What’s Up Doc: General Evaluation And Treatment Options

September 12, 2006 - Tuesday
3:54 PM to (EST)
Guest Speakers: Spencer Richlin, M.D.
Reproductive Medicine Associates of Connecticut

Categories
Acupuncture • Fertility • Infertility • IUI • IVF • PCOS • Pregnancy • Yoga

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spencer_richlin_md_rmact	Hi, Welcome
spencer_richlin_md_rmact	Spencer Richlin MD
honeybumblebee	HELLO DR RICHLIN
deb	Good evening and welcome to tonight's Online Education Session, hosted by The American Fertility Association and sponsored by Fertility Lifeline. As always, we will start promptly at 8pm Eastern.
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heatherhhrn	Hello Everyone ::smile
honeybumblebee	HELLO
deb	Our guest this evening is Dr. Spencer Richlin from RMA-CT. Dr. Richlin is a staff physician and RE at Reproductive Medicine Associates of Connecticut. Dr. Richlin is here tonight to help us explore evaluation and treatment options.
spencer_richlin_md_rmact	Tonights topic is infertility evaluation and treatments, I am a board certified REI at Reproductive Medicine Associates of Connecticut
spencer_richlin_md_rmact	Hello
honeybumblebee	HELLO AGAIN DR RICHLIN
deb	I am Deb Capone and I am your moderator. If you need to 'talk' to me privately, just double click on my name in the left hand column.
heatherhhrn	Do we just type our questions and you respond?
spencer_richlin_md_rmact	yes
deb	I want to thank Dr. Richlin for taking the time out of his schedue for joining us.
honeybumblebee	HELLO DEB, AND WHAT EXACTLY IS A MODERATOR?
spencer_richlin_md_rmact	my pleasure
spencer_richlin_md_rmact	ask any question
deb	Heatherhhrn, you can just type in your questions and Dr. Richlin will do his best to answer....
deb	Dr. Richlin has set the stage for tonight's topic which is infertility evaluation and treatments.
deb	Dr. Richlin, with everyone so anxious can we let it roll now at 7:59:
spencer_richlin_md_rmact	yes
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heatherhhrn	I started seeing a RE at the beginning of this year, a couple rounds of clomid in, all negative results. I am meeting with him in about a week or so, I am not sure what to expect next. Is there something that I should be asking?
deb	Welcome corgimommy. We are talking with Dr. Spencer Richlin about infertility evaluation and treatments
honeybumblebee	A MONTH AGO I STARTED SEEING A FERTILITY SPECIALIST AND I AM NOW GOING THROUGH MY FERTILITY EVALUATION
spencer_richlin_md_rmact	heather, you should do 3-4 cycles of clomid and then move on to either shots and iui or ivf. are your tubes open, semen fine, and fsh ok
honeybumblebee	I AM 26 YEARS OLD AND MY HUSBAND AND I HAVE BEEN TRYING UNSUCCESSFUL FOR 3 YEARS
heatherhhrn	I have never had a test to see if tubes are patent, that was going to be one of my questions at this next visit
spencer_richlin_md_rmact	heather do a hsg
spencer_richlin_md_rmact	honey have you been evaliated
honeybumblebee	I HAVE JUST BEEN DOING TEST AFTER TEST. THE DR ADVISED THAT WE WILL GO OVER ALL RESULTS ONCE THE TEST ARE DONE
honeybumblebee	LAST WEEK HAD AN HASG, AND THE DR SAYS THE TUBES AND UTERUS LOOK NORMAL
spencer_richlin_md_rmact	you probably did a hsg, semen analysis and a day 3 fsh?
honeybumblebee	ONE PROBLEM I KNOW I HAVE HAD OVER THE PAST THREE YEARS IS NOT OVULATING
spencer_richlin_md_rmact	honey, did you use clomid to induce ovulation
honeybumblebee	USED CLOMID LAST YEAR FOR 6MONTHS
heatherhhrn	have done 3 rounds of clomid, what would be the next step?
spencer_richlin_md_rmact	honey, have you moved on to shots iui or ivf
heatherhhrn	if tubes were patent
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honeybumblebee	DID HSG, SEMEN ANALYSIS AND DAY 2 FSH WHICH WAS 5.00
corgimommy	I dx with pcos and have done 3 rounds of clomid/hcg trigger shot/iui which lead to ovulation but no preg. Did an hsg tubes are cllear, sperm are normal, no other problems. I lost 30lbs and did not take any meds this cycle b/c of hsg. Did a P4 test yesterday and result was 15.5. Is this a strong ovulation on an unmedicated cycle (well still taking Met)???
spencer_richlin_md_rmact	heather shots/iui or ivf, I like ivf since it gives best pregnancy rates
honeybumblebee	HAVEN'T MOVED ON TO ANY TREATMENT AS OF YET. STILL BEING EVALUATED
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deb	Thanks for joining us Maddie1702, JC and Hope: we are here with Dr. Richlin discussing infertility evaluation and treatment options. Feel free to jump in when you are ready!
spencer_richlin_md_rmact	corgyou are doing fine, i bet you will do 2 more clomid cycles
heatherhhrn	are you under sedation for hsg?
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spencer_richlin_md_rmact	corg you obviously responded to clomid, how many follicles did you produce
deb	Welcome aboard Alia.
honeybumblebee	RIGHT NOW I HAVE BEEN TESTING FOR POSITIVE LH SURGE FOR 4 DAYS AND ALL HAVE BEEN NEGATIVE. WAS AWAITING POSTIIVE LH SURGE, SO I COULD HAVE A POSCOITAL THE FOLLOWING MORNING
spencer_richlin_md_rmact	no sedation just motrin
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corgimommy	Last cycle I produced 4-5 follicles measuring from 18-22mm and an E2 of 700. RE wanted to cancel but we went through with the IUI and NO PREG.
deb	Alia and liafa, we are talking with Dr. Spencer Richlin about infertility evaluation and treatment options.
spencer_richlin_md_rmact	corg a good cycle, try possibly 2 more, consult your Dr
honeybumblebee	I WAS DX WITH PCOS A YEAR A GO.SO I WAS PUT ON CLOMID, BUT DID NOT WORK. MY NEXT EVALUATION IS ON DAY 21 FOR AN ENDOMETRIUM BIOPSY
heatherhhrn	would there be a reason why RE would have not ordered an HSG, I've been seeing him since Jan.
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corgimommy	This cycle I did NOT taken clomid and had a P4 of 15.5 on day 23....should I even try clomid again?????
honeybumblebee	WHAT ARE THE NORMAL RESULTS FOR A P4 TEST?
spencer_richlin_md_rmact	honey i would like to see you do gonadotropins with iui at low dose or ivf, what does your Dr say
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spencer_richlin_md_rmact	i would do clomid and iui with monitoring
Alia	Thanks Deb
honeybumblebee	WHAT IS A GONADOTROPINS? DR HAS NOT SAID MUCH YET, UNTIL THE LAST TEST IS DONE, WHICH IS THE ENDOMETRIUM BIOPSY
corgimommy	What about aramotose inhibitors?
heatherhhrn	I havent even seen the doctor since my first visit, what do you think about Femara?
spencer_richlin_md_rmact	if you have done 3-5 cycles of clomid, often we move to shots of fsh , follicle stimulating hormone, to help recruit follicles
spencer_richlin_md_rmact	corg I like them if clomid has not worked, if it has, i would do 3-5 clomid cycles and then move on
spencer_richlin_md_rmact	femara works great, in patients who do not ovulate to clomid we often try femara
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spencer_richlin_md_rmact	in patients who are clomid we often use femara
spencer_richlin_md_rmact	clomid resistant
heatherhhrn	Ive had plenty of follicles but they dont seem to get to the right size. Also what about glucophage?
spencer_richlin_md_rmact	honey have your Dr. put together a treatment plan for you
liafa	I think I missed the start of the session. Trying to step in with a question. I am taking Bromocriptin to reduce Prolactin levels. After 2 months the cycle is still not regular. My husband has a very low sperm count. No cause has been identified. What treatment options could increase sperm count? Would it be better to directly start IVF or try IUI?
corgimommy	What level should a P4 be at after ovulation??
spencer_richlin_md_rmact	heather glucophage is used often in pts to help them ovulate on clomid
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spencer_richlin_md_rmact	12
Alia	I just did an IVF cycle - and it was unsuccessful. Did a month of BCP - which, I understand, may have over suppressed me. Was then on high dose of Follistim and Menopur. Only produced 4 eggs only one took. Probably should have done IUI but proceeded with IVF. Am going for round 2. Any suggestions for protocol
honeybumblebee	no treatment plan yet. i am assuming he will after the endometrium biopsy
spencer_richlin_md_rmact	liafa recheck your prolactin levels, you may have to increase dose, has your husband seen a urologist
corgimommy	Does a higher number = more likelyhood for pregnancy?
spencer_richlin_md_rmact	alia you could discuss a microflare protocol with your dr
spencer_richlin_md_rmact	corg, no just want level to be 10 or above
spencer_richlin_md_rmact	alia have you had a day 3 fsh
corgimommy	When would you take supplemental progesterone? What would indicate to you that a pt needed supplemental progesterone?
heatherhhrn	Thanks doctor....I'm going to keep my fingers crossed. GOOD LUCK TO ALL
spencer_richlin_md_rmact	liafa give it time, once your prolactin level is nl, i think you will cycle
honeybumblebee	how does iui work for someone who is not ovulating
spencer_richlin_md_rmact	corg if your levels on day 21 were less than 10 i would supplement
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spencer_richlin_md_rmact	honey you need to ovulate and kick out an egg in order for sperm to fertilize it
Alia	Yes, I had a day 3 fsh in may. Came in at 11.4. But apparently test was done incorrectly as estrodiol was at 130. Just had the test repeated but do not have results. Am also doing the Clomid Challenge test. Does a microflare protocol have a lot better results in terms of stimulated follicles?
corgimommy	What does an endo biopsy show you?
spencer_richlin_md_rmact	alia do the ccct, and flare protocal is worth a try to possibly increase follicle #
honeybumblebee	exactly how does iui work?
spencer_richlin_md_rmact	corg it tells you if the endometrium is in phase with your cycle day
corgimommy	What does a saline infused ultrasound show that a hsg doesn't?
Alia	Thanks doctor. Do stress levels ever effect FSH levels. I've been very stressed/depressed since the failed cycle last month.
liafa	how long should i wait before i increase the bromocriptin dosage? it is just 1 tablet and everywhere i have read that it should be 2 per day. My husband has seen an urologist who did several tests. he said it is a production problem. he recommended a genetic test, which may show if the problem is located there. he said that the sperm count may be too low for IUI. how high does it have to be?
spencer_richlin_md_rmact	corg it can find possible small polyps or cavity defects that a hsg can't see
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spencer_richlin_md_rmact	10,000 million total motile sperm is a good starting point for iui
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corgimommy	Would you test the FSH every cycle? I've only done that in the beginning of my work-up. Each cycle is just estrodial and progesterone....
spencer_richlin_md_rmact	liafa wait 2 months and then recheck prl, if still high increase dose
deb	Thanks for joining us bketchum and hoping. Dr. Spencer Richlin is talking about infertility and treatment options. Feel free to jump right in with your questions.
spencer_richlin_md_rmact	corg i would check fsh every 9-12 months
corgimommy	If a sperm analysis comes back normal is there anything else that should be looked at on the male side?
Alia	Also, do you have any suggestions on how long to wait after a ccct before doing a round of IVF. I will also be having a hysteroscopy this month and want my body to be as receptive as possible for a pregnancy. Should I go right into a cycle or wait?
liafa	with a sperm count of 3 million on average (3 tests) is ivf then the only option?
spencer_richlin_md_rmact	corg have him have a good diet, if sa ok, you are probably fine
spencer_richlin_md_rmact	liafa i would do ivf/icsi
lizzyprod	I did a failed FET (Frozen Embryo Transfer) and now gearing up for round two... they suggest putting 2 back in - the first time, we did 1 tranfer... it seems like the luck of the draw - is it really just a probability game. And second question - do you think accupuncture helps with the transfer?
spencer_richlin_md_rmact	alia there is really no need for a waiting period
corgimommy	When would you do a lap? Before starting injectibles?
liafa	if we have to do ivf, does it still make sense to reduce my prolactin levels? doesn't ivf shake up all hormones anyway?
spencer_richlin_md_rmact	lizzy accupuncture may increase rates, it is relaxing and my relax the uterus, more studies need to be done, i like it
spencer_richlin_md_rmact	corg i don't like doing laps, i like ivf
Alia	Is there any benefit to doing icsi if my husband sperm is fine in all senses (count, motility etc)
spencer_richlin_md_rmact	liafa you want a normal hormone axis before doin givf
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hoping	we've had 6 failed IUI's, i cancelled IVF--LH surge too soon. am 37, and am hoping to still try. Dr thinks it is diminished ovarian reserve, but still ovulating. when is it time to get a 2nd opinion, and/or laparascopy?
spencer_richlin_md_rmact	lizzy you should decide on how many embryos to place based on their grade and your age
liafa	thank you for the answers, this was really valuable advice for me
spencer_richlin_md_rmact	hoping what is your fsh
spencer_richlin_md_rmact	liafa thanks
lizzyprod	I'm 36 and they are all excellent grade
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hoping	oops, can't remember--i had thought it was in normal ranges.
spencer_richlin_md_rmact	lizzy possibly place 3 based on your past, talk to your dr
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spencer_richlin_md_rmact	hoping you could do a different ivf protocol
hoping	Dr thought i would have to go back on a tertiary protocol of clomid, then stims, then try for IVF
corgimommy	There is a possible clinical trail for non-ovulating pts but you have to stop metformin. That scares me. Isn't it the longer you've been on metformin the better??
spencer_richlin_md_rmact	hoping if you did 6 clomid cycles, you should do another ivf cycle with a diff protocol to try to stop lh surge
Alia	Is there any benefit to doing icsi if my husband sperm is fine in all senses (count, motility etc)
spencer_richlin_md_rmact	alia icsi is for fertilization failures, if his count, morphology and motility is fine, probably do not have to do icsi
corgimommy	What about combining clomid with injectibles? Or clomid with estrogen to help lining?
hoping	what sort of medicine would that entail? And can you tell me more of what could be causing a pelvic and abdominal pain during the last rest cycle, and even now that I am off the stims?
spencer_richlin_md_rmact	corg i like a protocol of 5 days of femara and injectibles day 7-9, works great
corgimommy	What is femara?
spencer_richlin_md_rmact	hoping how about a down regulation wit lupron
Alia	OK - of the 4 eggs retrieved only one fertilized. 2 were too immature. Wasn't sure if ICSI would help. Sounds like not really.
spencer_richlin_md_rmact	corg it is a new medicine, oral that is being used to help people ovulate
hoping	what would the lupron do? does it help with the rest cycle?
Alia	Does how quickly you stimulate affect egg quality? Does one want a longer stimulation period?
spencer_richlin_md_rmact	alia i would change your protocol, possibly give you 1 more day of stim and maybe do icsi
corgimommy	Do many women experience implantation bleeding?
spencer_richlin_md_rmact	lupron would fight off a premature surge
spencer_richlin_md_rmact	alia, you may simply want to try a diff stim to see how you do
hoping	what aobut the pain?
spencer_richlin_md_rmact	corg no
corgimommy	Stupid questions but people on the message boards say they feel implanation--isn't that impossible?
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spencer_richlin_md_rmact	pain can be from mant causes, ivf bypasses most pelvic and anatomocal problems asso with pain
spencer_richlin_md_rmact	corg probably
hoping	can you say more about acupluncture and iui/ivf? have read studies that it could be beneficial
corgimommy	When looking at eastern medicine ---What about yoga?
spencer_richlin_md_rmact	hoping we like it, the mechanism is no concretely known it may increase blood flow to the uterus
spencer_richlin_md_rmact	yoga is great, we like our patients to chose yoga, accupuncture, excercise or late night walks during stimulation
hoping	thanks
corgimommy	What about herbal tea like raspberry leaf to stimulate lining? Or this is a shame?
spencer_richlin_md_rmact	corg i don't know about this tea
corgimommy	How many of your pcos patients conceive? How much of a factor does age play?
spencer_richlin_md_rmact	corg many concieve when stimulated properly, age is important because as one ages, pregnancy rates decrease
hoping	can you tell me if a laparscopy would be helpful to learn anything else that is causing us to not gte PG?
spencer_richlin_md_rmact	corg with pco you want to ovulate, this is the bottom line
hoping	there's been times i've watned to take off work with stims, a wimp? or could the rest be helpful?
honeybumblebee	what helps best with ovulation with pco
corgimommy	Thanks! I have been ovulating on 50mg of clomid 3x and now on my own and still no pregnancy!
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spencer_richlin_md_rmact	hoping all laparoscopy can tell you is if the ovary and tube have a good relationship for egg pickup, and if there is any endo or scar tissue, based on this info, pregnancy rates can be calculated
spencer_richlin_md_rmact	honey, clomid and glucophage and excercise, or femara, if these don;t work, injectibles
deb	Thanks for signing on to our session tonight, nywebchic. Feel free to ask Dr. Richlin your questions on infertility evaluation and treatment.
spencer_richlin_md_rmact	corg, do 1-2 more cycles and then possibly ivf
corgimommy	What are the symptoms of endo? Can you have no symptoms and have endo?
spencer_richlin_md_rmact	hoping during surgery the surgeon can normalize the pelvis
honeybumblebee	THANKS SO MUCH DR FOR ALL YOUR HELP. WILL REVIEW TREATMENT OPTIONS WITH MY DR
spencer_richlin_md_rmact	corg pelvic pain, dyspareunia, dysmenorrhea, pain during bowel mvmts
honeybumblebee	GOOD LUCK TO EVERYONE
spencer_richlin_md_rmact	corg most of time people have symptoms
Alia	Yes, good luck to everyone. Thank you.
nywebchic	my husband recently had semen analysis.. how is interpreted ? His total sperm count is: 9.1M, motility 22% and morphology 40%
corgimommy	What about testing for sperm antibodies?
spencer_richlin_md_rmact	nyw count is less then 20 mill, his motility is less than 50%, his morph is ok, has he repeated it
nywebchic	no
corgimommy	How many days post ovulation do you recommend before taking a urine home preg test?
spencer_richlin_md_rmact	he should repeat it, and if still same should see a repro urologist
spencer_richlin_md_rmact	corg how is his sperm motility
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corgimommy	WNL
spencer_richlin_md_rmact	corg post ovul try test 14 days after
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hoping	would the urologist be able to do those tests for sperm? we've only had the counts, not the quality info
spencer_richlin_md_rmact	corg if you do ivf they don't matter
corgimommy	Do you think the conception rate increases after a HSG?
corgimommy	Would that be the same for IUI?
spencer_richlin_md_rmact	hoping yes, you need a complete SA
nywebchic	i have been able to get pregnant, unfortunately one chromosomal abnormality and miscarriage., my age is 41..that combined with husband's low count, can you say we should go the IVF route ?
spencer_richlin_md_rmact	iui's we base on follicle size on ultrasound, whrn they are 20 we trigger and do iui next 2 days
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hoping	would going to the 150 clomid make any difference if i was responding on 100?
spencer_richlin_md_rmact	nyw do ivf and have your dr explain ivf/pgd
corgimommy	Is there any benefit for doing an IUI on a natural cycle?
spencer_richlin_md_rmact	hoping only move to 150 if you didnot ovulate on 100
spencer_richlin_md_rmact	corg probably not
spencer_richlin_md_rmact	nyw have you been evaluated for recurrent pregnancy loss
nywebchic	no not yet.. what do i need to do ?
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spencer_richlin_md_rmact	nyw chromosomes and a day 3 fsh for starters
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nywebchic	chromosomes ?
corgimommy	Why do women with pcos miscarry more than the normal population?
spencer_richlin_md_rmact	nyw your and your husbands via a blood test
nywebchic	what are we checking for ?
spencer_richlin_md_rmact	corg pco miscarry very complicated
spencer_richlin_md_rmact	nyw a balanced chromosomal translocation
hoping	if we had 4-6 eggs, still possible for retrieval?
leanne	does metformin helps to regulate menstruation
spencer_richlin_md_rmact	nyw these are very rare but bring it up to your dr
spencer_richlin_md_rmact	leanne it can
spencer_richlin_md_rmact	leanne in 30-40% of pts it can alone induce ovulation
leanne	thanks spencer
deb	Thanks for chiming in, tcreed, leanne and kimcristo. We have about seven minutes left with Dr. Spencer Richlin.
corgimommy	Dr. Richlin, Thank you so much for all of your help in answering my questions tonight. Infertility stinks but it is very helpful to have resources like this in addition to our own docs!!!!!
hoping	thanks so very much Dr Richlin
spencer_richlin_md_rmact	corg keep on going, great questions
nywebchic	i am seeing regular obgyn...should i be seeing another type of dr ?
deb	I want to thank Dr. Richlin again for his participation tonight. He has been furiously typing to keep up with your questions.
spencer_richlin_md_rmact	nyw see an rei for reproduction issues
nywebchic	thanks
spencer_richlin_md_rmact	hoping great questions
corgimommy	Good luck to everyone!!
spencer_richlin_md_rmact	corg good luck
deb	As a reminder, if you are not already a member of The American Fertility Association, this is a great time to join. Just go to www.theafa.org and join as a 'no barriers' member-its free and its chocked full of great resources and information.
leanne	good luck to you too
deb	Dr. Richlin, do you have any closing remarks and can you share your contact information so that folks can get more information or get a hold of you if they want to?
nywebchic	would vitamins help sperm count and motility ?
kimcristo	Dr. R, what do you think of a "Natural Cycle of IVF" for a woman over 35?
spencer_richlin_md_rmact	Everyone keep up the great work, spencer richlin md 203-750-7400, RMA CT
spencer_richlin_md_rmact	nyw probably not
nywebchic	proxeed , fertiliaid
leanne	Dr. R what do you think about fertilityblend
spencer_richlin_md_rmact	kim i would not do a nat iui cycle, would rather a stim cycle to get more eggs retrieved
spencer_richlin_md_rmact	these vitamins probably do not substantially increase rates
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deb	We really are out of time. We respect all of your time committments and we begin and end our sessions on time.
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deb	Thanks again for tuning in. We will see you all next week: same time and place!
spencer_richlin_md_rmact	tahnk you
nywebchic	waht does pgd detect and not detect ?
nywebchic	oops
deb	Dr. Richlin, you were fabulous. Thanks so much.
spencer_richlin_md_rmact	thank you
nywebchic	thank you ..

disconnect or you might get stuck..
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