Ep 128: Fertility Trends Among Active Duty and Veteran Service Members with Dr. Samantha Estevez & Katrina Nietsch
Fertility Forward Episode 128:
In honor of Veteran’s Day, today’s episode explores the under-addressed topic of fertility care for active duty and veteran service members, the challenges they are likely to experience, and how to ensure they are better supported as patients. Joining us to discuss this subject is Dr. Samantha Estevez, a Clinical Fellow at Reproductive Medicine Associates of New York, and Katrina Nietsch, a medical student at Icahn School of Medicine at Mount Sinai. We discuss their fortuitous collaboration before delving into their recent abstract titled, Supporting Our Troops: 20 Years of Fertility Trends Among Active Duty and Veteran Service Members Seeking Fertility Care at a Major Urban Fertility Center. Tuning in, you’ll learn about Katrina’s long history with the military, what led her to medicine, and how she partnered with Dr. Estevez to explore fertility and fertility care within the veteran population. We take a look at the limitations that veterans or active duty service members might experience when seeking specialized fertility treatment and how our guests went about researching this topic. We also reflect on the important role of advocacy and policy initiatives in this area, and how they are pushing the Veterans Association (VA) and government to recognize and address pressing issues facing female service members and veterans. Join us for an eye-opening conversation about an urgent topic that should be receiving much more attention!
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 own best advocate.
Dara: Today we have a very interesting podcast and it's an honor of Veteran's Day, and we'll be discussing a recent abstract that was presented at this year's American Society for Reproductive Medicine Conference, the ASRM conference, that was spearheaded by Dr. Samantha Estevez, who is a third year fellow in Reproductive Endocrinology and Infertility at the Icahn School of Medicine at Mount Sinai, New York, and also RMA of New York. And Katrina Nietsch who is a current Mount Sinai medical student. Their abstract is titled, Supporting Our Troops, 20 Years of Fertility Trends Among Active Duty and Veteran Service Members Seeking Fertility Care and a major Urban Fertility Center. Katrina, Dr. Sammi, I'm so happy that you're both on today.
Dr. Estevez: Thanks so much for having me.
Katrina: Thank you for having us.
Dara: Of course. So I wanna start with you first, Katrina. I, you know, after looking at your bio, you've definitely had quite an interesting journey up until now and you have a long history of working in the military. So I would love for you to, to share with our listeners a little bit more of your time in the military and kind of when you made that transition into the medical world.
Katrina: Sure. So I grew up about an hour away from New York. So I was in grade school when 9/11 happened, so I'm dating myself a little bit here, but that definitely had a profound effect on me. And I had classmates and friends that, you know, their dads, and friends, and aunts, uncles, what have you, didn't come home that day. And my family didn't work in New York at the time, but they have since, you know, worked in, in New York. So it's very near and dear to my heart. So I thought when I got to high school, I thought deeply, deeply about what I wanted to do and that kind of led me to the Naval Academy and the Service Academy. So fortunate enough to get in. Similar to medical school, you pick what you wanna do your, your fourth year. And for me it was really something that I wanted, do something on the front lines, but I always thought about medicine, but frankly I had a lot of growing up to do at that point. So I decided to be a Navy pilot and that's what my grandfather did. So I did that route, did about two years of flight school and then spent most of my career flying the C-2. So a bit of a circuitous path to medicine. My first deployment, we had a patient with seizures. We flew into Acapulco, Mexico, and that's a kind of a story for another podcast, but essentially it inspired, just kind of totally galvanized this, this love of medicine and I came back to the drawing board and said, okay, well how can I do it? So Mount Sinai actually has a partnership, which is really cool, just a shameless plug for that, for active duty military that want to go to Mount Sinai. So I applied, deferred my acceptance, and here we are. So, living the dream!
Dara: Wow. So this was something kind of the back of your mind and then at the right time, you know, pursued this? That's, that's phenomenal. And it's so great. Like I, I'm really impressed, you know, that it, it was somehow influenced based on, you know, 9/11 and, you know, giving back to, to this amazing country. I think it's, it's phenomenal. And it's interesting to hear you say that you were inspired by your grandfather. My grandfather was a pilot, too, and, and I have a, a cousin who teaches like trains, trains other pilots. So it, it's so nice to see that, like that the next generation. I'm sure your grandfather's very proud.
Katrina: Thank you.
Dara: The interesting thing now is, is coming up with this topic, how did this, what was the next phase in terms of, of coming up or actually merging, you know, your, your experience in the Naval Academy and, and now bringing it into light into something that's more medical and in the fertility world, especially with you, Dr. Sammi? How you connected together?
Dr. Estevez: Yeah, so Katrina and I met last year. I believe it was after I gave a talk to a student group, and we just started discussing different possibilities and different interests and things like that. And if people remember from what I've been on the podcast before, a lot of my interests with infertility are working with subpopulations that often go unseen or not really recognized as individual groups. And that folded directly into Katrina's experience as a veteran and what her interests were in the broader sense in medicine. Since she's kind of at the beginning of her medical career, she's not as focused as I am, but she met me and I'm in this very specific field of medicine. So we found a way to really apply it into this field of medicine and use the capabilities that we have at such a large center to try to see what we could learn about fertility within the veteran population and fertility care and infertility and how we could share that. And, you know, Katrina can speak to this more, too, but there's a lot of limitations being a veteran or even active duty person who might be struggling with fertility and infertility, limited places people can go and resources that you can have within the VA system and within the military medical system just kind of inherent to that. And because of that, there's also limited research as well. So we were hoping to give a kind of perspective of veterans going outside of that system within the general population, which was what we had accessible to us in regards to information.
Dara: Yeah, I mean this, I, I am familiar, you know, in terms of, or I've heard that in terms of support for, you know, go to a VA hospital, there's somewhat limiting support. So is this something that, have you found, Katrina, in terms of, especially in the fertility world? Was this something that you've seen before?
Katrina: Yeah, so the genesis of this project, well, I was on my, it's called a shore tour in the Navy, basically you're, you're kind of sanctuary, you're in a sanctuary period. It's usually about 30 months where it's a assignment that you have where you, you will not deploy. They call it a shore tour in the Navy. And when I was on that shore tour, they introduced this project called the Aviatrics Project. And so I looked into it, I said, what's this all about? And they basically set you up free of charge with a nurse case manager to discuss family building, and you kind of peel back the curtain on it and say, well, why is the Navy investing in this type of thing? And it turns out that they were unable to retain any female aviators. So this pilot program, no pun intended, was intended to, to sort of sit down with somebody and discuss family building options. But again, keep in mind you're in a very short window, about 30 months. So to start the process from then and say you have, you know, PCOS, polycystic, you know, ovarian syndrome or something that's gonna cause a hiccup in that planning, really not quite enough time. So I, I looked into it and this, this nonprofit called the Military Family Building Coalition, discovered that actually turns out that a friend that I knew, navy spouse who kind of started this based on her own experience with IVF. So I kind of looked into it and said, you know, what are actually the trends here? What's kind of the science behind it? And so the Congressional Research Office did a pilot study just looking at what types of groups were particularly suffered from infertility or something, you know, along that spectrum and the female aviator, that that kind of sub-demographic, was the second most to experience some type of issue. So that was kind of the, the interest. Came into medical school, wanted to do veterans health. It just kind of happened that sort of fell into this and, and, and met Dr. Estevez, who was just kind of a salt of the earth personality. And so we kind of, you know, I, I was persistent about it and we were able to get off the ground.
Dara: Wow. Yeah. Is this one of the, appears as though it's not something, as you mentioned, it's not something that's really researched. Was it tough finding, you know, resources and how did you get started with it all?
Katrina: Yeah, it's very tough. There's, there's limited evidence and what's interesting is that female veterans, you know, there's kind of two buckets. There's active duty group, which is kind of the focus of that nonprofit that I just mentioned. And then there's the veteran group. And if you look at the growth of women veterans in the system, I mean, like, objectively, the, the VA is kind of unprepared. And the last statistic I read was like, 4-50% is the growth of female veterans, women veterans to 2040. So, you know, when you talk about under-resourced and then, you know, RMA posted something and I read a study about, it was one in 3 VAs didn't even have a full-time gynecologist on staff. So when you look at these numbers and you look at it and you know, you say, well, how do we close the gap here? And I think it has improved, but there's very little literature out there kind of on this topic. And, you know, the, the elephant in the room is, it's very difficult to do a prospective study because you'd have to take somebody very early on in their military career, enroll them and then see what happened. You know, men and women.
**Dara:* So how are you able to find these trends? So it's, it sounds as though, you know, one of the big trends as you mentioned is that there's a big decline in female aviators because they wanna start a family, number one. And number two that there's not a lot of support for the veterans in terms of fertility or, or family building. Was there, were there other findings that were really shocking to you?
Katrina: I, I think the, the issue sort of boils down. Originally when I came into it, I was hoping for a little, something a little bit more robust in terms of infertility trends. But as I mentioned, that's kind of a tough egg to crack. So I kind of think it's this problem, the problem as sort of like three pillars. You have, you know, advocacy, policy, access to care, then you have the infertility piece, and then you have military exacerbating factors like husband, spouse, partner has to deploy. Oh, by the way, you need to be married in, in order for that to be recognized. That's a whole other thing. So all these different factors where the lifestyle being in the military is just not really, it doesn't always foster, you know, the ability to do certain appointments and certain, you know, checks in the, in the block to kind of on your fertility journey. So our study that we just presented was retrospective in nature and we looked at about 112 service members or spouses, partners, service members, and just kind of looked at that. And you know, what we found from kind of the infertility trend, I think is somewhat limited. What we did find in terms of advocacy and policy is very interesting and I think is really what the future will be in terms of pushing these initiatives and pushing the VA to recognize that this is an issue that kind of needs to be reckoned with.
Dara: Yeah. It's interesting in terms of did you offer any, you know, it was retrospective, did you present like a questionnaire to kind of get some feedback on people's experiences and also kind of their thoughts?
Dr. Estevez: So that's definitely something as a potential project for the future. And even just doing this retrospective study, looking back at charts of patients who, whether they use VA insurance or military insurance or the attendings and the physicians who saw them, wrote down that they were veterans or active duty. You know, one of the ways that we're changing things at our office is to be even more comprehensive in ensuring that we recognize these patients who are military personnel or former veterans to make sure that we don't miss any of these possible things that could be influencing their fertility. And because of that, it might lead us to then be able to do something that's prospective where we would be able to survey and get a more robust and comprehensive picture of what is going on as they approach us. Because as Katrina and I have mentioned, there are some counterparts, obviously within the VA and military system and, and Katrina's actually done a great job of connecting with a lot of those researchers who are doing some of that groundbreaking work within the system there. But there are those limitations. And so what we tried to do within this study was look at it, like I said, from, you know, the outside perspective of what if you are a service member or a veteran and you don't have one of those couple of VAs or 4 VAs across the country that has a fertility center? So you're going to the local fertility center. What are the things you're bringing forward? What are the questions you have? What are the times and delays? And how, you know, hopefully in the future if we get a more extensive population, really compare that to the general infertility population that comes into, into our door. And really, we even saw when looking through the charts of the patients that we looked at, we saw some people who were active duty and then they stopped following up because they were deployed. We saw people who were veterans and they didn't have the coverage they needed so they had to limit what kind of services they would obtain. You know, there are a lot of different things that unless you knew this background of their military history or whether they were active duty or veteran, it, you wouldn't really fully understand some of those decisions they made. And so the possibility of, you know, in the future doing a prospective study where we could actually talk to those patients instead of making inferences, I think is a lot of potential to not only help us understand as physicians at RMA and any physician who might be across the country, outside of the VA system, but also to use as a point of advocacy within, you know, the government and within the VA system to say, these are places for improvement. This is how we could really serve these people who, who need care and it's not being recognized, being recognized to a greater degree, but should continue to be recognized and, and worked on.
Dara: Wow. Yeah, I, it was interesting - right after I said the question, I'm like, that's, you are right for a prospective study. But yeah, the fact that you were able to, to catch some of these, these trends and see kind of the missing links of the, of the areas that kind of could be helpful to future to to, you know, it's, it's unfortunate that, that sometimes you have to see some of the areas that we're missing to actually help for, for future patients and, and you know, the, the future in this field and in others. I think it's, it's very it's interesting. I think it's great. The fact - I'm actually shocked that it, this hasn't been something that's been widely researched, but at least we're starting here and I think this will definitely be of interest, I think for a lot of people in the future.
Dr. Estevez: Definitely agree. There's lots of potential. Katrina and I, you know, have very big goals for what we could do and what other people could do to, to really work with this.
Dara: Like, this is a great starting point to, to help kind of see where the gaps are. And I like, Katrina, how you, you said how it's, you know, there's, there's many different fronts where we, where you know, you know, people in, in healthcare can really support. And I think advocacy is, is a huge one. And I think, you know, especially we're more in the medical side, we’re less in the advocacy, advocacy side, but I think if we all help in, in various avenues, we really can see good change. So anything that, you know, down the, the road, any type of future research beside those prospective studies, is there anything specific now that you kind of wanna hone in on?
Katrina: I think that, you know, there's a few different way, a few different directions. Obviously looking at the exacerbating factors. I think, like, toxic exposure is very interesting to me. There's a nonprofit organization called Hunter Seven Foundation that looks at cancer within the military. So you know, there's a few different organizations out there and a few different kind of service-connected health issues. What I anticipate is that this will be sort of, you know, the PACT act, what kind of, you know, along those same lines, what people are talking about. And it's great to have, you know, sort of, you know, champions like John Stewart and these people that are coming out sort of advocating for veterans, especially of the kind of post-9/11 era. So there's a few different ways to do it and I hope, you know, to be a part of that in, in one way or another. And I think that just having the access. New York is an interesting place just because it's kind of a microcosm of the, of the world. And I think that it will just be amazing to see what we can do at RMA in terms of advocacy research and then just empowering physicians to ask the right questions when, you know, a, a service member comes in or a spouse comes in - did you deploy? Are you disabled? Do you see the VA? I think it's interesting to look at the, not to go on a tangent here, but to look at who's actually enrolled in the VA. And when you look at the numbers, especially female veterans of only about 60% that are in enrolled, or sorry, 40% that are enrolled. Of those that are enrolled, only about two thirds actually use VA healthcare. So just, you know, all these different layers of it where you kind of peel back the onion and, and look at what's leading to certain things and just really trying to understand why, you know, people make the decisions that they do and how they're limited by what insurance coverage they have.
Dara: That's, I guess, where my ignorance is. I didn't realize that. I thought, you know, once you're, you become a veteran that you're automatically enrolled in the VA.
Katrina: Yeah. So there's, you know, a lot of nuance in it, depends kind of a little bit on your, your disability status as well, but I think - I'm not super well versed in this - but it's definitely accessible, especially in mental health services. It's just a matter of whether people have other options or usually employed some other way. So they use some other, you know, employer-based insurance policy, which makes the most sense, I think for most people, especially if you don't have access to a VA. So, you know, it can be limiting in, in some respects. And I've, you know, I've heard nothing but good things about VA care. I personally don't use it, but I think that the, the research teams there are doing really good work and, you know, kind of asking the right questions and it's, it's just gonna be really interesting to see what happens with, with the, the kind of wave of female veterans in this post-9/11 era now that we're not, you know, actively at war to see what happens.
Dara: And then you mentioned, I I never would've even thought of that - toxic exposure. So is, is that in terms of, you know, is it a part of the aviation, is it part of what, what type of toxic exposure would they people potentially be involved with?
Katrina: Yeah, I think there's a lot of them. You know, I, I was deployed mostly on aircraft carriers, so the, you know, jet fuel. Definitely one of the most dangerous places to work just in terms of a lot going on and a small amount of real estate. My third deployment, you know, burn pits, that's kind of the big, the big one that you'll read about or, you know, a bunch of activism going on around that. So basically no, nothing to do. There's, there's no place to, you know, go and drop off the garbage, so they just kind of basically just light it on fire and that's a burn pit. So, you know, it could be anything from when I was on deployment, we had plastic water bottles and there was no way we had these shades over them, but there's no way to kind of keep those cool. So you just had kind of a, an oven of, of, of plastic water bottles and that was the only drinking water, you know, 'cause obviously you can't drink the, the tap water out there in certain austere places. So there's, there's definitely a variety and, and I'm sure, like, Dr. Estevez could talk more about like the endocrine dysfunction and the stress and the mental health kind of side of things. But I, I, my last job was with Navy Seals, Naval Special Warfare, so they came out, the medical community kind of came out with Operator Syndrome, which is sort of just like a, a morphine, and I'm not an expert on it by any means, but toxic exposure, oxidative stress, you know, mental, physical stress and then, you know, you're firing weapons, all of the chemicals you know, that are in the air, that kind of thing. So it's interesting and, you know, I didn't even talk about TBI and PTSD and or traumatic brain injury and those kind of other things that it's all, we think of it in, in separate boxes, but I think it, it kind of more or less falls under a little bit more of a, you know, sequela.
Dr. Estevez: And really all the things Katrina's been talking about really just kind of fold into what we as fertility physicians really have to keep in mind. Like I said, you know, we're at RMA making, making a lot of different changes to be even more direct and comprehensive when it comes to our care of veterans and military personnel, but there really isn't a guideline of how to ask the questions, what questions to ask. I have a number of friends who are veterans and a number of friends who have served, so I'm familiar with some of these things, but I've never been in the military, so I recognize that as, you know, something that I can't speak directly to. But having, you know, Katrina and other friends in my experience has peripherally allowed me to know some of the questions that need to be asked. But there's no series of questions that say if you have a veteran or a military person walking into your office as a fertility provider, what are the things you should definitely hit on? You know, mostly it's like, did you serve? Yes or no? And as we've already kind of talked about really, not even directly, but you can imagine just from this conversation, there's so many other layers that can be brought into that to have a more nuanced understanding of how that could impact their overall health, their health and their fertility, and what kind of care you could do. And with so many unknown questions, especially when it comes to toxic exposures, as we gather more information, you wanna make sure you have those people flagged appropriately because then if something comes up as a direct correlate or a possible cause of other problems, you can know, oh, this was my patient who was by burn pits, this was my patient who was by a lot of different chemicals. This was my patient who X, Y, and Z and you could come back to them with that information and really treat them even more appropriately and specifically. So I think, you know, other steps for us as physicians to keep in mind is really to come together to make a really discreet series of questions to really capture as best we can that basic picture of the, of the person, not just basic of you served or you didn't, but really how could this be influencing you and your care and your ability to, to, to build a family?
Dara: You, you make great points. You know, I think the mental health component is something that I think has gotten a lot of attention in the media, especially more recently. But still in terms of how that could even impact one's fertility health. And then the toxic exposure… it's interesting, I didn't even realize all those different avenues that you mentioned, Katrina, that could potentially, you know, impact. So there's a lots to think about and I think, I mean, it sounds very exciting, the, the potentials and the possibilities of creating these guidelines that really can be used not just in in the VA, but also in other fertility care settings specifically, or other medical settings. I do, I think the collaboration component is really important. I think it's great that with both of your experiences and interest, it's, it'll be exciting to see, you know, what's gonna come out of all of this.
Dara: And I hope to be the one to, you know, to witness it and also have you back on as the research continues in this area. Yeah, I, I'm really impressed with both of you. And I think this is a, especially for RMA I, I'm so proud of what we've accomplished over the years in terms of all the abstracts that we've presented at ASRM, but this is the first one that I've seen that's just very different than anything else that I've seen. And I, I really do think it's gonna spark a lot of, of interest and hopefully push people to really make an effort to dig a little bit deeper to help with this population, with this community. So thank you both for coming on. Any last words, kind of that you would like to, to share with our listeners? You don't have to - that's okay!
Katrina: I think, yeah, I think just kind of encouraging providers and personally I'm a total open book. You could ask me anything about anything and I will happily share, you know, and I'm an n equals one, but I think it's really easy to talk about culturally competent care, especially as somebody that's in the pipeline right now that I think in reality it's very hard and there's so many different subpopulations, you know, veterans included. So, you know, I hope, I hope to be a part of, you know, be the change. I hope to be a part of encouraging providers all, you know, all different specialties, all different, you know, avenues to, to ask those questions and don't be afraid. I think that's a little bit of, at least in my experience, people might not know as much as they think they should or some weird psychological block and then they don't ask the question. And it's kind of like, if you just ask the question, I guarantee that a veteran is gonna want to talk about their experience, you know, assuming it was mostly a good one. So I think just encouraging, you know, for your, your listeners to, to ask those questions and don't be afraid. It's okay to not know everything nobody expects you to. But just having that conversation and leveling with whoever the patient is, I think is really important.
Dara: Beautifully said.
Dr. Estevez: Yeah, and just to piggyback off that, really, it's just another perfect example of how many identities every person really has. Some of them are visible, some of them aren't visible. And it's our job as providers to really serve a person as a whole person - to really see how any of those things might intersect and overlap and influence not only their day-to-day and their general health, but when thinking specifically about what field of medicine you might be in, whether it's fertility or general medicine, how that could be impacted. And so just even putting this out there as a beginning of something to raise awareness, to get it on other doctors and other providers heads and in their mindset is going to be a change that'll be beneficial. Because even if somebody doesn't come and talk to me or Katrina or somebody at RMA about what we're doing specifically, it might prompt them to start asking questions and say, oh, we are by a military base. Do we actually ask this regularly? Or there's a VA nearby us and there might be some veterans who do come and see us. Like, how can we reach out or connect with them? Like just even starting that thought process in other people's heads is really, I think, the most important part of this initial kind of a study that can lead to a lot of growth and a lot more information then we won't be restricted by numbers. We'll have more people in different places able to add to the literature and really build this into something that can be beneficial for everybody.
Dara: I think that's wonderful to say. Bringing awareness, you know, you guys are really helping with the advocacy component. I think asking questions is great too. And really this is a topic that wasn't even something that I would've thought about. And now that I've both heard from you, it really kind of makes me wanna dive deeper into this. I'm super interested and I know our listeners will be, too. So thank you both for, for being on and before we wrap up, we like to end with words of gratitude. Dr. Sammi, you probably already know this, so, Dr. Sammi, what are you grateful for at this moment?
Dr. Estevez: As I'm coming to the end of my fellowship, I think I'm really reflecting on a lot of the time and learning I've had over the last few years at RMA and I'm just grateful for all the wonderful people I've worked with in my time here. I still have, you know, a little more time, almost a year left, but it's the point of inflection and a time for me to really think about next steps. And it’s really been a pleasure not only working with you, but everybody else at RMA and learning more and trying to be the best doctor possible. And then also having the opportunity to work with students and residents like Katrina to, you know, learn from them. This is a prime example. She brought me something, she brought an idea that she was passionate about and we were able to implement it and make something great. So I think moving from the position of being a learner to also being a teacher is a, is a really thing thing that I'm really grateful for.
Dara: Nice. I I think the, the best teachers are the ones that also learn from others, whether it's their students, whether it's, you know, their mentors, but I think it goes both ways and it's nice that you're able to see that, that, you know, you can learn from everyone that's around you. That's really nice. Katrina, what are you grateful for today?
Katrina: Yeah, I'll caveat that I am a big fan of your podcast. I listen to it in the morning, so I, I was waiting for this question.
Dr. Estevez: It's true. She told me!
Katrina: I'm, I'm grateful for you guys for having me on the, the, for this opportunity and for Sammi for, or Dr. Estevez for throwing me a bone on this and giving me the, the rope to climb. I, I real, I naively thought we would be in person. So I got you guys a little, a little token, no pun intended. This is a, it's called a challenge coin. Are you guys familiar with them?
Dara: I'm not.
Dr. Estevez: Yeah.
Katrina: Okay, so I'll explain. I I like history too. So I'll explain the history really briefly because I don't wanna run too much over time. But the history was World War I, they, they created these coins and there was a British aviator who had his coin on him. He ended up having to emergency land, his plane got captured by the Germans and they took everything, all of his clothing, belongings except for this coin that he had. And so he ended up escaping to France. He goes to France, there was a whole bunch of, you know, they were, they were ready. They had a lot of spies at the time, and so he had no way of proving that he was on their, on their team. So he popped out the challenge coin. So there's a little tradition in, in the military that now that you guys will have one, we'll give it to you that you're kind of like a part of the club and then the tradition is like you throw out your challenge coin, somebody responds with another challenge coin in their pocket, you trade, and then if you don't have one on you, you're kind of like not a part of the club, then you have to like buy a round of drinks. So I thought it was a fun little a little, you know, token of thanks for having me on the podcast and I will make sure you guys get this and can, little memorabilia. But I'm very grateful for you all and for the opportunity to be here and sincerely appreciate it.
Dara: I'm honored and I, it's so nice to be part of the club.
Katrina: You are a part of the club. You are in. I have knighted you.
Dara: So it's interesting. I, when I was thinking, you know, okay, what am I, you know, there's a lot to be grateful for today. And I actually was gonna say something, you know, about connecting with friends who I haven't seen in a while, but as we were just chatting now, I was really like, I, I love learning and I think a big reason why Rena and I are, are host of this podcast is, you know, we're interested in this, in this field, but we also come to recognize that there's so much that we don't know. And if there's a lot of things that we don't know and we're within this community, you know, our listeners, you know, I'm sure there's a lot of people who don't know either. And, and I think this is just one area where I'm excited to see. I'm so excited that you guys really are at the forefront of something that I think is really gonna be big. And the fact that I'm, I'm just shocked that it's taken this long, you know, for, for the ball to be rolling. But I'm also so excited to see that, you know, the interest and the collaboration and I'm just, I'm excited to see where this goes. I really do think that you're at the forefront of something really special. We're really gonna be able to help this generation and next, you know, make them as healthy as possible, giving them the best care as possible, really making them feel supported. So thank you so much Katrina, for finding Dr. Estevez coming together, collaborating and wishing you both the best with this. I know there's lots to come in the the future. Thank you.
Katrina: Thanks for having me.
Dr. Estevez: Thanks so much.
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.