Methadone in Hospitalized Patients (Bowen & Aguilar 11/6/2025)

 https://youtu.be/dqAxY3UjV8o

Integrative Approach to Anxiety and Depression (Brown, 10/30/2024)

A recording of this presentation is available HERE.

Many thanks to Dr. Andrew Brown, who gave an excellent Grand Rounds presentation this week on Integrative Approach to Anxiety and Depression. Anyone in primary care knows that we do a lot of management of psychiatric disorders in the primary care setting, often with very little specialty support. Many patients are interested in pursuing not just standard medical therapy (SSRI + cognitive behavioral therapy), but also integrative modalities.

Dr. Brown laid out the evidence for a wide range of non-pharmaceutical and non-psychotherapy treatments for anxiety and depression. The bottom line is that there are many, many, many integrative options with a range of small to moderate to strong evidence for the management of anxiety/depression. Put your seatbelts on. And don't use too many at once!

Integrative modalities, for the purpose of this talk include 

• lifestyle/behavioral 
• nutrition 
• supplements and 
• physical practices

Lifestyle/behavioral

Exercise works! The USPSTF recommends 2.5 hours/week of aerobic exercise for overall improved health. And good news, exercise can improved depression!  Some exercise modalities may be better than others, including: include walking/jogging/yoga/strength training. The more "intense" the better. However, in a 2023 review article, ANY regular exercise, regardless of type, setting, or supervision decreased depression scores by 5-7 points. 

There is not much evidence for exercise in anxiety, with a different review paper finding a benefit of exercise for anxiety in 7 of 25 studies and no benefit in the remaining 18.

It should come as no surprise that substance use and substance use disorders are frequent comorbidities with anxiety and depression. Note in the chart below:

• 16% of people with anxiety disorder also have SUD
• 16% of people with an adjustment disorder also have SUD
• 16% of people with depression also have SUD

Nicotine and tobacco, alcohol, and yes, even marijuana>>worsen anxiety

Sleep and anxiety/depression, as we know, have a bidirectional relationship. Treating the underlying cause of sleep helps (e.g. sleep disordered breathing). If you target insomnia, you improve mental health.

Social support helps too. Social support and connectedness -- perhaps even via online platforms-- helps depression and anxiety, even in people with a diagnosed social anxiety disorder!

Time spent in the natural world, including activities like "forest bathing", nature-based treatment, gardening, wilderness time, outdoor adventuring all have a positive effect on mood and anxiety. Many of the studies looking at time in nature are Korean studies, and plenty show positive effect, which is durable (at least up to 12 weeks after the outdoor time). One study even found that LOOKING at images of nature had a positive impact on mood. 

Nutrition 

Eating a healthy diet improves depression and anxiety! And there are plenty of different healthy diets that have been shown to improve mood in a 2021 Systematic Review: a diet high in fruits/veggies, a diet with less calories, a diet high in omega-3 fatty acids, probiotics, a diet rich in dietary minerals, and a ketogenic diet. Even eating breakfast works!

What doesn't work? An unhealthy diet: insufficient protein, high fat, lots of carbs/sugars, and a diet low in tryptophan (which is found in protein-rich foods, not just turkey).

Supplements

Many many botanicals are used to treat symptoms of depression anxiety. Four that Dr. Brown highlighted with moderate/strong evidence for positive effect are:

• Kava Kava (Piper methysticum): 50-70mg TID, mixed evidence, some concern for hepatoxicity
• St. John's Wort (Hypericum perforatum): strong evidence in depression, 500-1800mg/day. A 2017 Meta-analysis found it to be equivalent to SSRIs (of note, not safe to take at same time as SSRIs)
• Saffron (Crocus sativus): 30-200mg/day, strong evidence for depression and anxiety, $$ cost can be an issue, also concerns regarding first trimester SAB in early pregnancy
• Lavender (Lavandula angustifolia): "a few drops", moderate evidence, compared to lorazepam in a trial of preoperative patients was found to be "equivalent". SE: gynecomastia
• 
  
  

Probiotics: studies show a small but consistent positive effect in depression/anxiety (not enough to be used as monotherapy, but consider for adjunct)

Vitamin Supplements

Dr. Brown highlighted five vitamins with some efficacy in depression/anxiety:

• Vitamin D: stronger evidence in depression (than anxiety)
• B Complex, found in dark/green/leafy veggies, may be good adjunct
• Zinc: dose response benefit in depression and anxiety
• Magnesium: strong evidence as either monotherapy OR adjunct, depression more than anxiety, change of 4 points on GAD7 or PHQ9, so may be good choice for mild-mod depression/anxiety

Physical Practices

Dr. Brown finished up his presentation talking about a range of physical practices that, again, have some evidence for treatment of depression and/or anxiety, specifically:

• Acupuncture: 2024 Meta-analysis found that acupuncture was BETTER than SSRIs for depression, particularly if electro-acupuncture techniques are used. Most studies indicate that a combination of SSRI and acupuncture decreases rates of remission. There is less evidence for acupuncture in anxiety.
• Acupressure: no evidence for durable benefit, but may be good for episodic symptoms (and can be self-done)
• Progressive Muscle Relaxation: strong evidence in pre-procedural anxiety and symptoms report for patients. There are a wide range of muscle relaxation techniques, many can be taught in just a few minutes in the office setting
• Breathwork: Once again, there are many different breath practices. Two easy ones to teach in the office are: Box, 4-7-8 (see images below). Both have been shown to help with symptom management

Finally, do Apps work? Apps tend to be cheap and easy for patients to get, particularly in a low resource. According to Dr. Brown. There have been 50+ studies, including an RCT, looking at apps for physical practice changers, and they have shown a significant but small/moderate effect on depression/anxiety. So consider apps an option too!

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Hospital Medicine Update 2024 (Jordan, 10/23/24)

 A recording of this presentation is available HERE. 

Check back for a written summary!

Farmworkers’ experiences working during wildfires and impacts on health (Hyland and Gordon, 10/16/24)

This week, in commemoration of the 2017 Tubbs Fire, which destroyed over 5,000 homes in Santa Rosa, we had a really special presentation by two researchers from the Berkeley School of Public Health and Berkeley Law School on the impact of the Ag Pass program and wildfire smoke on Sonoma County farm worker health.  

If you can, please watch their presentation. A recording is available HERE.

It was both fascinating and disturbing to hear two researchers talk about the place we live and practice medicine-- and where thousands of vulnerable farm workers face dangers from our local policies during fire season.

• AB1103: California law that established a "Livestock pass" in 2021, work authorization program, allowing workers back into evacuation zones during natural disasters
• Counties have interpreted this law as permitting them to allow workers into evacuation zones
• Unfortunately, no occupational health analysis (by Cal-OSHA) was done in the passing of this law
• From 2017-2022, such passes were handed out in an Ad-Hoc manner by the Ag Commissioner, often based on personal contacts and phone calls

In 2022, the Sonoma County Board of Supervisors (BOS) passed their own version of the Ag Pass, which allows farmworkers back into an evacuation zones for "critical activities". The SoCo Sheriff decides when Ag Pass is activated.

In 2023, the local law was amended to include "grape harvest" as a "critical activity"

SoCo Ag Pass has three components:

1) Fire safety training (4 hours, no smoke or other exposure training required)

2) Apply through the SoCo Ag Commissioner

3) Go to the SoCo Sheriff's office to obtain the Ag Pass card

(this requires photo identification, address, phone number)

***

We have data from Sonoma County on the health impacts of wildfires on local health: 

• 25% increase in ED visits for respiratory symptoms
• 33% increase in hospitalizations for respiratory illnesses
• 18.7% increase in asthma prescriptions
• Disparities based on race and SES

This project was a collaboration between the Human Rights Center and Berkeley Public Health. Goal to examine health, physical safety, economic security, and data privacy

Law and policy analysis, health survey with overall goals to provide recommendations to Sonoma County and the State of California to improve health and safety of farm workers working in fire evacuation zones. 

Recruited local farm workers and trusted figures

Recruited farm workers: gain understanding of AgPass, their experience working previously in fire conditions (and symptoms), what information they need if they are working in wildfire conditions again, economic concerns related to wildfires.

1000+ workers from all over the county, 60% male, ~41 median age, 13 years on average experience working in agriculture

Experiences working during wildfires:

• 75% reported having worked during wildfire
• 64% received some protective equipment from employer
• many had to reuse
• many given surgical mask (rather than N95)
• 70% reported short term health impacts
• 36% who had health impacts indicated they lingered over time
• Mental health impacts

Barriers to accessing health care

• >50% reported no health insurance
• 39% difficult to get appointment at clinic (hours, days open, etc)

Gaps seen in the Ag Pass program as it relates specifically to health: 1) No consideration of short or long-term health effects to workers when Sheriff activates Ag Pass 2) Lack of criteria when Ag Pass can be activated (e.g. AQI level) 3) No health monitoring during/after wildfire events

Very real tension in this population between health and economic security. At baseline 75% are spending 50-75% of monthly income on rent (recommendation is 33%). If there is fire/flood/extreme heat, and farm workers cannot work and do not get paid, they cannot make their basic needs. Even though people are worried about health impacts of wildfire, even more are worried about financial impacts. 58% continued to work despite feeling sick because they needed income and were worried to lose the job. 

Most farm workers are most worried about paying for rent, groceries, gas, medicine/healthcare

Physical Safety Results

• There is no process to communicate with individuals who are reentering an evacuation zone.
• Currently employers are responsible to ensure workers leave in time
• The sheriff could request the information but no system at the county level to ensure this happens safely for workers. 
• No method for county agencies to communicate directly with pass holders. All communication is via employers.

The research team is holding local forums and events to disseminate these results directly to farm workers, two forums open to the public.

Recommendations:

• Recommending consolidating the AgPass application under one department (e.g. under Ag Commissioner) to make process more clear, streamlined, address concerns identified with signing up via the Sheriff's office (considering largely undocumented workforce)
• Support additional research: survey H2A workers inside evacuation zones, specific needs of indigenous language speakers in the county (current offerings only available in Eng/Spanish), understanding air pollutant exposures (increased monitoring), financial literacy needs (long-term planning in changing climate and extreme weather, likelihood this will only get worse)
• Health focused recommendations to SoCo BOS:
• Public Health and Health officials should be included in decisions to activate the Ag Pass, specifically tracking air quality and heat levels inside evacuation zones
• Increased air monitors across the county (hyper-local info needed in rural areas)
  
• Increase collaboration and support with Sonoma County Community Organizations Active in Disaster (COAD), 80 organizations across the county who have infrastructure to provider training and information to farm workers
• $$ support for health and safety training
• PPE to COAD that could be distributed BEFORE fire season in places that are comfortable
• Safety kids: N95, info about wildfire smoke, Cal-OSHA
• Training for employers and how to protect self and 
• Require sufficient stockpile of N95 for workers
• Increase hours of FQHCs across the county, expanded mobile health services, expanded monitoring 
• FQHC collecting farmworker employment
• Health focus recommendations for State of CA
• Update Cal-OSHA smoke standards (AQI >150, PPE needs to be available but not mandatory until AQI >500, no level which is considered unsafe to work)
• Need more monitoring of AQI levels during fire event
• Need requirements employers to communicate AQI levels
• Decrease barriers to reporting concerns to Cal OSHA
• Recommendation for Safety
• Use current active SoCo Alert system, require Ag Pass holders to sign up for these alerts, sign up all farm workers for these alerts
• Develop new alerts: e.g. Ag Pass activated, Deactivated, AQI levels
• Recommendations for economic improvements
• Interconnection of health/economic security
• Comprehensive disaster pay program; create meaningful choice for workers (e.g. hazard pay, disaster insurance, unemployment, paid sick leave)
• Enforcement of retaliation protection so workers don't lose job after choosing not to work for health and safety reasons

It is our duty as family physicians, particularly those of us working in the safety net, to pay attention to local policy and politic and to advocate for safer working conditions for our most vulnerable patients. Please help out where you can!

Inpatient End of Life Care (Selby, 10/9/24)

A recording of this presentation on Inpatient End of Life Care is available HERE.

***

We are so lucky in the hospital to have a talented and knowledgeable hospice liaison, Kristi Selby RN, who very much guides us through the process of transitioning patients onto hospice in the hospital. Most of those patients then discharge to home or the community, but occasionally we get to be witness to death of patient in the hospital. I am personally grateful for Kristi's attentive care of a patient with shared this past week.

I am also grateful to her for an excellent presentation she gave this week outlining the basics of hospice definitions, eligibility, services, and philosophy. Please watch the above link for the whole presentation. If you just want my notes, here they are:

Hospice is a level of care, not a place. Hospice offers expert medical care, pain management, emotional and spiritual support that is tailored to each patient (not to the disease). It includes facility support, bereavement for up to 18 months, and a focus on caring, not curing. It takes into account important aspects like anticipatory grief.

Just like many people these days have birth plans, hospice can help people have the death they want -- a death plan, of sorts. 

In order to be eligible for hospice, you need to have:

• terminal illness
• <6 months prognosis
• no curative treatment desired

While sometimes the condition of a "terminal illness" is obvious, but there are possible factors that can support eligibility for diagnoses that are less routine. These include: weight loss, a decrease in fluid/food intake, recurrent infections, increasing difficulty in attending to ADLs, frequent hospitalizations and/or ED visits, frequent falls with increasing weakness, and rapid progression of disease.

Some quantitative measures (e.g. Albumin <2.5 or EF <20%) can also help make patients eligible for hospice care. 

Additional information that may indicate hospice eligibility includes a change in function, a change in nutritional status, a change in weight, and a change in alertness. Don't forget to document these in your outpatient charts. AND, when in doubt, ask a hospice liaison for help!

Common barriers to entry into hospice include: 

• cultural/death taboo
• many people are unaware of hospice and hospice services
• family or providers don't want to take away hope
• there is a misunderstanding of what hospice is (it's not just give me morphine and kill me)
• death is really hard to talk about!

Hospice levels of care:

• Routine (multidisciplinary team with many visits/week in the home, SNF, etc)
• Continuous care (8 hours shifts, generally by RN)
• Respite care (short term, up to 5 days at a SNF for caregivers)
• General inpatient (GIP), in which a patient who is not stable to receive routine hospice care at home and/or needs up titration of medications can receive that level of care in the hospital

Routine hospice care gets reimbursed about $300/day; in contrast GIP costs Medicare about $2000/day so it must be justified on a daily basis. Issues that can justify GIP hospitalization include pain control, SOB, agitation, nausea/vomiting, wound care or any "skilled' needs

When a GIP patient is in the hospital, we focus on symptom management, which can be a shift for many hospital staff. Hospital care looks different for patients who are dying compared to those who are not dying. This can lead to nurse discomfort. It's important to talk about. In addition, more meds than we are generally accustomed to is better for comfort. We use benzos and opiates together in hospice care for comfort (the exact opposite of what we do for non-hospice patients). 

Finally, Kristi spent some time talking about how every person's situation is unique, every culture is distinct, and in hospice care we are really looking to provide the type of death the patient and their family desire. This may look very different than the type of death WE desire. That difference is okay, but we need to acknowledge it and be sure not to let our medical assumptions get in the way of what patients want. 

The Dobbs Crisis: A Family Medicine Response (Pfeifer, 10/2/24)

 A recording of this presentation is available HERE. 

A written summary will be forthcoming.  

Empiric Antibiotics and SSRRH Antibiogram (Patel, 9/25/24)

 Many thanks to Omi Patel, PharmD and head of our SSRRH pharmacy for an excellent and important talk on Empiric Antibiotics and the SSRRH Antibiogram. A recording of her presentation is available HERE. 

My notes:

Empiric antibiotics should be chosen based on many different factors:

• patient characteristics (age, comorbidities, recent hospitalization, etc)
• site of infection
• pharmacokinetics
• evidence-based guidelines (e.g. IDSA, John's Hopkins, Sanford guide)
• facility specific guidelines (CPMC, UCSF)
• clinical pathways (most recent possible)
• local antibiogram (which is what this talk focused on)

At SSRRH, there is a system-wide order set that offers empiric antibiotic options based on site of infection. It is available under order sets. Do NOTE these are not specific to SSRRH, and our local antibiogram should be consulted if using these order sets.

As noted above, the hospital specific antibiogram is essential to good antibiotic stewardship. Omi pointed out that for bacteria for which we have less than 30 isolates, the data is less reliable and trends over time (i.e. looking back at old antibiograms) may be helpful in choosing the empiric treatment. You can see on the antibiogram below, the numbers in red reflect the number of isolates from 2023 of that particular bacteria. Reach out to the pharmacist to help you with this. The "30 isolate rule" is a National standard so applies to any antibiogram

Gram Negative Organisms at SSRRH

trends over time for Morganella at SSRRH

Last year, at SSRRH 64% of Gram Negative Organisms were E Coli. Other more commonly isolated organisms include Klebsiella, Pseudomonas, Proteus and Enterobacter.

For general medical patients, >85% susceptibility is considered adequate for empiric antibiotics.

For ICU patients, the higher the better, >90% susceptibility is preferred.

Empiric UTI Treatment

In 2023, SSRRH changed to using Cefoxitin, a second generation cephalosporin, as our first line for empiric parenteral UTI treatment.

Of note, our current rates of susceptibility of E Coli to ciprofloxacin (80%), levofloxacin (77%) and Bactrim (79%) mean that we should NOT be using them for empiric treatment for UTI.

Omi reminded us of a few common clinical circumstances:

• Despite common practice, ceftriaxone does not concentrate well in the urine as cefoxitin. Ceftriaxone should not be first line for UTI treatment
• Once culture results return, use the specific data to drive antibiotic treatment moving forward
• If a patient has had a recent history-- meaning in the last 120 days) of infection at the same site, use that information (and NOT the antibiogram) to drive your empiric antibiotic choice
• ESBL is a form of resistance that presents in gram negative bacteria. 
• The CTX-M gene (aka Ceftriaxone resistance) is a surrogate marker for ESBL 
• Sutter labs will not specifically report out an ESBL organism, so LOOK for ceftriaxone resistance as a surrogate marker for ESBL organisms
• If you suspect an ESBL organism, do NOT use Zosyn, any cephalosporin for empiric treatment. Your best choice is a carbapenem

• For pseudomonas aeruginosa, the only oral abx for this organism locally is ciprofloxacin, and based on 2023 antibiogram, it is currently only 83% sensitive
• do NOT use levofloxacin (77% sensitive)

Empiric Staph Aureus 

• MRSA resistance to clindamycin has been consistently high since 2017 (around 59%)
• do NOT use clindamycin for MRSA coverage
• Resistance to TMP-SMX is increasing in Santa Rosa (>16% resistance rate)
• Doxycycline sensitivity (currently 95%) is significantly higher than tetracycline (68%).
• Tetracycline is NOT a good surrogate marker for doxy against MRSA. Therefore, susceptibilities should be reported separately.
• Doxycycline is a good local choice for empiric MRSA coverage

Empiric Group B Strep (GBS)

• Local GBS is resistant to clindamycin 50% of the time, GAS is resistant 25% of the time
• Clindamycin should never be used to empirically cover GBS in a pregnant woman without sensitivities 
• Unless sensitivity is known, linezolid is preferred over clindamycin to inhibit toxin production (usually just 3 days duration)

Restricted Antibiotics

At SSRRH, certain antibiotics are restricted to ID approval with the intention of preventing misuse/overuse and preserving susceptibility over time. This technique has proven successful in limiting our local resistance. The restricted antibiotics include:

Barriers to Fertility Care (Orozco-Llamas, 9/18/2024)

Many thanks to Dr. Orozco-Llamas for an excellent, thought-provoking presentation this week on Barriers to Fertility Care. A recording of her presentation is available HERE.

My notes:

2020 American Society for Reproductive Medicine definition for infertility:

• Inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing or any combination of those factors.

• Need for medical intervention to achieve a successful pregnancy either as an individual or with a partner

In patients having regular, unprotected vaginal-penile intercourse, evaluation should be initiated at 

• 12 months when the female is under 35 years of age
• 6 months when female is 35 - 40 years
• Immediate evaluation may be warranted in female >40 years

Infertility affects 15% of heterosexual couples in the US

Male factor accounts for 40-50%

Female factor accounts for 35-50%

Unexplained fertility accounts for ~30%

This talk did not cover the usual fertility evaluation, but a typical plan for infertility includes diagnostic services (serum lab tests, semen analysis, imaging and diagnostic procedures, e.g. laparoscopy or hysteroscopy) and treatment services, including medications (clomiphene/letrozole), surgery (laparoscopy or hysteroscopy), intrauterine inseminations (IUI) and in vitro fertilization (IVF)

Each of these components has an associated cost:

For patients who need fertility specialty care, costs are generally self pay. At our local fertility clinic-- Advanced Fertility Associates, Inc, here are some current out of pocket costs:

• Consult $280 

• US done in-house $275  (even if done already at outside facility)

• Blood work $350 (often needs repeating)

• IUI $400 per cycle

• IVF $10,000-$15,000 per cycle

It is important to note that fertility treatments do not every guarantee a successful pregnancy and many of these costs need to be multiplied to achieve success. If you look at the graph below from KFF, you can see that whereas a single cycle of IUI may cost about $3500 dollars, the average cost per successful pregnancy is over $10,000 dollars. 

Ovulation stimulating medication is relatively low-cost for our Medi-Cal and uninsured patients (~$18 for a course of clomiphene and/or letrozole), but there is currently no in clinic IUI offered at our community health centers. Patients can be counseled on doing home insemination, which has a lower success rate.

We know that IVF has been in the national political conversations lately. It is important to note that there is wide variability in states regarding private insurance mandates around fertility care. 

As of June 2024, 23 states have mandates requiring insurance companies to include some coverage for infertility diagnosis and treatment. Of these, 15 states specifically require coverage for IVF. Most require a clinical diagnosis of infertility, often requiring all people seeking coverage, including single people and people in same sex partnerships, to demonstrate clinical infertility (sometimes requiring a rounds of IUI before covering IVF).

Where policies cover IVF, coverage is limited by either a dollar limit or a maximum number of IVF cycles.  Several of the states that mandate insurance coverage of infertility treatment do not require religious organizations, small businesses, or employers who self-insure to offer coverage. Several states require that the patient be married. Many states place an age limit on infertility treatment.

No state Medicaid (in California, MediCal) currently covers IUI or IVF.

***

All this being said, patients of color and patients with low SES have higher rates of infertility! In fact

• All non-white racial and ethnic groups (black, other race, and Hispanic) are significantly more likely to experience infertility than whites.

• Both high school dropouts and high school graduates are significantly more likely to experience infertility than four-year college graduates. 

• Women who are not white and women who are of lower SES are significantly less likely to report ever having received infertility treatment.

This is an equity issue. It shouldn't be surprising that women seeking fertility treatments tend to be older, white, of higher income and privately insured. 

Also of note, there is evidence that women who work with pesticides have higher rates of infertility. See image below for details on two studies that are highlighted. This is particularly relevant to many of our local SoCo patients who work in vineyards and local farming industry. 

What can primary care docs working in the safety net do with patients who need fertility services?

• Talk to your  patients about fertility!

• Refer to WHPC or GYN clinic at Vista SRCH

• Education on infertility and ovulation cycle

• Mental health resources

• Diet and lifestyle modifications

• Guidance on when to refer and providing financial information

References:

• Bill Status - SB-729 Health Care Coverage: Treatment for Infertility and Fertility Services. leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202320240SB729.
• Figà-Talamanca, Irene. “Occupational risk factors and reproductive health of women.” Occupational medicine (Oxford, England) vol. 56,8 (2006): 521-31. doi:10.1093/occmed/kql114
• Fuortes, L et al. “Association between female infertility and agricultural work history.” American journal of industrial medicine vol. 31,4 (1997): 445-51.
• Gaskins, Audrey J, and Jorge E Chavarro. “Diet and fertility: a review.” American journal of obstetrics and gynecology vol. 218,4 (2018): 379-389. doi:10.1016/j.ajog.2017.08.010
• “Infertility: An Overview Patient Education Booklet.” Infertility: An Overview Patient Education Booklet | ReproductiveFacts.Org, American Society for Reproductive Medicine, www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/infertility-an-overview-booklet/.
• Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstetrics & Gynecology 133(6):p e377-e384, June 2019. | DOI: 10.1097/AOG.0000000000003271
• Katz, Patricia et al. “Costs of infertility treatment: results from an 18-month prospective cohort study.” Fertility and sterility vol. 95,3 (2011): 915-21.
• Mays, Mackenzie. “A Bay Area Cancer Patient Froze Her Eggs in Hopes of Having Children. She Can’t Afford to Finish IVF - Los Angeles Times.” Los Angeles Times, 9 Apr. 2024, www.latimes.com/california/story/2024-03-31/ivf-isnt-covered-by-insurance-in-california-hopeful-parents-are-struggling-to-afford-fertility-care.
• Phillips, Kiwita, et al. “Infertility: Evaluation and Management.” AAFP, 15 June 2023, www.aafp.org/pubs/afp/issues/2023/0600/infertility.html.
• Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. “Definitions of infertility and recurrent pregnancy loss: a committee opinion.” Fertility and sterility vol. 113,3 (2020): 533-535. doi:10.1016/j.fertnstert.2019.11.025
• Weigel, Gabriela, et al. “Coverage and Use of Fertility Services in the U.S. | KFF.” KFF, 15 Sept. 2020, www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s.