Ep 87: Project AIM with Dr. Natan Bar-Chama and Dr. Barrett Cowan
Fertility Forward Episode 87:
Traditionally, infertility has been seen as a woman's issue, to the point where even infertility centers focus predominantly on the female evaluation. But we all know that it takes two to tango: not only does this impact women's mental health in an already stressful situation, but it also doesn't acknowledge the impact that sperm quality has on miscarriages or the health of the child. Today we are joined by two experts who are here to talk about a really exciting initiative called Project AIM, which addresses this issue and brings access and inclusion to men. Returning guest Dr. Natan Bar Chama from RMA, and Dr. Barrett Cowan, a reproductive urologist and the founder of Posterity Health, share with us the really exciting work Project AIM is doing, as well as the advantages of the at-home kit that they have created. We discuss the vast psychological benefits that such telehealth provides, including compassionate and supportive care around an issue that can feel sensitive or shameful for many men. The conversation also covers the importance of simultaneous evaluation at the onset, not only because time is of the essence, but also because it creates a bridge between the couple that supports the mental health of both partners. To discover more about where and how you can get this kit and begin your journey today, tune in, and let's dive in.
Rena: Hi everyone. We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your best advocate.
Rena: I am so excited to welcome to Fertility Forward today two wonderful reproductive urologists. We have Dr. Natan Bar-Chama who is now a recurring guest on the podcast. He is a colleague of mine at RMA. And then we have Dr. Barrett Cowan, a reproductive urologist and founder of Posterity Health. And I am so excited to have them on today to talk about a really, really exciting initiative called Project AIM aim that RMA just joined on to share what this is, and we’ll talk about male factor fertility and how we are going to make this space better. So thank you both so much for coming on.
Dr. Bar-Chama: Our pleasure. Thank you for having us.
Dr. Cowan: Great to be here.
Rena: So let's jump in, I guess first maybe tell us what is Project AIM?
Dr. Cowan: Yeah, so Project AIM is a way of reaching out to the public and also to OBGYNs and other fertility specialists to really get more males involved in the fertility process. You know, for traditionally fertility centers have been really female fertility centers and RMA has been really forward looking in that they realize that, you know, it takes two to tango. And so what Project AIM is, is a way of saying, Hey, let's get the male more involved. AIM stands for access and inclusion of the male. And so we really want to get the male evaluation and treatment involved in this process to remove some of the burden that's really being shouldered by women in this process.
Dr. Bar-Chama: Exactly. I think that, you know, it's important to always highlight that infertility is very common. It affects one to eight or one to six couples who try to have a child. And that when you look at, you know, the cause of infertility, the male is a contributing factor in close to 50% of cases. And so that we now know or appreciate that we should be evaluating both the male and the female simultaneously in parallel from the get go. And so what Project AIM and Prosperity are focused on is to make this process more accessible and easier to do.
Rena: Okay. So for those of us in the field, we know the stats, right? We know that it's, you know, one third female, one third male, and then one third unexplained for infertility. I think a lot of times people go into this and I always dissuade people from using the terminology ‘fault’. A lot of people say, oh, it's his fault or it's her fault. And I always work with patients on not saying, it's nobody's fault, it's a disease. But it seems like across the board, it is very common in our field to do, you know, this whole workup on the women first and then later, okay, let's look to the male. And so it sounds like, you know, what you've developed seems to be such a no-brainer. Why wouldn't you simultaneously test the male and female together?
Dr. Cowan: That's a, that's really a great point. And to me, infertility is not a male issue. It's not a female issue. It's a couple's issue. And so the ability to evaluate both partners simultaneously is such a great thing. And not only is it, it really creates this so the couples are together in this journey, but it also is a much more efficient way of achieving their goal. So if the woman gets evaluated first and then the male partner doesn't get evaluated for a year or more, that's really wasting a lot of time. In the meantime, the female’s ovarian reserve or really egg reserve is potentially decreasing with time. So there's a time factor as well. And so we really wanna make this as much more efficient so the couple can conceive as easily and as quickly as possible.
Dr. Bar-Chama: Yeah. Exactly correct. The guidelines that were laid out by both ASRM and the AUA last year are game changers in that there should not be a sequential evaluation. That it should be in parallel. And now what we need to appreciate is that men still have a reluctance to go to an office, to take time off from work, to assess, you know, their fertility status which may be very sensitive and related to their ego. And what we're trying to do is learn from the experience that we've had over the last two, three years with this horrific pandemic, is that telehealth and telemedicine is here to stay. And we need to bring that into the fertility arena, especially with male factor evaluations that we can do the two things that need to be done to assess the male. And that is a semen analysis and an interpretation of that by an expert, as well as a reproductive history. And that can all be done from the safety and comfort of one's home and should be done in the beginning of one's attempt to establish a family.
Rena: So you've created something that, it's an at home test kit, correct? So a male can provide a sample at home, send it in and then do get the results, via telehealth?
Dr. Cowan: Yeah, it's really interesting because, you know, traditionally when a couple's having a hard time conceiving or considering conception, the woman will go to her OBGYN and say, Hey, I need some help, or evaluate me, or something's wrong with me. And that may or may not be the case quite honestly, because again, as Natan mentioned, half the time that it's due to a male factor. But in addition, the fact is, is that, you know, going to a lab to collect a same analysis, many males have found it to be kind of an awkward at best situation. And so not only is it taking time off from work and, you know, trying to find a place to park or taking the subway across town, but doing able to do this at home and collect this sample at home and get the results is really, really efficient. What we find also is that many OBGYNs are just not well equipped to handle dealing with an semen analysis because it's not in their area of comfort, you know, they're experts on female fertility care. So when they're asked to really address an abnormal semen analysis, it turns out to be not a good experience for them and, and frequently not a good experience for the male patient as well. So we say, Hey, we'll take on this responsibility so that we can communicate accurately what the results are, what the implications are and what can be done to do it. And it's all done from the privacy and comfort of their home. So the patients don't have to wait in a waiting room. They're have to do it really in a very private situation setting.
Dr. Bar-Chama: It's a convergence of multiple events. One is that the technology to collect at home and ship it, it is now stable and proven. Five years ago that technology didn't exist. Two is the acceptance and security of telehealth. And if you put those two together, you are basically bringing to the patient, to the male, to the couple, the assessment of the male early on in the process. And, and it's, there's nothing more painful than having a couple who've been told by the physicians - go try and everything looks fine and they come back six months or a year later and you know, that better than we do that, the psychological stress and the anxiety of having spent six to 12 months trying is very different then when you're starting, you know, the process and you're getting information that helps you guide and make the decisions that are personalized and informative and specific to your case. Now, how many times do we have, you know, men with no sperm at all, that is from a genetic reason or cause that to see us for an evaluation after a year, a year and a half of trying when that time was just unfortunately wasted. And time is of the essence, you know, you know, we can utilize advanced technologies to overcome low sperm concentration, right? We have the technology of injecting a sperm into an egg. We can do IVF. We have, you know, we can assess the embryos. But one thing we cannot do is make eggs younger. So we always, even as male factor experts, our priority is to expedite, you know, the process of having a child and that is foremost, making sure that the data is reliable and that the time that we have available to us is used efficiently.
Dr. Cowan: Absolutely agree with Natan. And I would add to that, that look, male fertility is not an issue of virality or masculinity. It's a medical issue and let's address it in a very compassionate and caring, supportive environment.
Rena: Well, I'm so glad you said that Dr. Cowan, because I think so many men, you know, there's so much shame associated with this. There's, you know, shame for both men and women in this process. But I would say, I definitely see it probably exacerbated with males. And so I think, you know, as we've sort of, we've mentioned here, you know, it's a disease, it's not a choice. It's not somebody's fault. It just is. And I think knowledge is power. And I think that, you know, you've done something incredibly smart, you know, just how the pandemic has really changed the mental health field. You know, you're recognizing it's changed healthcare in general and the advent of telehealth and letting people see doctors efficiently from the privacy of their home is, it's incredible that we're able to do that.
Dr. Bar-Chama: You, Rena, have described it, how powerful telehealth is in the mental health arena. We as physicians have similar experiences and fertility is often seen by a couple as a month to month experience. Okay, this month I tried - it failed. Okay, I'm gonna try again and again. And what we're trying to say is if you get the facts upfront and create a plan that's a little long term. And, and if you fail, you know, in the first month, what are you gonna do the second month to increase your chances? It's very powerful and important to do that sooner than later.
Dr. Cowan You know, many couples these days have the desire and the ability to do genetic screening before they try to start the conception process. And so it’s part of their preconception thought process. They'll say, Hey, let's make sure there's no genetic basis that it's going to impact potential offspring. And at that same time, it's very reasonable to assess the male's fertility status because it's inexpensive, we've made it incredibly convenient and so we know upfront whether it is an issue or not, and we can address it if necessary. And we find that about 70% of the time, we can actually improve a male's fertility status if there is an issue. In addition about 10% of the time, when there is a male fertility factor, there's an associated health issue that's presenting as fertility, whether it's testicular tumor, pituitary tumors or a significant hormonal imbalance that can be addressed as well. And so, while we're both Natan and I are male fertility specialists, we're physicians first, and we really wanna make sure that the patients are being cared for because frequently males in this age group, the last doctor they saw was their pediatrician. Many of 'em just don't go to the doctor. They feel almost, you know, imortal.
Rena: But I think that's a great point. So is this, so say you're a male and you're, you know, you feel like something's off. Maybe you're not trying to conceive, but you wanna run a test regardless. Do you have to be a patient at a fertility clinic to get this test? Or can you just do the test and see a reproductive urologist or, or urologist just to make sure everything's kind of, you know, as it's supposed to be?
Dr. Cowan: The beauty of this is that you don't have to be a patient at a fertility center. We're reaching out to the public at large and ironically, most urologists don't have the interest or the expertise to be able to handle fertility issues. It's really people who are well trained and experienced in fertility management, which is reproductive urologists like Natan or myself. And so we're saying, Hey, we're happy to work with you. Let's assess you. We're happy to take care of you and really help you along this process in make sure there's nothing else going on as well.
Dr. Bar-Chama: And I think also it's important if one is planning for the future to realize that there are things that one can do to optimize one's fertility, right? We now know that nutrition and environmental exposure and lifestyle choices, drug usage, excessive alcohol, all these have an impact on male fertility potential. And that we know that this is modifiable so that if one wants to get an assessment, this is an efficient way to do that. And then work together with a platform to say, okay, I can lose weight. I can, you know, optimize my lifestyle and repeat the test in three to six months or two months, you know, and see how I'm doing. And the important message here also is that the impact of sperm quality isn't just manifest in the ability to initiate a pregnancy. It has direct impact on miscarriages as well as the health of the child. So we want to engage in men, get them involved, accept responsibility that their lifestyle and the quality of their sperm has an impact on initiating, maintaining pregnancy as well as the health of their children.
Dr. Cowan: Yeah, it's really interesting, Natan, you're absolutely right. It turns out that, you know, when people are able to get pregnant, either through natural conception or IVF, but are not able to carry the pregnancy to term because of early miscarriages or they've had multiple IVF cycle failures that most people kind of assume that it's the female factor that's causing this whereas really half the time, there's a male factor and all too frequently, the male doesn't get evaluated in those situations. So we offer what we call a recurrent pregnancy loss or RPL consult for people on the male side who have been going through this experience as a couple as well. And we find we're able to really help people. I just really, interestingly, this weekend, I got a text from a patient of mine, came to find me from Toronto and said, Barrett, we failed, you know, four IVF cycles. What can we do differently? We know there's some male factor here. And so we end up doing some special treatments on this individual and low and behold, this woman sent me a, a picture of a healthy baby boy. I know it's very obviously very rewarding and I was really thrilled for them for this to occur. But it's real, that male factor absolutely has an impact on not just being able to get pregnant, but on maintaining that pregnancy.
Rena: Well, let's talk a little more about that because I, I know a lot of people listening are gonna hear this people that have had, you know, multiple miscarriages and all too often, I see the female blame herself. And I think this will give them a message of hope. You're saying, okay, recurrent pregnancy loss could be due to male factor, but there are things that you can do to then help your case. So what might some of those modifications be?
Dr. Cowan: Yeah. Some of it is a lifestyle change that Natan mentioned earlier. Sometimes there's anatomic issues that can cause these. And sometimes we find that if someone's going through multiple IVF cycles and failing, then instead of using sperm from the ejaculate then actually doing a fine needle aspiration from the testicle and using sperm obtained directly from the testicle, that can really be helpful as some of the sperm can be damaged during their maturation process down the line. So there's a variety of different things, depending on the individual situation, we really try to individualize the person's care
Rena: And this, and I know we've mentioned this in other podcasts, but maybe if one of you doesn't mind sharing some of those lifestyle modifications to specifically, because I know that's what people wanna hear so they can go do that.
Dr. Bar-Chama: OK. I think common sense is important here. Okay. So what we realize that, and now there's very good scientific data to support that, you know, excessive marijuana usage, environmental toxins, even obesity can have an effect on DNA fragmentation and other changes in sperm DNA changes. And that these changes affect the embryo development, the fertilization rate, as well as potentially having an impact on risk for cancers and diseases in, in the children. So, you know, I think the first step is when there are recurrent pregnancy losses or, and like Barrett, we're often asked to assess the male when the IVF cycles don't go well, when the eggs look or seem to be competent and have good quality and yet the fertilization rate and the embryo development is poor. And I wish we could assess the embryos to determine what is the male component and the female component, but we can't yet. We need to assess the male independently and ask these important questions. What is the DNA fragmentation? What is the carrier type of the male? Are there things that have not been picked up that would be relevant to IVF cycles? What can we do to improve things? And again, losing weight, optimizing lifestyle, whether one, you know, uses testicular sperm or whether one goes ahead and uses microfluidics or special high tech sorting in the lab to get better quality sperm. These are all things that are now being utilized in the forefront of how we practice the state of the art in reproductive medicine.
Dr. Cowan: Rena, what I tell my patients is this, look, if you wanna be a father, listen to your mother and they say, what are you talking about? I say, well, when you're growing up, your mom said, Hey, don't smoke. Don't drink too much. Don't use drugs. Eat right. Don't get overweight. And those are all really important aspects. And so, you know, this may sound over-simplified, but it's actually your, your mom was actually kind of right in a lot of aspects.
Rena: I like that. And I think that gives people a message of hope, you know, and unlike eggs, we know that sperm regenerates. So if you can make lifestyle changes and you can improve sperm quality,
Dr. Bar-Chama: Yes. That's a great point, Rena, that there is opportunity for improvement and optimization on the male side. That is one of the most important features of this platform. Project AIM is here not to just do the test and let the male be on its own. It's just to take the first step, get input, get expertise, get coaching, get information that will optimize their chances, including improving semen quality.
Dr. Cowan: Yeah. In many ways we give patients hope because the reality is is that the majority of patients, we can actually help improve their fertility stats.
Rena: And I love that. And I think that, I mean, hope is what's so necessary in this process. You know, I think as, as we all know, trying to conceive in the fertility process can be brutal physically and emotionally. And so I think you've created something that is really going to improve the process and inspire hope for so many people.
Dr. Bar-Chama: What I think is also important to realize is that just because you've gotten the test doesn't mean that the interpretation of the results are sometimes more complicated in that the access to getting the test done is the first step. But after that is, what do you do with those results? You know, are they normal? Are they widely abnormal? Are they severely abnormal? You know, there are many parameters associated with the semen analysis that makes it a fairly complicated test to an interpret. And that's what we want to try to achieve here as well, is the ability to interpret these results and help make the next step occur sooner than later.
Dr. Cowan: Rena, I mean, it's really interesting, both Natan and I see strictly male patients and yet by taking care of the males, we're actually helping the women who have really been bearing the burden of fertility care for so long. And we're saying, Hey, let's share the burden. Let's help these women out by helping the guys out. And it's really something that all couples really should consider doing.
Rena: Absolutely. And so tell us how it works. So how do you get a kit and then what happens from there? It certainly sounds like these are not results you should interpret on your own or doctor Google. Like you need to work with a real doctor. So how does it work?
Dr. Cowan: The first thing is to order the kit and by going the Project AIM website, which either you as an individual can do or through your OBGYN. And then once the kit is ordered, we'll ship you the kit. If you're doing an at home kit, or you have the other option of doing the, the sample in the RMA clinic. And obviously there's a variety of different clinics of RMA within New York. And then once the results are available, then we set up a telehealth visit to discuss those results and talk about potential options of things that can cause that. But if people really want to know, we can speak in generics on that initial visit. But the reality is, is when Natan and I do is we put people through a very thorough evaluation to figure out really what is best for this individual patient, because there's a variety of different things and factors that can influence a male’ fertility status. And so some of it's lifestyle, some of it's other medical issues, sometimes it's other kind of anatomic issues or physical issues. And so all those aspects are very important to evaluate, to come up with a game plan. And then once we have all that information, we'll say, let's put all our cards on the table. Here's your situation. Here are the treatment options, advantages and disadvantages and let's work together to improve your situation.
Rena: Okay. So I know for women, obviously we talk a lot about fertility preservation and so maybe you're not quite ready to conceive, but you have the option to freeze your eggs, or maybe just do a consult to see if there's any red flags. So, you know, okay, do I need to do anything? Should I, you know, be prepared that I may need fertility treatment in the future. Now, is that something you think applies to men too? You know, so someone who, again, maybe they're not thinking about family building this second, but do you think doing this test and getting this information is advisable before they're ready? Just to know?
Dr. Cowan: No doubt. I mean, knowing one's fertility status is really very important so that you can kind of plan the future. So if, and when you decide to start a family, you're ready for that moment. I think there's several instances where we strongly encourage people to cryopreserve sperm or freeze sperm. And those would obviously be anybody who's of potential reproductive age, who is going to undergo medical treatment for, for chemotherapy or radiation, for example, which can have obviously have a huge impact on sperm production. So some people have already had children or have had, who are considering having vasectomy, wanna keep their options open. And we say, look, those are other people that may wanna conserve sperm. People who are considering gender reassignment is also someone. Before you initiate hormonal or surgical intervention, then maybe you don't wanna start a family right now, but that may be something that becomes very important for you down the road. So consider really cryopreserving sperm. And the final group of patients is, there's no doubt that just as a woman's egg deteriorates with age, although sperm continue to be produced as a male ages, the quality of sperm actually does go down. And so with advanced paternal age, we say there's increased risk of having some children with some genetic issues and sort of saying, look, it's probably appropriate if you're in your late thirties and considering having children a little bit later in life to cryopreserve sperm in advance before there's the deterioration of sperm associated with age.
Rena: OK. I'm so glad you brought that up because I think there's such a broader knowledge. You know, people understand women in fertility and age and, you know, we kind of go by after 35 is usually when our eggs start to decline. Now what would be the age for men, because I think men often think there's no ageism with sperm, but there is,.
Dr. Cowan: There is age associated with sperm deterioration. And typically most of the studies say at age 40, there's a risk for a deterioration in sperm DNA, which doesn't make it impossible to conceive. And doesn't guarantee you of having a child with schizophrenia or autism, but there's a higher risk. And if those of fathers are over 40 years old,
Dr. Bar-Chama: And again, there's absolute risk and relative risk, and certainly men over 40 of fathering, you know, healthy children. And I think what I would say is that age is a variable, but you know, you have men who are really in excellent health in their forties and fifties, and you have men in their twenties who are making very poor choices and their sperm quality is gonna be suboptimal. And the male who’s in his forties is going to be producing a much better quality sample. So it's a component, it's not an independent variable that is isolated. The other thing I would add to what you were asking before is if someone has risk factors, if someone has had undescended testicles, if someone has scrotal surgery, if someone has a family history of male fertility issues, cystic fibrosis or mutations that are associated with that, these are all red flags that might warrant somebody to question their male fertility status early on. So that if there is an issue they can reach out and get help sooner than later.
Rena: Great points, really great points. So I, I think it sounds like the two of you have really created something to help raise awareness, to improve the space. I, and make this a better experience for people, you know, going through this process.
Dr. Bar-Chama: Access is a priority. It's very important to bring, you know, the male, the opportunity to assess and get a reproductive history and to do a semen analysis in the environment that he's most comfortable with. In some cases it's producing a sample in a lab and other cases it's producing it at home and getting it shipped and making it easier, taking advantage of the technologies and the advancements in telehealth that we are now experiencing.
Rena: I mean, I have to say as the resident female on this podcast, I love that you've created this for the male and recognize people, you know, wanna be in the comfort of their own homes and they don't wanna have to, leave work or take the subway or whatever for appointments, but can you create something for women too? I mean, all those monitoring appointments, we don't wanna have to do that either!
Dr. Cowan: That's a great point, but we recognize that, you know, currently women still kind of drive this fertility journey. So, all too frequently, right? And we're saying, Hey, even if you're a woman listening to this podcast and you're interested, you know, encourage your male partner to get evaluated and let's see what we can do to help them, because we, again, ultimately we wanna make this easier and more efficient for the two of you to conceive your child.
Rena: Sure. I love that. You've created something to help both people feel involved. You know, of course I work with many single parent people, family building solo, but for those that are in a hetero couple, I think it is really common for the woman to feel really alone and then the man to feel really alone. And so when I work with couples I help them see how they are in this together, how they are a team, they are going through this individually, but they have the same shared goal. And so I think this is a really wonderful way to show the male and the female too, how important the male is here. And that he's just as much a part of this, you know, as the woman.
Dr. Bar-Chama: Yeah. I think that's a great point is by doing the initial assessment on the male and the female at the onset from the beginning creates a bridge between them. Not just a dynamic between them and the physician, but a dynamic between the couple that is so helpful from a mental health and optimization of care perspective.
Rena: Sure. I mean, right now, you know, I see couples and, you know, they bring up, oh, well, the man feels, you know, like his only role is to go provide a sperm sample and he doesn't feel involved. And then the woman feels like she's doing everything. You know, she's the one going to all the appointments, fielding all the calls, the emails, you know, and I work with them and help them strategize, you know, how to delegate things to the man to do, which is all great. And it can be super helpful, but I think this is even, you know, takes it next level because it's really, you know, having him be involved, providing a sample from the beginning and being involved.
Dr. Cowan: Yeah. Infertility journey can be really stressful in a couple and a lot of couples actually don't survive that process. And our goal is actually to help unite the couple in this process, not separate them and really say, Hey, let's work on this together. Let's pull in the same, I'll pull in the same direction.
Rena: I love that. Well, I'm so happy that you have created this and that you're raising your voices to really change the dialogue and the stigma surrounding this. I think, you know, that's how we're gonna move forward with this and make this a better process for, you know, the millions of people going through it. So really happy that you have created this and you're working this, I know how much you both deeply care about your patients. So really happy to be able to share this with people.
Dr. Bar-Chama: Thank you so much for having us.
Dr. Cowan: Rena, it's been a pleasure. Thank you for work. You do as well.
Rena: Any other parting thoughts or anything that you wanna share with our listeners about Project Aim or Posterity Health before we wrap, you know, we'll put everything in the show notes, how to get in touch with you, how to find your product, but anything else that you wanna say before we wrap?
Dr. Cowan: I just wanna give acknowledgement to RMA for really taking a step forward in this innovative step of saying, Hey, let's work with the couple. And I, I think it's, you know, Natan and the rest of the crew at RMA have just really been awesome in that regard. And I give them great credit for their willingness and their acceptance of saying, let's look, we do to help the couple some more.
Dr. Bar-Chama: And I, you know, Barrett and Pam at Posterity have created a platform, which is I think the future. And I think Rena, you said, well, can we do it for the women and for the, you know, on the female side? And I think the future is positive. And I think that in a couple of years from now, we're gonna look back and say, wow, the home environment has real opportunity for testing and telehealth for both, you know, the male and the female. And I think that as these developments occur, we need to embrace them and highlight them and move forward in how best we deliver, you know, fertility care to our patients.
Rena: Love that. Well, the way I like to wrap each episode is by sharing a gratitude. So to end it on a real positive note. So who wants to go first to share something they are grateful for?
Dr. Bar-Chama: Look, I think that we have all been through very difficult times with the COVID pandemic and global events and the way medicine and science has been challenged over this recent period. And for us to come out of that with new technologies and new platforms and being able to care for our patients, better provide access, and expedite their journey to parenthood, it just continues to be a privilege and an opportunity.
Dr. Cowan: Yeah, similarly, I'm, I'm very grateful that we have the opportunity to make a difference and to really help more people achieve their goal. I think a lot of people kind of take the chances of having a child and starting a family, they take it for granted. And I'm really grateful that we're able to really help people achieve this goal, whether it's in a heterosexual couple setting or, or otherwise. And we're, these people actually are the ones who inspire us to do these things. And so we're very grateful with having the opportunity to do that.
Rena: Lovely. And I will say, I am grateful too, for, you know, sort of this advent of telehealth and, you know, as difficult as the pandemic was and continues to be, I think telehealth and telemedicine and embracing new technologies has made such a difference to people and really improved access to care. And so it's so wonderful to, you know, I have seen how it's, you know, specifically really impacted the mental health field, but now to speak to you and really see, wow, this is, you know, huge what this is doing for reproductive urology as well. It's incredible. So thank you so much for coming on. This was so lovely and we will share everything with our listeners and hopefully you will get many, many orders and people, you know, getting on board with project aim.
Dr. Bar-Chama: Thank you, Rena.
Dr. Cowan: Rena, thanks for having us.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.