Journey to Fertility by Mediaplanet_USA

MARCH 2020 | FUTUREOFPERSONALHEALTH.COM

An Independent Supplement by Mediaplanet to USA Today

THE FERTILITY JOURNEY

Anna Victoria

The Fit Body app founder and fıtness influencer opens up about her IVF treatment

Discover the questions, fears, and answers about egg donation and surrogacy How Future Family is taking a new approach to fınancing IVF and other infertility treatments

your fertility story at RMA.

See back cover for more information, or visit RMAnetwork.com.

How to Navigate Financial Risk of Assisted Reproductive Technology The road to parenthood does not look the same to all people. Whether you are navigating infertility or using an egg donor and a gestational carrier, you begin to map out your journey to parenthood. One of the most important aspects is to understand the financial implications of your choices and the tools available to minimize the financial risk through insurance and cost-saving methods. Before starting the journey, work with a broker who specializes in assisted reproductive technology (ART) to ensure insurance policies you are considering cover infertility and/or surrogacy. Some policies contain exclusions; it is best practice to review your policy and others available through the market when your journey is merely an idea. If using donor eggs, sperm, or a gestational carrier, make sure the insurance requirements are met according to your contractual obligations. Providing your ART insurance broker with those obligations maximizes your financial safety, as more than one type of insurance may be needed to insure all open contractual risks. n Virginia Hart, ART Insurance Broker

Access to Fertility Care Should Be a Basic Right Simply and precisely stated, far too few patients in the United States can access the infertility care that they need.

Dr. Catherine Racowsky President, American Society for Reproductive Medicine

While exact numbers are difficult to find, we know that too many Americans lack good, comprehensive health insurance, and that far too many health insurance policies fail to provide coverage for infertility treatments. Covering infertility We can debate why this happened, but surely, we can all agree that this is wrong. The purpose of

health insurance is to allow patients to get care when they are sick. Yet for some reason, too many insurance companies and the employers who purchase employee health insurance coverage feel they can exclude coverage for the disease of infertility. I hear over and over again from my colleagues in the American Society for Reproductive Medicine (ASRM) how frustrating it is to see patients, diagnose their infertility, and recommend treatment, only then to discover that they donâ&#x20AC;&#x2122;t have insurance coverage. Some patients are able to save or borrow so they can afford their care; many, however, are forced to forgo care and give up their dreams of having children.

Changing the insurance landscape Working with our colleagues around the country, ASRM has been pursuing laws in those states that will require insurance plans to include infertility coverage. But even now, only 17 states have any laws relating to infertility care coverage, and many are not sufficiently comprehensive to be helpful to patients. I urge everyone to find out if your state has a law requiring coverage. If it does not, contact your state legislator and demand it. Even better, contact your member of Congress and ask that insurance discrimination against those with infertility be stopped. Together, we can make this happen. n

Publisher Chloe Addleson Business Developer Joelle Hernandez Managing Director Luciana Olson Lead Designer Tiffany Pryor Designer Kayla Mendez Lead Editor Mina Fanous Copy Editor Sydney Scott Director of Sales Stephanie King Director of Product Faye Godfrey Cover Photo Sarah Orbanic All photos are credited to Getty Images unless otherwise specified. This section was created by Mediaplanet and did not involve USA Today. FOLLOW US: @MEDIAPLANETUSA

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Personal trainer Anna Victoria never imagined she’d have trouble conceiving, and found her fertility journey challenging but ultimately rewarding. Anna Victoria, a personal trainer and creator of the Fit Body app, had been told all her life that she would be a “Fertile Myrtle.” “I am one of seven children, and all of us were conceived naturally,” Victoria said. “I had never heard of anyone in my family having issues conceiving, so for my entire life I thought that once I was ready to conceive, it would be like flipping a light switch.” Conceiving proved more difficult for Victoria than she had imagined, but she is using her online platform to discuss fertility and IVF treatments openly. Attempting natural conception Victoria first began trying to get pregnant with her husband in January 2018. “I’d been on birth control since I was 17 years old,” Victoria said, “so I never had to pay attention to my cycle. I didn’t know anything, and to this day it blows my mind being almost a 30-year-old woman how little I knew about my cycle.” Victoria began tracking her ovulation using apps and ovulation predictor kits and was hopeful about

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the outcome. “Coincidentally, my best friend starting trying at the same time, and she got pregnant the first month,” Victoria said. “I was like, ‘I’m going to be right behind you.’” A year went by without any progress, which is when Victoria and her husband first visited the Southern California Reproductive Center. They ran many tests but nothing seemed to indicate why Victoria should be having trouble conceiving — everything looked “perfect.” “That is the word that is so frustrating to hear when you’re trying to conceive and it’s not working,” Victoria said. “On one hand, it’s good because there’s nothing severely wrong, like endometriosis, for example, but on the other hand, when you can get those diagnoses at least you know what to treat. It’s kind of a double-edged sword.” In vitro fertilization Victoria and her husband decided then to try IVF treatments. “The egg retrieval is step No. 1,” Victoria said. “In a normal cycle, a woman produces one egg at the beginning of the month. During IVF treatment you’re doing about three to four injections a day to stimulate your ovaries with the end goal of

PHOTO: BRE THURSTON PHOTOGRAPHY

Anna Victoria Opens Up About Her IVF Treatment

ideally producing 15 eggs. I produced 25.” This is done in order for the best chances of securing a golden egg: one to two eggs of the highest quality that have also passed genetic testing and other screenings. Egg retrieval can be one of the most painful phases of IVF, depending on how many eggs are removed. “I really underestimated the pain,” Victoria said. “I think you can’t fully comprehend what your body goes through until you go through it.” The hardest part After inseminating the eggs and replacing them, the hardest part for Victoria was waiting. About 10 days after her IVF treatment, Victoria took a pregnancy test.

“They tell you not to,” she said, “but I couldn’t wait to find out. After two years of squinting at negative pregnancy tests hoping to see the faintest line, I was not expecting to see a positive. I did not need to squint. It was right there.” Victoria encourages women also considering IVF to speak openly about their experiences. “It doesn’t always go the way that you hoped it would, and at the end of the day, you just have to accept that this is your journey,” she said. For women like Victoria who have experienced difficulty with their fertility, Victoria said, “This is just a season in your life; it’s not going to last forever. Go easy on yourself.” n Ross Elliott

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The journey to parenthood is not always easy. If you are struggling to build your family, WINFertility is here to help. For more than 20 years, WIN has been managing family-building benefits through: • Clinical patient & partner advocacy • Access to top doctors • Increased pregnancy outcomes • Fertility management • Medical treatment education • Health plan & Rx integration • Reproductive genetics • Fertility preservation • Adoption & Surrogacy • Lowest cycle costs Speak with your employer today to see if one of WIN’s familybuilding benefit solutions is part of your employer-sponsored benefits package. If you are not being provided employer-sponsored fertility benefits, contact WIN directly and we can explain how we can help. Visit www.winfertility.com to start your journey today.

JOIN US AT THESE FERTILITY CONFERENCES

Navigating the Third-Party Parenting Rabbit Hole

Midwest Reproductive Symposium June 3-6, 2020 Chicago, IL

The IVF Talks June 13, 2020 Los Angeles, CA

American Fertility Expo August 1, 2020 Pasadena, CA

Moms in the Making October 2-3, 2020 Dallas, TX

ASRM Scientific Congress & Expo October 17-21, 2020 Portland, OR

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For parents new to thirdparty parenting, the process can feel overwhelming and isolating. But using an egg donor or surrogate can be just as rewarding as traditional parenthood. Let’s face it — unless you are a same-sex couple, single person, or born with a genetic anomaly, when you are told you need an egg donor or a gestational surrogate to complete your dream of having a baby, it hits pretty hard. There are so many unknowns, questions, and fears. The truth is, you already feel completely out of control; sometimes, this blow can put you over the edge. This is where I come in. With over 25 years of thirdparty parenting experience as the owner of an agency, I help try and assuage those concerns. I am not suggesting proceeding with blind faith and naïveté, by any means. In fact, quite the opposite. It is time to take back

control of your fertility, and the only way to do that is by becoming informed. Knowledge equals power Ask questions, trust your gut, and don’t be disillusioned if you must go through a few trials and tribulations to reach the end goal. Remember, it takes a village, and it is all about finding that perfect team to support you on your journey to parenthood. There are numerous agencies. I encourage you to interview several and make sure you ask every question you can. Find out if you have a specific case manager and how accessible that person will be as you navigate this process. Inquire about all the fees and when they are to be paid, so there are no surprises. Third-party parenting advice A word of caution: try to refrain from reading too many horror stories on the internet. I don’t know why

it is that people prefer to go viral with all their negative experiences; it’s like going on an Easter egg hunt to find the positive ones. Contrary to popular belief, there are egg donors and surrogates with truly altruistic motives who are not just doing it for the money. If egg donation is the path you are on, it is important to keep in mind, with the DNA advances in technology, the idea of an anonymous egg donor is almost obsolete. Therefore, the notion of not telling your child is something that needs to be given quite a bit of consideration, as it is very possible your child will find out on their own. Then what? Always remember, your goal and dream is to have a healthy baby. DNA is just a genetic blueprint, and there is a reason most women don’t remember their labor. Neither makes you a parent. n Rozanne Sher, Owner, Footsteps to Family; Founder, The IVF Talks

How One Company Is Solving the Cost and Complexity of IVF Sabrina, pictured with her daughter, Brooklyn. Photo: Drew Bird Photography

SPONSORED

Everyone deserves a chance to create the family they want. That’s the message from a company helping women and their partners to understand fertility treatments. Over 6 million women in the United States struggle with infertility, not being able to get pregnant after at least a year of trying to conceive. Many women turn to fertility care such as egg freezing and in vitro fertilization (IVF) to someday make their dreams of parenthood a reality. Future Family is helping ease some of the major stresses of that fertility journey. Claire Tomkins started

the company after her own experience with IVF. She’s now CEO of the company, as well as a mother to three children conceived via IVF. “That experience of going through IVF was incredibly eye-opening. It was a very diffıcult journey,” she says. “It’s a complex and costly experience, and I think those are really the two barriers that we see and we set out to solve with Future Family.” Designed for you The average cost of IVF in the United States is between $10,000 and $15,000. That price tag can be intimidating. “People feel like they can’t afford to go forward with fertility treatments. It’s a big fınancial commitment,” says Tomkins. “And then they also feel overwhelmed by the idea of having to manage a complex healthcare

journey. Our vision of access is to make it easy to pay for and afford fertility care, and to reduce the complexity creating a level of support and convenience.” Future Family has an exclusive fınancing program offering low interest rates. Members can design their own loan plans to cover everything from clinic costs to medications. Next, they can set up the plan to span 2-7 years with low monthly payments and no prepayment penalties. The plans start around at $250/month simplifying all of the different costs into one easy monthly payment. The company offers a variety of memberships for individuals and couples who are in different parts of the process, including memberships for those trying to conceive, those ready for IVF, and

others who want to freeze their eggs. Because Future Family was built by a team that experienced IVF fırst-hand, the plans also include not only fınancing, but sessions with a dedicated fertility coach, who is a registered nurse with years of fertility healthcare experience. Fertility coach Nicole Fry loves getting to bond with her clients and answering questions they may have. She is available by phone, text, Skype, and chat. “Trust in your team, and realize that everything your fertility center, your doctors, your nurses, and your coaches are doing for you, is specifıcally designed for you,” Fry says. A chance to grow One Texas couple, Sabrina and Robby, used Future Family to help them through IVF. When Sabrina and her

husband had trouble getting pregnant, they went to a fertility clinic and decided on IVF. They found Future Family from an ad on Facebook and liked the idea of making monthly payments for their treatments instead of spending a lot of money at once. Sabrina and Robby enjoyed working with the fertility coach, who answered all of their questions. They also appreciated how the company handled the bill pay with the clinic, leaving the couple time and space to be able to focus on their pregnancy. “In that hospital room, I watched love multiply immediately to become a family of four from a family of three,” Sabrina said regarding the birth of her daughter, Brooklyn. “It felt so right. ■ Kristen Castillo MEDIAPLANET • 7

How to Find Your Fertile Window

While trying to conceive, you need to make sure you’re trying at the right time under the right circumstances. Your fertile window refers to the most fertile days in your menstrual cycle, when you have the highest chance of conceiving. A normal menstrual cycle is 28 days, with your fertile window calculated around ovulation. However, very few women have a regular 28-day cycle or ovulate on cycle day 14. To calculate your fertile window, it’s essential to know the day that you ovulate during your unique cycle. This can be done through ovulation strips, monitoring cervical mucus, or using an ovulation monitor. Using a device that tracks core body temperature offers a greater level of accuracy, as it’s less susceptible to external fluctuations. Tracking slight fluctuations in core body temperature that happen during ovulation allows you to see your unique ovulation date and fertile window. n Kate Davies, RN, BSc (Hons), FP Cert.

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Male Factor Infertility: Causes, Screenings, and Treatments Male factor problems as a contributing cause of infertility are very common — up to 30-50 percent of infertility cases.

vasectomies) or spinal cord injuries resulting in damage to nerves that innervate the testicle and male reproductive tract.

Many fertility specialists will recommend a semen analysis as one of the very first tests that should be done. It is relatively simple and inexpensive, and yields much information. The two main causes of male infertility can be divided into problems in manufacturing sperm or problems in getting sperm outside of the body (ejaculation of viable sperm). Sperm manufacturing problems can reside in the testicle or from signaling problems from the brain to the testicle. Problems in ejaculation of sperm can arise from obstruction of the ducts that carry sperm to the outside (such as previous

Screening for infertility The initial work-up for sperm problems should include a comprehensive semen analysis which will evaluate the semen against fertility standards. These include the volume of the ejaculate, concentration of sperm, motility, and morphology. These tests will assist in determining if the problem lies in the proper signaling of the testicle from the brain in order to manufacture sperm. Additional evaluations, including but not limited to blood karyotyping, will further assist in determining if there is a chromosomal or genetic abnormality in the male causing lack of sperm manufacturing.

Once these are ruled out, then issues of obstruction must be considered. After a thorough history and physical exam, a urologist might perform an ultrasound of the testicle, a dye test (vasogram) of the male reproductive tract, and possibly a biopsy of the testicle. Treatment options There are various potential treatments of male factor infertility, including hormonal treatments to try and improve production of sperm to ligation of veins that feed the testicles (varicocelectomy); the performance of intrauterine insemination (IUI); and in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). In severe cases, it might be necessary to biopsy the testicle, a procedure called testicular sperm extraction (TESE). The biopsied sperm cells can then be injected in to eggs to attempt fertilization. This procedure can diagnose as well as treat severe male factor cases. Some cases of male factor infertility are beyond using the male partner’s sperm, and in such cases, there is still hope by using donor sperm. The use of donor sperm is safe and effective. n Dr. Geoffrey Sher, Owner, Sher Fertility Solutions

5 Ways to Boost Your Fertility With Nutrition People can use nutrition to boost their chances of conception. Have you been told that your genes may lower your chances of conception? I heard that myself — and now I have two beautiful daughters. Current research says that while your genes “load the gun,” it’s your lifestyle that pulls the trigger. Diet and lifestyle changes can normalize hormones and optimize fertility, helping you strike the Goldilocks hormonal balance — not too much, not too little, just right. You may feel like you don’t have control of your hormones — but you do! Using food as medicine can put your fertility into your own hands. Here are five steps to harmonize hormones and improve fertility.

Eat to ovulate To make progesterone, you must ovulate. Enough calories from real foods will let your body know it’s safe

to conceive: high-quality protein, good fats, and yes, carbohydrates in their real, whole form: beans, rice, oats, squash, etc. Eat important micronutrients for ovulation including iodine (seafood) and zinc (meat or pumpkin seeds).

Have a carb strategy Carbs have a bad rap these days. However, they are important macronutrients for fertility. Instead of talking about if carbs are good or bad, let’s discuss quality of carbs. Make half your plate non-starchy carbs (lettuce, radish, broccoli, bell peppers, etc.) and a quarter of your plate starchy carbs (winter squashes, whole grains such as oats, or legumes such as black beans).

Supplement to procreate All prenatal vitamins contain folate. But not all folates are created equally. Look for the methylated form of folate (methylfolate).

Folate means “foliage,” so eat leafy greens such as kale, bok choy, Swiss chard, spinach, and dandelion or beet greens.

Reduce stress Worrying about the perfect diet for fertility ironically raises stress hormones such as cortisol and adrenaline, which disrupt the hormonal balance you need for optimal fertility.

Detox your kitchen Toxins associated with infertility and birth defects are everywhere (clothing, furniture, nonstick cookware, etc.). Use cast iron or stainless steel and munch on broccoli to help your body detox. When you think about it, it’s actually quite simple to eat your way to fertility, one bite at a time. When we do the things we can control and let go of the ones we can’t, the body responds beautifully. n Lizzy Swick, MS, RDN, Consultant, Lizzy Swick Nutrition

Healthy Pregnancy for Every Body Plus-size women can ensure successful pregnancies with the help of the initiative Healthy Pregnancy for Every Body. Healthy Pregnancy for Every Body, from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) at the National Institutes of Health, educates plus-size pregnant women and healthcare providers about the importance of working together for a healthy pregnancy. The initiative provides tools and resources for plus-size pregnant women and providers to use together. Taking charge of your pregnancy The NICHD’s National Child & Maternal Health Education Program and its Pregnancy for Every Body initiative wants plus-size women to feel empowered and knowledgeable about their pregnancies. Every woman should be confident that they are equal partners with their providers in their prenatal care. Research shows that pregnant women who are obese or overweight are at higher risk for pregnancy and childbirth complications, including gestational diabetes, preeclampsia, preterm birth, miscarriage, stillbirth, and surgical or cesarean section delivery. A team effort Healthy pregnancies for plus-size women do not happen alone: women and healthcare providers need to work together to ensure the best outcomes. But many women who are overweight or obese delay or avoid prenatal care because they don’t want to be shamed or judged. That’s why Pregnancy for Every Body offers healthcare providers ideas for discussing weight and pregnancy in a sensitive and respectful way, and tips for supporting plus-size women before, during, and after pregnancy. n Triesta Fowler, M.D., Medical Officer, NICHD MEDIAPLANET • 9

Helping Expectant Women Make Informed Decisions About Labor and Delivery SPONSORED

While you won’t necessarily know when labor will happen, you can prepare for it. Although it’s not required, creating a birth plan can be a helpful tool for women to understand labor and delivery options. Rebecca C. Garrett-Brown, a certifıed nurse-midwife for 29 years, encourages pregnant women and their partners to take a childbirth class at their hospital to learn about labor and ask questions. The stages of labor During the fırst stage of labor, the cervix will dilate and soften, known as effacement, in preparation for a vaginal delivery. Full dilation is approximately 10 centimeters. Ask when laboring women should go to the hospital — many hospitals 10 • FUTUREOFPERSONALHEALTH.COM

won’t admit a woman until her water has broken and/or she’s in active labor, dilated at least 3 centimeters, and effaced. Ask about pain management. For a natural birth without meds, women use controlled breathing, relaxation and body positioning, such as counter back pressure and hip squeezes. An epidural is another option. An expectant mother can learn labor strategies, too, like how moving around — sitting on a bouncy ball, taking a shower — can help labor advance naturally. Some hospitals have volunteer doulas, trained professionals who can guide and assist women through labor. Labor can be long. Garrett-Brown says on average, a fırsttime mother will be in labor for 16 hours. “Labor is kind of like running a marathon,” says Garrett-Brown, who works at UC San Diego Health Systems. “You need calories.” She suggests snacking lightly, such as eating peanut butter, sucking on popsicles, and drinking clear liquids.

According to Garrett-Brown, while full term is considered 40 weeks, some women don’t naturally go into labor until 41 or 42 weeks. In those instances, there may be increased maternal risk for diffıcult labor, postpartum hemorrhage, or infection. The risks for babies after 41 weeks can include stillbirth, placental disorders, delayed fetal growth, and umbilical cord complications. Planned elective induction One in 4 women have their labor induced. It used to be that only high-risk pregnancies were induced. Nowadays more doctors are inducing mothers-to-be at 39 weeks. This planned elective induction could improve maternal outcomes. A medical study, known as the ARRIVE Trial, compared 3,062 women, who had their labor induced at 39 weeks, with 3,044 women, who were not induced and delivered via spontaneous labor. The study was designed to evaluate a range of safety outcomes in the newborn. Although the study did not show differences

in these outcomes, there was a signifıcant difference in cesarean delivery (C-section) between the two groups. Importantly, the induction group had a lower rate (18.6 percent) of C-section, compared to the women who were not induced, (22.2 percent). Also, maternal pregnancy-related high blood pressure problems were lower in the induction group. “From a practical perspective, less C-sections, less maternal complications, and a hint at probably less neonatal complications. From my perspective, those are exciting results that would lead us to do more deliveries in 39 weeks, rather than continuing pregnancies beyond that point,” says Dr. Rodney K. Edwards, the director of obstetrics at The Children’s Hospital at OU Medical Center and professor and section chief at the University of Oklahoma College of Medicine. C-sections are considered major surgery and can have complications, including blood clots, hemorrhaging, infections, and more. Babies born by C-section may also have breathing problems. During induction, if a woman’s cervix isn’t dilating fast enough, a doctor may use a medication to speed it up. A time-released medication may help a woman’s cervix gradually soften, thin, and dilate, making it easier for the baby to be born. Once the cervix dilates, the rest of the labor and delivery process is standard. Get ready Every woman’s labor is different. Throughout the pregnancy, it’s important for pregnant women to talk with their doctor and ask questions. Expectant mothers can start thinking about labor and delivery during the second trimester. It’s a starting point that can make everyone involved feel in-the-know and ready for the upcoming birth. ■ Kristen Castillo

Is a Freestanding Birth Center Right for You? While the majority of babies in the United States are born in hospitals, there is another option for women who wish to birth in a homelike setting but desire many of the resources and safeguards of a hospital: freestanding birth centers.

The Importance of Prenatal Care for Maternal and Infant Health As a public health and primary care physician, I find it troubling that across our nation, virtually every measure of the health of pregnant women, new mothers, and infants is going in the wrong direction. According to the latest statistics, about 1 in 10 babies is born too soon (before 37 weeks of pregnancy) each year. Premature birth and its complications are the largest contributors to death in the first year of life for babies in the United States and the leading cause of death of children under age 5 worldwide. Maternal and infant health The state of maternal health mirrors that of infants born too soon. Every 12 hours in the United States, a woman dies from pregnancy complications. For every maternal death, another 70

Freestanding birth centers are designed for healthy, low-risk women, seeking a natural birth experience under the care of midwives. Birth center midwives practice a wellness and holistic approach to pregnancy, birth, and womenâ&#x20AC;&#x2122;s healthcare that is evidence-based. Advantages of a freestanding birth center

women suffer life-threatening health challenges. These startling statistics make the United States one of the most dangerous places in the developed world to give birth. Historically, maternal and infant health has served as a barometer for civilizations. To save the lives and the health of moms and babies, our nation needs more robust health policies, better access to quality care for women, and greater support for women before, during, and after pregnancy. One way to achieve these goals is by expanding proven programs and innovative solutions such as group prenatal care. The importance of prenatal care The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics state that group

prenatal care can improve the health of pregnant women and babies, reduce prematurity, and provide greater patient satisfaction with their care services. Group prenatal care matches pregnant women with similar due dates together in small groups for prenatal care. Unlike traditional one-on-one care, sessions usually last two hours, during which women receive a physical assessment, share support with each other, and gain knowledge and skills related to pregnancy, childbirth, and parenting. Sessions are typically offered in hospitals or community centers, and participant costs are covered by most insurance and Medicaid in most states. n Rahul Gupta, M.D., MPH, MBA, FACP, Senior Vice President and Chief Medical and Health Officer, March of Dimes

Time-intensive care In a freestanding birth center, midwives take time to answer your questions and respond to your individual needs, giving you confidence in your ability to give birth.

Avoiding a cesarean section The national C-section rate for freestanding birth centers is 6 percent, compared with 32.7 percent for low-risk women in the hospital.

Water birth All freestanding birth centers offer water immersion in labor, and most (93 percent) offer water birth.

Individual attention Personalized, respectful care that balances human touch and technology.

Variety of options for pain management In a freestanding birth center, you have the freedom to find the positions and comfort measures that offer the most relief, including nitrous. n

Amy Johnson-Grass, President, American Association of Birth Centers MEDIAPLANET â&#x20AC;˘ 11

You weren’t meant to be a mom. your fertility story at RMA. Transform your feelings of fear and uncertainty into hope—it all starts with a conversation at Reproductive Medicine Associates. We get to know your unique fertility goals and challenges, combining a personalized approach with industry-leading research to help you start a family.