We’ve discussed the overall issues of dealing with infertility on our blog, and we’ve also gone into a bit of detail in the female factors for infertility that we manage more frequently, but today we’re going to take a look at infertility from the male perspective.  This is pretty important as male factors can contribute to infertility in at least 45% of cases (roughly 35% male factors alone and another 10% contributing to cases also involving some female factors). 

So, what makes for healthy sperm?  Essentially, the goal is to have an adequate number of sperm that look and move normally.  That number ranges from a minimum of around 15 million per mL of ejaculate to over 200 million per mL.  Typically, there is about 2-5mL of semen per ejaculate, so if you do the math, that’s a lot of swimmers to try to fertilize one egg.

If a man’s count is low, what kind of testing is done, and what may be some of the causes?  Depending on how low the count is and if there are any concerns noted on either exam or history, testing can involve urinalysis (to look for backward ejaculation), ultrasound (to check for testicular or vas deferens lesions), bloodwork (to look for hormonal causes or genetic issues) and in some cases, even testicular biopsy.  That being said, for levels that are only mildly low, skipping to treatment for the low count may be a reasonable option. 

How can a man help improve the health of his sperm?  Turns out, a man’s overall health can play a big role in his ability to conceive.  Maintain fitness by doing exercise of any type (unless you’re over 6 hours per DAY), and particularly resistance training, which has the greatest effect on increasing testosterone.  From a dietary standpoint, limiting processed foods and emphasizing whole foods will certainly be beneficial.  Also, any food high in zinc such as seafood, legumes, and meats can help with improving fertility. 

As always, there are some things to avoid when trying to achieve pregnancy as well.  Alcohol intake and should be limited, and men should avoid tobacco and drug use, both while trying for pregnancy and even when not trying.  Anything that causes significant increase in heating “his boys” should likewise be avoided.  This can include hot tubs, laptops (on the lap), really tight underwear, and saunas.  Any prescription medications should be reviewed with his doctor to see if decreased fertility may be a side effect, but please don’t have him stop any prescription without reviewing your medication change with your prescriber.  Lastly, some lubricants can be toxic to sperm.  Be sure to check the label, and if you are planning to use lubrication, then select one like Pre-Seed that’s approved to not hinder conception.

If my partner has a low sperm count, what can we do about it?  One of the simplest approaches involves IUI (intrauterine insemination).  This involves collecting your partner’s sperm and have a lab concentrate it for placement directly into the uterus by your provider.  Think of this as providing a head start to the sperm to reach the egg by cutting their travel time down to maybe half.  For other causes, hormonal treatment may be the next step, or in cases of a lesion in the scrotum, surgery may be required.  If all else fails IVF (combining the sperm and egg outside of the body with placement into the woman’s uterus after the embryo begins to develop) may be the best bet.

Discussion of infertility often starts at the ob/gyn office, but depending on the cause, collaboration with either a urologist or a reproductive endocrinologist may be required to achieve successful pregnancy.  The journey can sometimes be rather long, but in the end, a healthy pregnancy is definitely worth it.  Regardless of how you get there, we wish you all the best in having your most enjoyable pregnancy and cutest baby 😊

Dr. Nick

Every couple of months I read a new article about something that needs to be placed in your vagina for for one reason or another.   So, do these products serve any purpose in your vagina, or is this just a way to scam you into purchasing something?  You decide…

​First, there was vaginal steaming, which was touted on popular celebrity websites.  So, what is vaginal steaming?  It involves positioning your vagina for up to 45 minutes over a steaming pot of herbs such as rosemary or basil.  I guess you could figure out how to do this yourself or pay $100 a session at a fancy spa offering such services.  The idea is that the steam can relax your muscles and help rejuvenate your vagina. Spas that offer these services even claim that this increases fertility and helps promote weight loss.  If steaming your vagina could cause weight loss, we would likely see a vagina steaming spa on every corner. 

Next came the Jade Eggs.  For a reasonable price, you can purchase a 1-inch egg shaped stone made of jade to put in your vagina.  So why would one want to put stones in her vagina?  Apparently, it allows you to have better sex, improves bladder control, prevents prolapse, intensifies feminine energy and even invigorates life force.  What can’t these eggs do?  Apparently, they’re good for just about anything but weight loss.  Is there any scientific evidence backing the alleged benefits?  Unfortunately, the answer is no.  However, if you want Jade eggs for your vagina, you may have to wait.  In the past, demand has been so high as to cause the eggs to be sold out online!

Another recent trend was wasp nests in your vagina.  On Etsy, you can purchase oak galls, a medicinal paste of bark and wasp excreta (less gross-sounding, scientific way to describe any waste from the body) to put in your vagina.  The product is touted for its ability to tighten and dry the vagina.  What an awesome treatment goal-hooray for the dry vagina? That would just make intercourse more uncomfortable and increase your risk of infection and abrasions. 

Now the latest fad is inserting garlic in the vagina to treat vaginal yeast infections.  Yep, you heard that right- garlic in the vagina.  This fad has become popular because garlic contains “allicin.”  In a laboratory setting, it may be associated with some antifungal properties.  The operative words here are “in the lab.”  This has not been proven effective in animals, much less humans, and last time I checked, the vagina wasn’t a high school chemistry set.  In addition, the idea of crushing garlic (sorry, it wouldn’t work unless you crush it first), and inserting it in your vagina-ewwww!!!  If you just left cloves in there, would you wait until it sprouted to remove it?  Another serious concern is that garlic grows in the soil.  While there are bacteria in the soil and there are bacteria in the vagina, these bacteria are NOT the same.  This sounds like a vaginal bacterial infection waiting to happen.  It would be a lot easier to go to the pharmacy and pick up some Monistat!!

Why do people keep on coming up with all these strange expensive things to put in your vagina?  Probably in order to make some money.  The list keeps on getting longer and crazier.  It’s especially frustrating because most of these items are touted under the guise or organic, natural, and holistic when they should really be described as dangerous and/or expensive, or at least without a proven scientific benefit.  Before placing anything in your vagina, please talk to your provider because, chances are, your vagina is happy just the way it is 😊

Dr. Pam

With over 70% of Americans taking at least one prescription medications and 20% of Americans on 5 medications, it's not surprising that patients are noticing changes in their health other than just what these medications are taken to improve.   Side effects can range from from as mild as an occasional headache to as severe as bleeding from the intestines.  In this blog, we'll take a look at some of the more common complaints from patients.

1.  Weight gain - many women come to my office concerned about their weight, and the go-to medication for blame is often the birth control pill.  Unfortunately for them, while we can see up to a 5% weight gain on Depo Provera injections, typical weight gain, if any, on the pill is between 1 and 4 lbs, and this weight usually goes away after several months of being on the birth control pill.  That being said, there are a number of other common medications that can be associated with weight gain.  Many of the most common antidepressants, especially SSRIs, have been associated with weight gain, in some cases as much as 24 lbs in a year.  Other mood stabilizers can also contribute to weight gain, as can steroids, antihistamines (sorry fellow allergy sufferers!), antiepileptics, and some blood pressure medications.

2.  Loss of libido - as I was reviewing the data for this article, it turns out that there are a LOT of medications that can affect libido, and many of them have negative effects.  We again see SSRIs as a very common culprit for loss of libido.  Birth control is also a common medication blamed for loss of libido, but as opposed to weight gain, in this case, certain types of birth control may decrease libido.  The goal for hormonal contraception is to prevent pregnancy, but some formulations can decrease testosterone, which in turn may reduce libido for some patients.  For others, this change may be a benefit these same decreases in testosterone can improve acne.  Other medications that may decrease libido are pretty similar to those may cause weight gain:  mood stabilizers, antiepileptics, some blood pressure medications and also opioids.

3.  Fatigue - pretty much any of the medications listed above may also cause tiredness or fatigue.  We can include some antibiotics and heartburn medications in this group as well.  If you've recently started any of the medications listed above and have noticed some loss of energy despite adequate sleep, exercise, and nutrition, then it may be worth examining the medicines you're taking.

4.  Insomnia - the counterpoint to fatigue, but if you're not able to sleep, then you're definitely going to be tired.  Some of the more common medications that may negatively affect your sleep include supplemental thyroid medications, ADHD medications, weight loss medicines, steroids, and once again, some of the antidepressants and mood stabilizers.

For some women, their prescriptions can cause nearly as many problematic symptoms as they improve.  While we often look for a simple fix for health issues, the side effects of any medications should also be taken into consideration, and the pros/cons of these medications should be discussed with your provider.  In some cases, there may be non-medicinal options to manage your health concerns, whether diet/exercise for weight/mood, meditation for sleep/focus and other non-prescription treatment options.  That being said, before making any changes with your prescribed medications, be sure to discuss any adjustments with your prescriber as they will be familiar enough with your health history to ensure the desired change is appropriate.  Together, you and your provider can ensure your medical regimen is optimal for your health goals :) 

Dr. Nick​

I get this question a lot from my patients during their postpartum visit.  “So, I just had a baby and would like for my kids to be close in age- when is the best time to have my next baby?”
In the medical literature, this is called “birth spacing” and there have been lots of studies that have looked at ideal timing between pregnancies. 

1. What is optimal time to wait between pregnancies?  If you are <35 and healthy, the ideal time to wait before planning your next pregnancy is 18-24 months and less than five years.  If you are over the age of 35, as fertility decreases at this age, the ideal interval may be closer to 12 months.  Remember these numbers do not apply to a miscarriage.  Most people with a first trimester loss are safe to start trying during the menstrual cycle following their loss.  However, you should consult with your doctor as they would be aware of your medical and pregnancy history and would be able to help you plan accordingly. 
2. What are the risks of spacing a pregnancy closer than the recommended intervals?  Studies have shown that pregnancy within 6 months of a live birth increases the risk of premature birth, placental abruption, low birth weight, anemia, and congenital disorders.  Very closely spaced pregnancies often do not give mom enough time to recover from pregnancy and breastfeeding, as this can deplete your folate and iron stores, and which is why they are at higher risk of being anemic. 
3. What are the risks of waiting too long? Long intervals between pregnancies can affect fertility and can increase the chance of developing preeclampsia.  Moms over the age of 35 have increased risks of preeclampsia, hypertension, diabetes, problems with the placenta and stillbirth.  There is also a higher chance of having a baby with a chromosomal issue.
4. What is different if I had a c-section?  If you have had a c-section, waiting at least 6 months is preferred in order to allow the uterus to heal and decrease the chance of uterine rupture.  Most physicians also require a minimum of 6-12 months between pregnancies if you are considering a vaginal birth after cesarean (VBAC). 

Planning your family can be tough.  Even if you have the perfect plan in mind, there’s no guarantee that your body will cooperate, but by keeping the above guidelines in mind, then you can help make your pregnancy safer and more likely to result in the outcome you (and your provider) are hoping for:  healthy mom and healthy baby 😊

Dr. Pam

For many moms-to-be, the focus is on getting pregnant, but once that happens, there isn’t always great information on what to expect during labor.  As the end of pregnancy looms, some expectant mothers don’t have a clear idea of exactly the next step is going to be.  So, here’s a quick overview looking at the end of pregnancy and delivery.

​When should I expect pregnancy to end?  Full term for pregnancy is beyond 37 weeks, and your due date is at 40 weeks.  We offer induction for patients who haven’t gone into labor spontaneously by their due date because we can begin to see an increase in the risk of stillbirth and need for cesarean section in pregnancies beyond a certain duration.  In fact, the ARRIVE trial suggests that we may even see a reduction in risk for cesarean section with inductions as early as 39 weeks.

How does this labor thing work? 
There are 3 main stages, and the first stage of labor has two parts.  Latent labor, or the beginning of contractions, can last anywhere from hours to weeks.  This process involves the cervical change from closed (0cm) to 4-6cm.  For some women, these contractions may not be noticeable until near the end of latent labor whereas for others, there can be significant discomfort and even frustration if the intensity of contractions increases without cervical change.  Active labor starts between 4-6cm and often progresses around 1cm per hour or sometimes even faster.

The second stage of labor begins following full dilation (10cm).  This stage involves pushing and delivery of the baby.  The second stage of labor can last anywhere from one contraction with pushing (usually a mom who’s done this before) to as many as 3 hours for first-time mothers in certain situations.

After baby gets here, the last stage of labor is delivery of the placenta.  This generally happens shortly after the delivery of the baby, although in some cases the delivering provider has to manually extract the placenta by placing his/her hand into the uterus to remove the placenta.

What conditions would cause the need for intervention for either my baby’s health or my health?  Sometimes, an intervention can be as simple as adding Pitocin to help labor progress.  Since prolonged labor can result in increased risk for intrauterine infection, abnormal heart rate for baby, low oxygen levels for baby and increased need for cesarean delivery, we like to see contractions reach a level of intensity that will continue to cause the cervix to dilate.  Sometimes, the pushing process can cause a lot of stress on the baby, and in this case, operative vaginal delivery (vacuum or forceps) may be indicated.  Also, while we prefer to allow the vaginal tissue to stretch to minimize tearing, an episiotomy (cutting the vaginal tissue) may be required to speed the delivery of a baby in distress.  A cesarean delivery is generally reserved for when all other options have either been tried or are not appropriate.  Some reasons for cesarean delivery can include a baby that is too big to pass through the bones in mom’s pelvis (i.e. mom has been pushing for a long time without having the baby move closer to delivery), a heart rate pattern for baby that suggests waiting for the entire labor and delivery process would increase risk of harm to the baby, or if mom’s cervix stops dilating despite having adequate contraction strength from the uterus.

What can I do to prepare for delivery?  I’d suggest making sure that you and your partner know how to get to the labor and delivery area of the hospital, especially after hours as some doors may be closed during the middle of the night.  If your significant other takes you on the “scenic route” to labor and delivery, you may not appreciate the detour.  I’d also suggest getting a bag together of the things you might want in the hospital for a several day stay.  If you’re not sure what to pack, you can check out a sample packing list here:  https://www.tetonobgyn.com/blog/what-to-pack-for-the-other-labor-day4298355  Lastly, knowing the reasons to go to the hospital are very important.  If you think you might be in labor (generally painful contractions every 5-7 minutes for an hour, although you can always go if you’re not sure), if you think your water has broken (even if you’re not in labor), if you’re concerned that your baby isn’t moving normally, or if you have heavy vaginal bleeding (more than a pad per hour), then you should go to labor and delivery.  You don’t have to call for permission in any of those cases as sometimes we can be busy in a delivery and not able to immediately return a call.  We don’t want you waiting on us to call back while you have your baby in the bathtub.  Just head to the hospital, let the nurses know what’s going on, and they will start an assessment while they get in touch with us.

While a list like the one above can’t take all of the uncertainty out of your labor and delivery course, it can provide a little more information about what can happen and what you might expect.  As every woman is unique, so, too, is her pregnancy.  Please be sure to discuss any concerns you have with your provider, and we hope that you have the perfect labor, delivery and new baby for you 😊

Dr. Nick

We always strive for our patients to have an uncomplicated easy vaginal delivery with minimal tearing and discomfort.  However, sometimes a c-section is necessary to get both baby and mom safely through the labor and delivery process.  Some reasons for a c-section include the following: fetal distress in labor, problems with the placenta, position of the baby in the uterus, the cervix stops dilating or the baby stops moving down through the pelvis….
For many moms having their first c-section, a lot of times this is the first major surgery they have ever had.  They have lots of questions but have very little idea on the best way to get through the recovery.  Here are some tips that we hope can help you through the process.

1. Use a belly band:  So, both hospitals will provide you with a belly band if you have had a c-section; if you don’t get one right away- just ask your nurse for one.  When you are walking and moving around this will really provide you with the back and abdominal support you need to make the recovery process easier. 
2. Use a pillow when contracting your abs!  Anything that works your abdominal muscles, like coughing and laughing, can be pretty painful after a c-section.  We recommend placing a pillow on your abdomen before coughing and laughing to provide some support and help ease the discomfort your will feel when using your abdominal muscles. 
3. Make sure you stay on top of the pain!  I’ve seen lots of patients try to tough it out and not take pain medication because they did not like the way it made them feel.  For the first 3 days, it is very important to use these medications to help with the pain.  Initially we want your body to focus on healing, not on fighting pain.  Everyday will get better, and once the pain has improved, then you can decrease the amount of pain medication that you are taking.
4. Don’t compare your recovery to others.  I always hear family members talk about how they had a vaginal delivery without an epidural and toughed it out or stopped taking pain medication 1 day after the c-section.  Don’t let other people get to you.  This is not a contest.  If your family and friends are not being supportive, then you may have to consider temporarily limiting their access to you and the baby.  This time is about your recovery, not theirs!
5. Do what you can to prevent constipation before it happens!  Make sure you drink as much fluid as you can.  Usually we will provide you with a stool softener after your deliver. Recovering from a c-section and constipation can make you pretty miserable- we are there to help if you are struggling. 
6. Breastfeeding is hard, especially if you have just had a c-section!  This is a very anxiety provoking process for most new moms, especially if they had an unanticipated c-section.  Your milk probably has not come in and you are pretty sore from your c-section and your baby is not latching on- this is a pretty classic scenario.  Take a deep breath, utilize the nursing staff and lactation consultant and don’t fret- your milk probably won’t come in until the moment you’re are discharged.  Please let us know if you are struggling and need help.  If you decide breast feeding is not for you- that is ok- we are here to provide support, whatever your decision may be!

For most new moms, pregnancy is just the beginning of the baby challenge, and especially for those recovering from a cesarean section, the newborn time can seem even more daunting as you recover from surgery.  Please let others spoil you and take care of you while you are healing.  Try to take advantage of friends and family if they are available.  Utilize their help with the baby, meal planning, cleaning and whatever else they may offer and try to get some sleep!

​Dr. Pam

​Ever wonder why your fried and marinated foods taste so good?  A big part of the richness and flavors you love come from the oils you cook with.  That being said, just like adding a pound of butter to your popcorn, we wouldn’t necessarily endorse cooking or preparing your food in a vat of oil either.  Moderation is always helpful with any cooking oil, but if you’re looking for a comparison, here’s the scoop on some of the most common cooking oils:

1.  Olive oil – a good standby with lots of monosaturated fats.  These “good fats” have been linked to a Mediterranean diet, which has in turn been shown to have some cardiovascular health benefits.  That being said, it does have a low “smoke point,” making it good for cooking, dipping or sautéing, but probably not ideal for baking. 
2. Canola oil – high in polyunsaturated fat as well as high in smoke point with less flavor makes it a good choice for baking or frying.
3. Coconut oil – obviously a super-healthy choice, right?  Actually, it probably isn’t.  While some studies have linked coconut to everything from loss of belly fat to improved cholesterol, it turns out that if you look more closely, the studies were in fact touting the benefits of medium-chain triglycerides (MCTs).  Even though you can make MCT oil from coconut oil, it generally only composes about 15% of the coconut oil.  That’s kind of like calling a Snicker’s a healthy food option because it has peanuts.  Also, typical coconut oil has a very high saturated fat content (about the same as lard), and this type of fat has been linked to heart disease.
4. Avocado oil – composed largely of monounsaturated fat and with a naturally buttery flavor, this is a very versatile cooking option.  It’s high smoke point also allows for a variety of cooking techniques.  That being said, it is a bit pricier than some of the other cooking options.
5. Nut oils – hazelnut oil combines monosaturated fat and vitamin E, but even though its high smoke point allows for many types of cooking, don’t use it unless you want to add a pretty pungent nut flavor.  Macadamia nut oil has a slightly less pronounced nutty taste, so it can be used for grilling and salad dressings.  It also packs a combination of omega fatty acids to promote heart health.  Peanut oil is often used in stir-fry, and has a relatively even balance of poly- and monounsaturated fats.
6. Corn oil – commonly used for frying and cooking, it contains a combination of monounsaturated and polyunsaturated fats similar to olive oil, but it may be even more effective at lowering cholesterol and blood pressure.
7. Palm oil – given it’s high percentage of saturated fats (over 50%), it would generally be advised to consider other oil-based options.

So, there you have it:  a quick rundown on some common cooking oils.  The bottom line is to remember to avoid any types of trans fats, limit saturated fats, and, again, use these oils in moderation.  Even one serving of olive oil has over 100 calories, and even though there’s a lot of “good fat” in it, you’d still be consuming 14 grams of fat with each tablespoon!  So, pick your oils carefully and happy cooking!
Dr. Nick

In this day and age with two working parents, its so easy to stop by the frozen aisle in your grocery store and grab a quick-frozen meal for dinner.  I never thought much about it or felt that it was a potential health hazard.  However, a recent study out of France shows that frozen dinners (which are considered “ultra-processed foods”) are not only dangerous to your health but also increases your risk of early death!
Ultra-processed foods are foods that are “manufactured industrially from multiple ingredients that usually include additives used for technological or cosmetic purposes.”  They are consumed in the form of snacks, desserts, or ready to eat or heat meals.  The study examined the health and physical habits of 45,000 adults over a two-year period and they found a 14 percent higher risk of early death for each 10 percent increase in consumption of ultra- processed foods.
So, what about frozen foods makes it so unhealthy?

1. Added Starch: Many frozen foods have added starch to keep the frozen foods tasting fresh.  Starch is just extra glucose and all this extra sugar increases the risk of developing insulin resistance and eventually diabetes. 
2. Added Trans-fat: Frozen foods are usually full of trans-fat.  Foods that have a lot of trans fat contribute to raising cholesterol and putting you at an increase risk of heart disease. 
3. Added Salt: Salt is a well-known preservative.  Most frozen foods contain more salt than what you would add if you made the meal out of scratch for immediate consumption.  This can increase your cholesterol and your blood pressure.
4. Lots of preservatives: there are lots of other preservatives that are added to frozen foods to improve the texture and keep them tasting fresh.  Many of these have not been well tested by the FDA and most manufacturers don’t need permission to use these preservatives. 

I think it is easy to forget that frozen foods are still ultra-processed foods.  I always thought of frozen foods as freshly prepared foods that were just frozen- kind of like when your friends bring you freezer meals after you had a baby.  Unfortunately, frozen foods bought at the store have lots of preservatives, additives and extras that you did not likely anticipate.  So, before you stop by the frozen aisle to buy dinner for the family, remember that despite all the fancy packaging and healthy claims, these quick-fix options can increase your risk for hypertension, diabetes and even early death.  The best choice is to buy fresh ingredients and cook the meal yourself.  You know exactly what is in the meal and can tweak the sugar and salt amount to your own dietary needs.  Not to mention, busy moms can still freeze the leftovers for later 😊

Dr. Pam 

For most couples getting pregnant is simple and easy.  They just get pregnant and don’t have to go through expensive infertility testing and years of praying and hoping for a successful pregnancy.  For others it is a difficult struggle.  While there are many reasons couples may suffer from infertility, one of the biggest hurdles that prevents them from getting pregnant is the financial aspect.  Infertility treatment is expensive and not covered by most insurances.

So, I get this question a lot from patients struggling from infertility.  If you are going to dip into your personal savings or take out a loan to start a family, what makes more financial sense IVF or adoption? 

Let’s start with IVF.  Let’s just review what IVF is first.  The infertility specialist will extract some of your eggs and then add your partners sperm in a laboratory outside of your body and then at the appropriate time place that embryo in your uterus.  Now, what does IVF cost?   On average, one IVF cycle will cost somewhere between $10,000-$15,000.  Of course, the variation in cost is also dependent on the reason for infertility and a lot of other parameters.  Now this in no way guarantees you a baby.  However, the technology is improving every day and the success rate is rather impressive at certain facilities.  A good percentage of youngish (early thirties) healthy women will likely get pregnant by three cycles.  

My patients that pursue IVF frequently get asked- why not just adopt?  Well for one it is way more expensive than the average person realizes.  The average adoption in the U.S. costs between $27,000-$30,000.  The average adoption overseas can cost as much as $58,000-$65,000.  Most patients have this perception that adoption is cheaper until they have already invested in the process.  And again, just because you spend this money, there is no guarantee that you will get a baby.  Another consideration with adoption is time.  Even under the best of circumstances, adoption can take years to bring a child home.  

Another less well-known option that is much more affordable than IVF or traditional adoption is embryo adoption/transfer.  When couples go through IVF, they usually end up creating more embryos that they can use.  So, thousands of embryos sit in a lab and go unused.  With this procedure, couples with infertility will use donated embryos and just have them placed in their uterus at the appropriate time.  The cost of this procedure is about $3,000-$5,000.  

The decision on how to expand your family if you suffer from infertility is very complex.  It is important that you educate yourself on your personal fertility.  If the cause of infertility is known, treatment will likely be a lot more successful.  Know and research different options on building your family before deciding whether it be IVF, adoption or even foster care.  If electing to try IVF or embryo transfer, be sure to research your local infertility specialists and make sure you know their pregnancy rates.  The best programs out there will have a high pregnancy rate and a lower number of embryos transferred.  We are fortunate to have two options here in town:  Idaho Fertility Center and Reproductive Care Center.  If seeking adoption (and there are definitely many children who would benefit from these services), then be sure to research and find a reputable adoption agency.  Your needs may vary depending on the area from where you are hoping to adopt a child.  Whatever you decide, good luck in finding the best option for you to bring the newest member of your family into your home :)

​Dr. Pam