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New to Infertility

award winning fertility doctor new york city

 

Hello Everyone,

As the years have gone by, I have very much enjoyed explaining the fertility treatment in a way that is a little more detailed and hopefully more clear than what you might be getting at your doctors office or from other infertility web sites.

The first blogs were more of a “basic training” in infertility, and with time the posts have become more focused on more complex elements of diagnosis and treatment.

The next few blogs will go back to more basic information for those who are new to the infertility world and need a starting point.  Certainly, all of the posts are available for reference.  Here you are with todays entry.

 

Infertility: The Basics

Infertility is a disease, and as with most diseases, nearly all suffers never thought they would be the ones afflicted.  Becoming pregnant is natural, necessary for us all to continue, and it doesn’t make much sense that barriers to conception could exist.  Unfortunately, some if us are indeed sub-fertile or even infertile.  In some cases there have been indications along the way that a woman or man may have trouble conceiving, maybe due to treatment of other medical or surgical conditions, but for most people, finding out that pregnancy has become evasive is troubling news.  The bright side is that significant advances in infertility care have rendered more people fertile than ever before.

I will first establish a few definitions.  I don’t like to spend too much time categorizing patients because it can lead to depersonalization, but you may encounter some of these terms, so here are a few.

 Infertility: the inability to conceive after one year of actively trying. This should be modified in women over the age of 35 to 6 months of trying.  Age is a very sensitive subject: no one wants to be told they are older or not be enthusiastically treated due to age, but age matters, as we will discus in a later blog.

Primary infertility: infertile and never pregnant.

Secondary Infertility: infertile after being pregnant in the past.

So if you have been trying for 6-12 months with no pregnancy, what is your next step?  It’s time to see a doctor. The workup is very simple, and who knows, there may be something discovered that is very easy to remedy that can quickly fix the problem.  Some people are worried about seeing a doctor because they have heard or read misinformation about the diagnosis and treatment options, but you owe it to yourself to at least find out what the problem may be.  Plus a good infertility doctor will explain many things to you about natural and assisted conception; this is valuable information that you should get from an expert.  Alternative educational sources can be excellent (like this website), but having a single experienced resource put everything together will help you make the best decisions.

What does the doctor do to determine what the problem may be?  The testing phase is not very complicated.  There are 3 initial tests.

1)   The hysterogram (the long word is the hysterosalpingogram, also abbreviated HSG). This is an x-ray test to confirm that the fallopian tubes are open. In order for pregnancy to occur, the egg has to make it from the ovary in to the tube, and then pass through the tube into the uterus.  And, the sperm needs to swim up from the uterus into the tube.  Thus, blockage of the tube does not allow for pregnancy to initiate.  The HSG also confirms that the shape of the uterus is normal. Previous uterine surgery can alter the shape. Also, some women are born with an abnormal shape to their uterus, which at times can be corrected.  Some doctors perform alternatives to the HSG, but others believe it is the best test to confirm normal anatomy.

2)   The Semen Analysis.  This is where the sperm is counted and checked for motility (movement) and morphology (sperm shape). If the counts or motility are low, the male partner may be referred to a urologist who can develop a treatment strategy.

3)   Analysis of ovarian reserve. All women lose eggs as they age, and unfortunately, even some very young women are left with a low or absent egg number.  The lower the egg reserve, the more difficult pregnancy becomes. To test for a diminished ovarian reserve you may be asked to have a blood test in day 2 or day 3 of your cycle for the hormones FSH, Estradiol and AMH (more on this in the next blog).

Once all of these tests are performed, your doctor can help you formulate a plan. There are many options available, your doctor will work with you to develop a course of action that is best for you.

Thank you for reading and I look forward to writing again soon,

Dr. Licciardi

AMH (Anti-Mullerian Hormone)

 

award winning fertility doctor new york city

 

Hello to all.

In this blog I will review the usefulness of Anti-Mullerian Hormone, otherwise referred to as AMH. AMH is one of the hormones, along with estrogen and a few others, produced by the ovary.

Like estrogen, AMH is produced by the granulosa cells. The granulosa cells are the small cells that surround each egg.  These small cells are tightly attached to egg surface whereby they help to vitalize and, when the time is right, mature the egg.   This egg-granulosa cell unit is called the follicle.

No one yet knows what the function of ovarian AMH in females.  AMH is present in males, and we know that it has a very important role in the development of normal male sexual anatomy.  What we do know about AMH in females is that the more healthy follicles one has, the higher the AMH levels.

Measurement of AMH levels can help us predict a woman’s fertility, in a very general way.  We already said that estrogen is also produced by the granulosa cells, so why wouldn’t we just need to measure estrogen levels to find out about ovarian health?  Because estrogen only comes from follicle at a time; the one that is in the process of ovulation. A woman may have 100,000 follicles, but on most cases only one per month gets involved in ovulation and becomes an estrogen producer.   Follicles may make different amount of estrogen each month, so judging fertility based on an estrogen test is not helpful.

Many follicles at one time, however, are producing AMH. Now it’s not every follicle, but it is a large number.  It works like this. The ovary contains different follicles in different stages of maturity.  Here is a microscopic view of the ovary.

 

Some follicles are very immature and have few granulosa cells; just one layer surrounding the egg.   Some follicles are more mature and their granulosa cells have multiplied into more cells in multiple layers.  These are the ones producing the most AMH.  In general, if you have a lot of eggs, you have plenty of follicles in all of the stages of development, giving you higher AMH levels.  Lower AMH levels mean fewer follicles of all types.

Follicles are always making AMH therefore levels can be measured any day in the cycle. In fact, it does not matter if a woman is on oral contraceptives, AMH is still produced and can be measured.

AMH may turn out to be and excellent way to measure a woman’s fertility potential, but we are not quite there yet. We do know that a high AMH is good and a low AMH is bad. What’s a good high level? We are still not sure. We know a little.  Any level over 2 is really not bad at all. Certainly, higher than 2 is better still. We know that undetectable levels, less than 0.16, are bad.  But, we have had women with these low levels become pregnant.  The odds of pregnancy are much worse for women with low levels, but people frequently get pregnant with low odds.  Some women have asked me if the level can be too high.  High levels may indicate the presence of polycystic ovaries (ovaries with an above average number of follicles).  While it is true that some women with polycystic ovaries have trouble conceiving, a high AMH level is not the issue.

Recent studies (one was in the headlines a few weeks ago) have used AMH levels to predict IVF outcome.  But again, really high levels were shown to be good and really low levels bad, but overall, not predictive enough to tell someone they can or can not get pregnant.

What we typically do is to put all of the information we have together to estimate ovarian health.  If we use age, FSH levels, AMH, antral follicle counts, the prognosis becomes a bit more clear, but the system is still not perfect.

AMH testing will become more useful sometime soon. More and more women need to have the test done do we can compare levels to outcomes on a large scale. In addition the laboratories need to get better at the testing.  But once we get better with AMH levels, we may be able to do some very important things.

For instance, some studies have been done comparing AMH levels to the time of menopause. Again, not ready for prime time, but the concept may be very important.  What if we could measure AMH in a young woman and determine at what age she will start losing her fertility? Or at what age will she lose half her fertility? What if we could measure AMH levels in a woman destined for chemotherapy and determine if she should freeze her eggs first?

These would all be wonderful uses of this test and it may be that in the future we could reach these goals.

It’s more likely that newer tests will be developed to improve ability to predict.  As alluded to before, combination tests may be more accurate. For example labs are starting to market “fertility profiles” based on AMH, FSH, inhibin and other hormones.

But in the end, like in all of medicine, the genetic tests will dominate.  Scientists are looking for a gene or groups of genes that control the fertile lifespan of women.  As genetic testing becomes less expensive and as we increase our ability to look at more and more genes at one time, the goal of accurately determining a woman’s ovarian age and potential will be reached.

 

Thanks for reading and please don’t forget to read the disclaimer from 5.17.06

 

Dr. Licciardi

 

Important Final Words on Pre-Implantation Genetic Diagnosis

award winning fertility doctor new york city

 

Good Day to All,

These past few blogs covering PGD raise a few important issues. There are some well-know fertility centers that are really pushing TE biopsy. The feeling is that the technology has finally become accurate and safe enough.  It may be that doing IVF with PGD leads to a higher pregnancy rate and a lower miscarriage rate.  Plus, if you know you are getting a normal embryo, we can transfer fewer embryos, lowering the rates of twins and triplets.

This all sounds good, however, I think we need just a little more time, but maybe not much more.  In a good center, the pregnancy rate for a woman under 37 years of age is 40-50% without PGD.  PGD adds an invasive procedure. The shell of then embryo has to be opened, usually by a laser beam, then some of the embryo, even if it’s a small piece, has to be chopped away.  We make it sound simple, and so far it seems safe, but no one should promise you all of the safety data is in.  Not to mention the additional costs, which could vary from program to program, but $6,000 is a safe estimate.

In theory, ideally, PGD will be the way to go and everyone doing IVF will have their embryos tested, the pregnancy rates will go up, miscarriage rates will go down and we will say goodbye to IVF twins.   And if the system works really well, in the end this will save money because people will need fewer IVF cycles for success (not to mention the drug cost savings if fewer cycles are needed).

Encouraging news concerning PGD is coming out of the data on miscarriage. Good PGD does decrease the rate of miscarriage. A very high percentage of miscarriages are caused by aneuploidy, which means an abnormality in the number of chromosomes present in the embryo. Just one example of aneuploidy is Down’s syndrome, which is the result of an extra chromosome 21 (also called trisomy 21).  The bulk of PGD is performed looking for aneuploidy.

The reduction of miscarriage rates after PGD has 2 important implications. One is that preventing a woman from having a miscarriage is obviously a welcome idea, as the emotional toll of pregnancy loss is significant. The second is that miscarriage takes time.  While many miscarriages occur early, many women do not suffer their loss until 7-10 weeks, later if the fetus survives to the CVS (10 weeks) or amnio (17 weeks).  When you add in the recovery time of 1-2 months before a woman can try again post-miscarriage, the total time lost could be 2-4 months. This is especially difficult in an older woman whose reproductive time is already limited.

One shortcoming of this technology is that this new method of testing requires a blastocyst. Many IVF programs are still not comfortable growing their embryos to blastocyst; they prefer transferring their embryos on day 3.  These programs will not be able to provide these new services until they become very good a growing embryos out to day 5, which for some clinics could take a very long time.

Lastly, not everyone who wants PGD is a candidate for PGD.  The group that may benefit the best from a PGD cycle is those who are above the average age for reproduction. However in this group, egg production is lower, as is the rate of good (biopsyable) blastocyst formation. So there may be the intention for PGD at cycle start, but if the egg number or embryos quality is low, the option for PGD in that cycle may be lost. Straight IVF may or may not still be a viable option, but at times even those are not possible.  I try to be positive to the end, but it is always necessary to cover all eventualities.

 

Well, that’s quite a bit about PGD. Thanks very much for reading.

Don’t forget to read the disclaimer from 5.17.06.

Dr. Licciardi

References:

  • Braude P. Preimplantation diagnosis for genetic susceptibility. N Engl J Med 2006; 355(6):541-3.
  • Gutiérrez-Mateo C., Colls P., Sánchez-García J., Escudero T., Prates R., Wells D., Munné S. Validation of microarray comparative genomic hybridization for comprehensive chromosome analysis of embryos. Fertil Steril. 2011; 95: 953-958.
  • Twisk M, Mastenbroek S, van Wely M, Heineman MJ, Van der Veen F, Repping S. Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2006; 25(1):CD005291.
  • Munne S, Fischer J, Warner A, Chen S, Zouves C, Cohen J, Referring Centers PGD Group. Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study. Fertil Steril. 2006; 85(2):326-32.

 

 

Trends in Pre-implantation Genetic Diagnosis

award winning fertility doctor new york city

Welcome,

So what are the new developments increasing interest in PGD?

The first is that there is more laboratory expertise on growing the embryos to blastocysts (see blog on blastocyst). These are embryos that have grown not 3, but 5 days in the lab.  As the embryo grows with time, the total number of cells increases from 6-8 to 30-60. Because the cell number is much higher, we can more safely remove more than on cell, maybe 3-5 cells. All of that extra DNA helps us reach much more accurate results.

 

The second has to do with the way we test the DNA.  The DNA amplification techniques have improved, as have the techniques for identifying important areas in the DNA.

 

An advantage of blastocyst biopsy is that in a good blastocyst, we can tell by looking which cells will be the embryo (the inner cell mass) and which will be the placenta (the trophectoderm- thus the term trophectoderm biopsy, also called TE biopsy for short).  Naturally, at the time of the biopsy, it is the placental cells we take as not to interfere with the fetal cells. Taking a few extra cells from the placenta is much less harmful than taking cells needed for the fetus.

 

Another advantage of performing the biopsy on day 5 is that mosaicism is much less of a problem in a blastocyst. (The last blog explains mosacism), The cells we get on day 5 more accurately reflect the DNA status of the embryo as a whole.   We are not sure why mosacisism is less of a problem on day 5, it may be that it’s common for an embryo to start off with some abnormal cells, but with time the normal cells outgrow the bad ones.

 

One downside to TE biopsy is that in most cases, the results of the biopsy take 1-3 days to process. We do not want a day 5 embryo growing extra days in the lab waiting for the results. Therefore, we usually freeze the blastocysts just after the biopsy, get the results a few days later, and then have the patient come back the next month for a thaw cycle.  This gives the patient a one month delay, which may or not be an important factor, depending on the expectations of the patient.  There are some programs that offer same cycle PGD biopsy and transfer, but usually those women with only the fastest growing and best looking are candidates for the same cycle process.

 

Patients are naturally concerned about embryo freezing, as is it is mostly true that embryos in a frozen cycle have lower pregnancy rates than when the embryos are transferred when fresh.  However, there may be some very explainable reasons why freezing normal blastocysts may not be problematic.  In a standard fresh cycle, the best embryos are transferred. While the extra embryos may look very good, the best ones go back originally, leaving the left overs for the frozen cycle, and this could explain the lower rates.  In a PGD cycle, even the best embryos are frozen, upping the odds for a successful cycle after the thaw.  Also, at least from what I have seen, normal embryos seem to thaw and freeze very well. So if you know you have a good one in the freezer odds are good that it will survive the freeze and thaw and have good potential for success.

 

In addition, freezing techniques have really blossomed in the past few years.  Most programs have moved to vitrification (the fast freezing method), and embryos do have better outcomes when preserved this way.

 

On top of all of this, there are some doctors who believe that all embryos, even without biopsy, should be frozen. There is the revival of an old theory that the endometrium of an IVF cycle is not ideal for implantation, possibly due to excessive estrogen levels caused by the fertility drugs. Others feel that the relationship between the timing of ovulation and embryo transfer is altered with IVF, lowering the ability of the embryo to implant.  I’m not so sure about theses theories, but I am raising the point here to say that a frozen embryo cycle is not necessarily a bad thing.

 

There are still a few more points about PGD that I will go over next time.

 

Thanks for reading, and don’t forget the disclaimer 5.17.06

 

Dr. Licciardi

 

References:

  • Braude P. Preimplantation diagnosis for genetic susceptibility. N Engl J Med 2006; 355(6):541-3.
  • Gutiérrez-Mateo C., Colls P., Sánchez-García J., Escudero T., Prates R., Wells D., Munné S. Validation of microarray comparative genomic hybridization for comprehensive chromosome analysis of embryos. Fertil Steril. 2011; 95: 953-958.
  • Twisk M, Mastenbroek S, van Wely M, Heineman MJ, Van der Veen F, Repping S. Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2006; 25(1):CD005291.
  • Munne S, Fischer J, Warner A, Chen S, Zouves C, Cohen J, Referring Centers PGD Group. Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study. Fertil Steril. 2006; 85(2):326-32.

 

Sperm Deficient Females Can Be Quite Fertile

This is a phenomenon that I have observed since I started practicing. Basically these are women who are not exposed to sperm ie: single and or lesbians. When I consult with such women I go through all the possible treatment options, but say, “It may just be that you are sperm deficient, and with just a whiff you could be on your way.” I like saying this because it usually invokes a little smile.

As we have discussed, women who have not become pregnant after 6-12 months of trying have low fertility rates going forward. Not getting pregnant means there is a problem that will stick with you until you get help. If a woman has not yet tried, her fertility may be quite high, and one of the most important points here is this is especially true in older women. If a 43 year-old woman has been trying with her sperm-filled husband for a year, I would be eager to treat her. However I would need to tell her it’s going to be a rough road that may not get her to pregnancy.

I am much more optimistic with a 43 year-old sperm-deficient woman. Here I go through the options and say, “Listen, I don’t know about your journey. We need to forget about your age and get you some sperm. If you not pregnant after a while, then we’ll start worrying”.

Now I still need to check the FSH, but even if it’s borderline I don’t worry much. It is also true that some of these women want to go straight to IVF. This is never a bad idea, but a few months of insemination may be all they need. So this entry is not meant to delay anyone’s treatment. If you are thinking about getting pregnant, try as soon as you can. Waiting is always a big mistake.

Your best chances of getting pregnant come from calling a qualified specialist. Taking that step is an easy phone call. Waiting is rolling the dice.

How Can the Pregnancy be Bad But Still Growing?

This is a common unfortunate situation. There are a few typical scenarios. One is when a woman has a normal or lowish first beta. Then she has a second beta a week later that is not perfect but close enough. Another scenario is betas that go up slowly but are never in the normal range. Another scenario is when the betas are very nice and all is well until an ultrasound shows a problem.
All of these cases sometimes have a sad ending, as an ultrasound that shows a normal sac, without an embryo. So how can this be? How can you hear from your doctor that the beta is rising but the pregnancy is abnormal?
The early embryo is composed of 2 types of cells: the cells that go on to form the embryo and the cells that go on to form the placenta. Most of the cells are for the placenta, only a few are for the embryo. It’s the placental cells that make the hCG and this is the hormone of the pregnancy test. It is possible for the placental cells to continue grow even if the embryo is growing poorly or not at all. Some of you have heard a term for this problem, an “empty sac”. Except in rare cases, the placental cells will eventually stop growing after a few weeks, and an early miscarriage will occur. Sometimes a D and C is recommended.

References:

  • Regan L, Braude PR, Trembath PL. Influence of past reproductive performance on risk of spontaneous abortion. BMJ 1989; 299:541-5.
  • Chen BA, Creinin MD. Contemporary management of early pregnancy failure. Clin Obstet Gynecol. 2007 Mar; 50(1):67-88.
  • Barnhart KT. Early pregnancy failure: beware of the pitfalls of modern management. Fertil Steril. 2012 Nov; 98(5):1061-5.

But Doc, What went Wrong? Maybe Nothing.

Today’s story is of a women in her early 30’s who, as you might suppose, could not get pregnant. She tried for a while on her own, then moved on to insemination using fertility drugs, and then IVF. Her IVF cycle went very well. She responded very nicely to the drugs and had a more than adequate endometrium. She had a retrieval of plenty of eggs, and most of her embryos were of good quality. She did a day 5 transfer of 2 nice blastocysts. Everything looked good, but unfortunately, she did not get pregnant.
So want went wrong? Well sometimes the answer is nothing, it just didn’t work. The most plausible explanation is that despite her embryos looking normal, the embryos may have been genetically abnormal, and pregnancy did not occur. (this is not a push for PGD, the subject of another day).
To me this is not a story of despair, but a story of hope. Yes it’s sad, it didn’t work. However, everything in this woman’s cycle was pointed in the right direction. She is much better off that the person who has trouble stimulating or has a bad uterus or poor embryo quality. The odds of her becoming pregnant in her next cycle are still excellent. The problem becomes when we all try to micro analyze the cycle. Patients think, “Maybe it was my cold, or I picked up my daughter and got a cramp, or there was stress at work.” Doctors look at the medication protocols, day of hCG, ease of transfer and many other things. Every failure needs to be carefully reviewed, but in the end, sometimes it’s just a matter of trying again. The best thing a patient can do to help her odds is to get treatment at the best facility available to her.

FSH and Estradiol(Estrogen)

It is also important to measure the estradiol on day 3. Day 2 is fine. The reason its day 3 is 15-20 years ago, the IVF medications were always started on day 3. So everyone who started an IVF cycle had Estradiol and FSH measured on day 3. Pregnancy rates were checked against different levels of FSH and Estradiol, and that’s how the original work was done. I did research with the day 3 Estradiol level when I was a fellow.
If the estradiol level is high, the FSH level will be artificially lowered, and the FSH level will therefore not accurate. For example, I may have a patient with an FSH an 18 and an
estradiol level of 45. Next month the FSH is 8, but the Estradiol is 92. This is just as bad as her first test. Once the estradiol is over about 50, the FSH will be lowered. Just because the FSH becomes lower does not mean the patient is more fertile. If the estradiol is elevated month to month, this is as bad as the FSH being elevated month to month.
Why does the Estardiol level become elevated? For some women, the cycle gets shorter as their ovaries age. So that by day 3, when the follicle should not yet be growing, the follicle has already started to grow and produce estradiol, and for reasons we don’t yet understand, this is bad. Taking estrogen pills to lower the FSH level does not help. It’s like taking Tylenol to lower your temperature if you have appendicitis. Your temperature may come down, but there is still a problem. Some doctors say there is a benefit to lowering the FSH level with estrogen. They say that when the FSH is high, the ovary become resistant to FSH and can’t be stimulated by fertility drugs(which contain FSH). The theory is that by lowering FSH levels with estrogen, the ovary will respond when high doses of FSH are added(in the form of the fertility injections). It sounds reasonable, however there is no literature to support these claims, i.e. there is no evidenced based medicine.

References:

  • Licciardi FL, Liu HC, Rosenwaks Z. Day 3 estradiol serum concentrations as prognosticators of ovarian stimulation response and pregnancy outcome in patients undergoing in vitro fertilization. Fertil Steril. 1995 Nov;64(5):991-4.
  • Bancsi LF, Broekmans FJ, Eijkemans MJ, de Jong FH, Habbema JD, teVelde ER. Predictors of poor ovarian response in in vitro fertilization: a prospective study comparing basal markers of ovarian reserve. Fertil Steril 2002; 77(2):328-36.
  • Broer AL, Mol BWJ, Hendriks D, Broekmans FJM. The role of antimüllerian hormone in prediction of outcome after IVF: comparison with the antral follicle count. Fertil Steril 2009; 91(3):705-14.
  • Toner JP, Philput CB, Jones GS, et al. Basal follicle-stimulating hormone level. Fertil Steril 1991; 55:784.

The Dreaded Biochemical Pregnancy

Here I will tell of a typical story about a woman who has been suffering from infertility, and finally becomes pregnant. After the relief of a positive pregnancy test her doctor repeats the test and says, “Well Lisa, it looks like your pregnancy is biochemical”.
Now I can’t completely describe what Lisa is saying to herself, but it’s probably something like this.
“What is he talking about? A biochemical pregnancy? Did I get pregnant? Am I pregnant? Biochemical? It’s bad enough I have felt like a science experiment, now I’m biochemical?”
Let me try to straighten this out. The definition of a biochemical pregnancy is a pregnancy that stops growing before it is large enough to be seen on ultrasound. It’s a very early miscarriage. The causes are the same as for any miscarriage. By far, the most common reason is that the embryo is genetically abnormal, that is it doesn’t have the right number of chromosomes. And although it has the tools to grow for a while, as the embryo grows and needs to become more complex, the tools run out and the embryo can grow no more. There are other causes of miscarriage and that will be topic of a later blog.
The word “biochemical pregnancy” is a terrible term. It’s very cold and scientific and inhumane. I try not to use it, I just say it’s a very early loss. I thing the fertility community should throw out the word. I’m going to ask them if they will.

No More Happy Birthdays

I wanted to be a doctor from a young age. I was one of the few kids who thought it was neat to get a shot. I was inspired by my physicians, and I think MASH is still the best show on television.
When I started medical school I was sure that I would be a family physician. Yes I enjoyed medicine, but I found that paying attention of the personal aspects of care to be very rewarding. Asking patients about their family, jobs and family was very appealing to me.
So I went on to became a fertility specialist, but attention to the personal details was still important to me. I like asking patients the details about their lives outside the fertility world. And that’s how I became frustrated with “Happy Birthday”.
Birthdays are difficult for women who are infertile. As they get older, the hands of their biological are chipping away at their chance to be a parent. When I first started practicing I would feel awkward about bringing up the subject.
And then I thought, what force has the right to take away one of our most basic pleasures? Who doesn’t remember the fun in having an entire day dedicated to you? Blowing out the candles was always thrilling. Heck, you even got presents for no reason at all, except for the fact that this was the anniversary of the day you graced the world with your presence.
So I say now have a very Happy Birthday. It’s your day, soak it up.