The episode reveals that Alex has reconnected with his former wife, (Katherine Heigl). After contacting her for a letter of recommendation for Meredith Grey’s medical license trial, Alex discovered that Izzie had used the embryos they froze years ago when she had cancer. She is now living on a farm in Kansas raising their five-year-old twins, Eli and Alexis.

The Grey's Anatomy episode is one of the most divisive in the series' long history, serving as the official farewell to original cast member Alex Karev (Justin Chambers). The episode is unique because Chambers did not appear in person; instead, he provided voiceovers as his character explained his sudden departure through handwritten letters to the people he left behind in Seattle. The Narrative Resolution

Alex decides to leave his life in Seattle—including his wife, Jo Wilson—to be a father to his children, explaining that he wants to give them the stable family life he and Jo never had. He mails four primary letters:

He thanks her for her mentorship and for "literally taking a bullet" for him.

He credits her for making him a better person and acknowledges that she was always her own "person".