunction is really defined as persistent, recurrent problems with many areas of sexuality and sexual activity, including response, desire, orgasm or pain, and significantly that distress you or strain your relationship with your partner. Studies show that up to half of women with IBD can experience sexual dysfunction. It's very common. And while they overall report average rates of sexual activity, they also report less satisfaction. This issue is really inextricably tied up with body image. That can be greatly impacted in women with IBD depending upon corticosteroid use like prednisone and other steroids, as well as prior surgeries. And depression and anxiety often play a role.  So it's really important despite the discomfort to talk to your doctor if you're experiencing any issues with this. The next topic I'll talk a little bit about is contraception. And Dr. George mentioned some of these issues in terms of hormone replacement therapy. One of the couple things that I wanted to emphasize with contraception is when you have a small bowel involvement with Crohn's disease, your contraception absorption can be impaired. And that is also true when you've had extensive resection of the small bowel. And finally, talking about estrogen or the kind of contraceptives you have is really important if you have a personal or family history of blood clots. As Dr. George mentioned before with hormone replacement therapy, similarly estrogen containing contraceptives have been found to increase this risk. So moving on to fertility. Now overall, women with IBD who have disease in remission and have no history of surgery really have fertility rates that are similar to the average population. But it is thought that active IBD may decrease fertility. This may be for a lot of different reasons, not least of all because when you're sick, you may not be engaging in sexual activity as much. What is clear is that our medical therapy for IBD does not decrease fertility. Now surgery is something to be considered. Patients with ulcerative colitis who undergo J-Pouch procedures or patients with both kinds of IBD who undergo proctectomy or permanent ostomies can experience decreased fertility. And the main driver behind this is really thought to be the generation of scar tissue from a pelvic surgery, which can really affect many areas of the reproductive organs and impact their ability to function normally. Laparoscopic surgery may improve fertility rates in some studies, so that is also something to be considered. Overall, we do recommend that at any age, any woman with IBD who is unsuccessfully trying to conceive for over six months should consider fertility treatment or evaluation for such. The next issue at hand is something we frequently get asked is what is my risk of passing on or increasing, what is my child's risk of developing IBD? So the risk of Crohn's disease in offspring born to a mother with Crohn's disease is about 2.7%. And for ulcerative colitis, that risk is thought to be about 1.6%. This is important because while genetics can play a role in the development of IBD, it's certainly not the whole story. Now we do know that if both the mother and the father have IBD, the risk to the child is about 30%, so increases significantly. And unfortunately at this time, there are no genetic tests that are able to predict whether your offspring would be born with IBD. It's something to take into consideration, but the risks again are still quite low. So one important thing to consider when possible is planning, thinking in the preconception time period about setting yourself up for so to speak in the process, we recommend shooting for three to six months minimum of remission prior to conception. And the reason is this really reduces the risk for flare during pregnancy and the postpartum period. In addition to other issues to deal with the pregnancy, which I'll discuss in a few minutes. This may require kind of evaluation with multiple modalities endoscopic evaluation, biomarkers, et cetera. And then as with any pregnancy with or without IBD, ceasing smoking, alcohol use and drug use, including prescription opioids as possible is an important thing to consider before trying to conceive. What will happen to your IBD during pregnancy? Generally, overall, it seems to follow the rule of thirds. A third of women will feel better. A third will be stable and a third can experience a flare of their disease. We know that women with active disease at pregnancy are twice as likely to flare and also have a significant increased risk for preterm birth. When flares do occur and evaluation is required, there are certainly considerations for the safety of the pregnancy in terms of endoscopic evaluation, unsedated, unprepped flexible sigmoidoscopy overall is very safe. And then colonoscopy can be considered, if we need to do it, we're looking to perform after 24 weeks of gestation with fetal monitoring. So it's certainly something we are very cautious about, but can be done. One huge area of interest for most women with IBD who are pregnant or planning pregnancy is their medical therapy and their greatest tools in thinking about this issue has been a large registry study called Piano. The full title of the study is a multi-center national perspective study of pregnancy and neonatal outcomes for women with inflammatory bowel disease. It's currently in its 11th year and it's in three sites nationwide. In case you are interested in looking into this more, the website below will take you to details about that study. These 1600 women have been followed for years through pregnancies and have been on a variety of medications for inflammatory bowel disease and the amount of information we've gleaned from this has been incredibly useful in guiding our patients and the treatment of their IBD during pregnancy. Here is a quick chart with some of the most important lessons I think we have learned from this. Misalamine products like misalamine, misalazine, balsalazide, there are a lot of different trade names that go under, in general are continued. Sulfa salazine is a little bit of a special consideration. It can impact folic acid metabolism in our bodies and that is especially important in pregnancy because of the neural core development of the baby. When people are on sulfa salazine, when women are on sulfa salazine during pregnancy we recommend that they take an increased dose of folic acid. Corticosteroids we typically try to taper off. It has been associated with increased risk for preterm birth, low birth weight and gestational diabetes and it's overall not an appropriate method for maintenance in IBD. Azethioprine monotherapy or treatment alone with that medication is typically continued. We do recommend avoiding starting it as a new medication during pregnancy and the main reasons for that is that it can be associated with a small increased risk for pancreatitis, low blood counts and there is a delay in time to affect. If it is being started for significant symptoms it's not going to be effective for a long time as we'll talk in a minute that has a big impact on the pregnancy. Now methotrexate is the one medication that is unequivocally contraindicated in pregnancy. In fact it should be stopped at least three months longer before conceiving. Biologic therapy and this is a category that includes anti-TNF agents like infliximab, adelimumab, the trade names of those may be include remicade, humera, as well as betelizumab or antivio, and eustachinumab or stilara. These medications have been shown to be in pregnancy in that they are safe and have not been associated with adverse pregnancy outcomes. We do continue these medications throughout pregnancy. We monitor levels to ensure they're within a tight range and not deviating too much during pregnancy. We do recommend using them as the only medication in other times of life. These medications can be combined with other immunomodulators, but during pregnancy if at all possible, we do recommend trying to just stay on one medication. There are some specific factors to consider. These medications do cross the placenta with the exception of sertilizumab or simsia. As I mentioned, they have not been associated with adverse pregnancy outcomes. This study, the piano study, has also shown that they have not been associated with any increased risk of infection in infants to one year. That's an important piece of data to know. Tophacitinib is a newer medication that we are using in all sorts of colitis in some patients. There is very little data regarding the use of this medication in pregnancy. We really recommend if at all possible to avoid this, especially in the first trimester. Overall, this class of medication biologics to include Tophacitinib, there are newer recommendations about possibly adjusting the intervals to try to minimize or increase the distance between placental transfer or transfer of these medications across the placenta and the time of delivery. That's a really nuanced area to discuss in detail with your doctor. Finally, antibiotics are really something that we consider stopping, particularly superflexus and metronidazole and tetracycline. Prenatal care, in terms of the OB team, every pregnant patient with IBD should have at least an initial consultation with a maternal fetal medicine specialist. These are obstetricians who have increased or additional training in high-risk pregnancies. That can be reasons for mother's health or the baby's health. You may sometimes hear them called high-risk OBs. MFMs and primary OBs can then decide upon subsequent appropriate monitoring and delivery plan. In some patients and depending upon the OB, they may just need distant monitoring or monitoring as needed. In other cases, it may require regular follow-up with MFM. What should we be thinking about in terms of nutrition in pregnancy? One thing we can certainly target is to look for and correct common vitamin deficiencies that we can see in IBD, particularly B12 iron and vitamin D. Folate administration, as we briefly discussed before, is important in all pregnancies and in sulfasalazine, or if you are on a significantly modified low-residue diet because of narrowings or strictures in your gut, if there is significant, active, really considering an increased dose of folate in those cases is also beneficial. Finally, women with IBD are at higher risk for inadequate gestational weight gain or not gaining enough weight during pregnancy. That is often associated with active disease. An inadequate gestational weight gain is also hand-in-hand with increased risk of preterm birth and small for gestational age infants. What should we be thinking about in terms of delivery? It is certainly well-proven that women with IBD undergo C-sections at a higher rate than most women. But what is not true is not that all of these C-sections are necessarily medically indicated. In fact, most deliveries in women with IBD can be vaginal. We consider C-section to be indicated in only a couple of instances. We consider C-section to be indicated in only a couple of instances. Active inflammation in that area, draining fistulas, abscesses. That is because there is a ten-fold increased risk of high-degree perineal laceration in the setting of active perianal disease and vaginal delivery. In particular, in the setting of surgical repair, it should be a case where C-section is considered. Finally, J-pouch history. Patients with ulcerative colitis who have undergone a colectomy and J-pouch should be considered for a C-section. What we are cognizant of is that women with IBD who undergo C-sections have been shown to have higher rates of blood clots. So, really considering prophylaxis against that, which can be done with medication, should be highly considered and discussed with your OB. Finally, after delivery, and after a few years after an uncomplicated C-section, you can resume your medications safely. Just a few notes about lactation or breastfeeding. In general, following standard nutritional recommendations for the lactation period is recommended. That generally means taking in 400 to 500 more calories a day, making sure you have Omega-3 fatty acids and that you stay very well hydrated is important for optimal breastfeeding. Fenugreek is a commonly recommended herbal medication to increase breast milk production, but that's something we generally advise avoiding because it frequently causes diarrhea and it can increase bleeding risk, so that's something to be a little bit cautious with. None of the IBD therapies that we use suppress lactation. However, we do recommend avoiding sulfasalazine, methotrexate and topocitinib in the lactation period. These have been shown to enter breast milk and either are unsafe or have not been proven to be safe in the newborn. Other IBD medications are either undetectable in breast milk or present in very low concentrations with no negative impact on infant health outcomes, including developmental milestones and infection. Other medications really no need to, as they say, pump and dump. And infant consideration, so what does this mean for the baby? If the mother is on a biologic therapy, particularly during the third trimester, but truly it's a consideration I consider for all women who are on biologic therapy at any time of pregnancy, the infant should not be receiving live vaccinations and in the US vaccination schedule, the only consideration is the rotavirus vaccine. So aside from that, all other vaccines can be received on schedule. And the live vaccination restriction is true for six months. There are additional live vaccinations, particularly the MMR, which is given at a year and is safe to administer to the baby. And IBD medications, as we know the Piano Registry, do not affect infant developmental milestones. Some of these babies actually have been followed into toddler hood without any impact on developmental milestones. However, the effect of inflammation is actually a very important area of study looking at in utero, baby's exposure to mother's inflammation does it affect brain development. So that's still something we are staying tuned to figure out. So in conclusion, these are just some of the main points that I wanted to get across today, that sexual functions an important part of quality of life. It can be uncomfortable to discuss, but when it is impacting your quality of life it is important to bring it up to your gastroenterologist, your gynecologist, just reach out for help. Overall, a healthy mom is the best chance for a healthy pregnancy and baby. When you are considering pregnancy, even if it may be in the distant future, bring it up with your GI and your OB or GYN at that time, bring it up early and often. And when you do become pregnant, assemble a team. It should consist of your GI, your primary OB, and maternal fetal medicine specialist. And finally, staying healthy during your pregnancy and the postpartum period really does include maintaining your medications as well as close GI monitoring. Thank you. At this time we can take any questions. Please leave them now. We'll give everyone a second to get caught up. The first question that's coming is, is there a connection between IVD and polycystic ovarian syndrome? So to my knowledge, I don't know a significant increase in risk, although there are some certainly clinical considerations that would complicate things. Certainly some of the symptoms that you can experience with polycystic ovarian disorder and Crohn's disease can, or IBD in general, can overlap. And in terms of thinking about management, some of the issues in terms of surgical options may be further complicated by a polycystic ovarian disorder. Thank you. Oh, can I, sorry, I mentioned one other thing. The fertility issues also, certainly with PCOS, can also become a little bit complex, particularly in the setting of surgery for IBD. Thank you. This is a specific medication question. And if we need to, if you think the recommendation should be to follow up with the doctor or yourself, we can do that too. So the question is, I've been on as a feely prime, I'm not going to say this correctly, as a feal prime. As a friend. Thank you. And mesolamine. Mesolamine, yeah. Okay. Mesolamine for several years with great success. My GI has warned me for years, however, that when I'm ready to get pregnant, I can't stay on as if the, as a feal prime, but you mentioned it can be used during pregnancy as a mono therapy. Does that mean I'd need to stop the mesoline or keep that and stop that as a feal prime? So in general, what I would say the general approach and not being too specific about the details of your specific disease is, if a medication was required to put you into remission and manage your inflammation with the exception of methotrexate or TOFA-sittenin, that medication should really be continued during pregnancy. When I spoke about mono therapy, I was mostly referring to other medications that may impact your immune system specifically, things like biologics. So the addition of mesolamine is, doesn't have a significant impact. Overall, certainly for simplicity, if the mesolamine is something that has not been shown to be necessary for management of your inflammation, that can be discontinued. Now, there used to be an older or a previous thought that azathioprine may not be safe in pregnancy. This was primarily based on studies in rats. In those studies, rats were given what would be equivalent to about 80 times the dose that we would use the corresponding human dose of azathioprine that we use in IBD. And in those rats with 80 times the dose, they were seeing increased risk of congenital abnormalities. But when, now that we are decades upon decades out from those kind of studies and with a lot of help from literature studies from, for example, other populations that use this medication, like transplant patients, rheumatologic patients, we have not seen the same issue with humans. There is no increased risk of congenital disorders or any other adverse pregnancy outcome specific to azathioprine monotherapy. And we've seen that in that piano registry I've mentioned as well. So the general recommendation is if someone is doing well on azathioprine, that that should be continued. Thank you. Looks like we have time for one last question. If Crohn's is entirely within helium and not reachable of typical colonoscopy, are there non-invasive techniques that can be used to determine muscute mucosal healing? So in general, other things that can be considered and this is all first speak sort of globally outside of the realm of pregnancy and specific, but we do use non-invasive tools like blood and stool, what we call inflammatory markers or biomarkers. Those can be elevated in the majority of patients with active IBD. And that is true of ilial involvement as well. In addition, there are other ways that we can reach the helium outside of a classic colonoscopy. There are extended sort of a little bit more complex endoscopic procedures and there is also capsule endoscopy. Now, if you talk specifically about pregnancy we're generally not recommending those procedures either capsule endoscopy or balloon endoscopy in the setting of pregnancy. But the other non-invasive tests definitely can be employed blood tests and stool tests to get a sense of activity. Thank you. So that's all we have time for today. Thank you to Dr. George and Dr. Patil from the University of Maryland IBD Program at University of Maryland Medical Center. If you'd like to make an appointment you can do so today by calling<PHONE_NUMBER>. Thank you to everyone for tuning in.