Ep 133: Breaking Down Barriers to the Male Fertility Evaluation in the Reproductive Clinic: Optimizing New Technology
Fertility Forward Episode 133:
Dr. Natan Bar-Chama is a board-certified reproductive urologist and has been the Director for the Centre for Reproductive Health at RMA of New York for the past 20 years. His practice is exclusively dedicated to the field of male fertility. During this episode, he shares a summary of his recent presentation at the ASRM Conference, titled Breaking Down Barriers to the Male Fertiltity Evaluation in the Reproductive Clinic: Optimizing New Technology. This episode centers on two elements that the male reproductive analysis is based on, and how evolving technological solutions facilitate the process of extracting necessary information for fertility treatment. We discuss Telehealth assessments, how a couple can assess male reproductive factors through conversation, and how to approach fertility treatment planning. Dr. Bar-Chama also touches on research into testicular surgery and sampling for men. Listen in to hear all this and more!
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 Ford 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: Dr. Natan Bar-Chama is a board certified reproductive urologist and has been the director of the Center for Male Reproductive Health at RMA of New York for the past 20 years. His clinical and surgical practice is exclusively dedicated to the field of male infertility and we are very excited to have him on today, once again. It's been a number of years and today he'll be sharing with us a summary of his recent presentation at the ASRM conference. And this was titled, Breaking Down Barriers to the Male Fertility Evaluation in the Reproductive Clinic: Optimizing New Technologies. Dr. Bar-Chama, thanks so much for being here today.
Dr. Bar-Chama: Thank you, Dara, for that introduction, and Rena as well, and really excited to update and to share how we've gotten better at delivering care to couples with male fertility issues. I think that one of the things that we've learned is unfortunately, you know, from the covid experience is that, you know, access to care is an issue. New platforms that enable the initial experience to be done through new modalities like telehealth, home testing, these are all things that we now have available and utilize regularly for infertility. And my experience with that has really been extremely positive. I look forward to sharing that with you and the audience.
Rena: Super psyched. And I think, you know, before we, we officially started this, we were talking about the importance of streamlining care and no longer, you know, first checking on the female, then checking the male, and really being able to work together, you know, with a heterosexual couple to really test everyone at once. It just, you know, I think makes things more efficient and just makes so much more sense medically since infertility is one-third female, one third male, and one third unexplained.
Dr. Bar-Chama: Rena, I one hundred percent agree with you. I think that if we just go to the most recent guidelines, guidelines that were designed by both the Urology Association and ASRM, they clearly shifted their position to support this concept that you raised, which is that from the get go, we should evaluate both the male and the female in parallel. Now, what does that mean? It doesn't mean that all the testing has to be done, you know, on both ends upfront, but there are initial tests that can give us a signal to understand if there's a problem. And I think that couples really want to be able to know that everything is okay before they're trying. And certainly one of the things to talk about is how painful it is to see couples who try for six months or a year, assuming that things are fine and things are not on the male side. So I think that, you know, a phrase that I really say often is, we can walk and chew gum at the same time. We can evaluate the male. We can evaluate the female. We can supplement data for assumptions. And then based on good data, make recommendations and proceed, you know, in a more efficient way. And I think it's also important to highlight what is that initial male evaluation and how, specifically, we can bring that to the patient, to the couple. So the guidelines really highlighted that the initial nail evaluation comprises of two elements. One element is that we do a reproductive history, we do an assessment, and the second is a semen analysis. Now the assessment of the male factor is really something that couples can do on their own by asking obvious questions. Is there a history of a sexually transmitted disease? Has there been an injury to the scrotum or the pelvis? Are both testes descended, what medications are you taking? Is there a history of male fertility in the family? Are you exposed to steroids or testosterone? These are all things that if present, they really suggest that an evaluation by an expert or a reproductive specialist is important. And the other is a semen analysis. Now we can go into that I think, in depth in terms of, you know, what have been the obstacles? What have been the psychological barriers for men to go ahead and do a semen analysis? Unfortunately, we have good data to show that 25% of couples do not get the initial analysis when they start their fertility journey, you know?
Dr. Bar-Chama: Yeah, it, it's really astonishing, you know, but I think that we have made progress in making that process more accessible and less burdensome.
Dara: So I had no idea that, I guess that goes to show you my ignorance and my assumption. You know, first time someone walks into a fertility clinic, I thought that was basic rules or basic guidelines. So, I guess I’m wrong.
Dr. Bar-Chama: You know, like many parts of medicine and in life, you know, what we understand as, you know, what should be done versus what gets done is a gap in that. And certainly, you know, it's better to appreciate that gap and try to help bridge it as opposed to just, you know, ignoring it. And I think that that's focused on today. You know, I think that if we start with the experience, you know, the telehealth platform, okay, I think is really uniquely suited for the initial male fertility evaluation. You know, men really, you know, wanna know if everything's okay and, and one of the things that I really, I think is important to highlight here is I really would suggest that couples do this together, okay, early on, you know, this fragmentation of when who's being evaluated and what tests are being done. I would make the argument that right from the beginning, you know, right from that initial telehealth experience, have both the male and the female be present so we can start the discussion. You know, it's tough to play telephone tag on in, you know, telephone in life in general, but when it comes to medical issues, it's even more complicated. I think the first thing is, is if you're doing a telehealth encounter, try to do it together. Now, telehealth again is, I will sing its praises because men don't have to take off from work. You know, they can be in their car, they can be at the gym, they can be at home, you know, it's convenient. It's opening up a black box that is, you know, stressful and sometimes directly impacts one's perception of themselves. And, and male macho, you know, is something that is sometimes a barrier to getting, you know, fertility tested. So I think certainly what I really value about that initial telehealth experience is that, you know, a dynamic is established, a relationship is formed where we can start talking about, you know, that history that we talked about, what is important, what risk factors do you have, but not, you know, but to do it in a way that creates a dynamic. And then there's a commitment to put time into getting those tests done. I think to ask a male to go through testing without context or relationship, I think is not ideal. And telehealth really, you know, bridges that gap. You know, I'm very fortunate to be involved in an entity that has many reproductive endocrinologists. We have multiple sites and facilities, and having men be able to access the evaluation, the initial phases of the evaluation via telehealth, you know, really addresses access to care and enables this process to be expedited. You know, we see Telehealth taking off, everyone is comfortable with Zoom. Everyone is really willing to start, you know, to have this dynamic, you know, it's part of our daily routines at this point, and we just need to take advantage of it for male fertility assessments.
Dara: It's really interesting. You know, COVID was a very challenging time, but it really did open the doors and helped people try new approaches to care. And it sounds as though this one actually had its advantage, which is something that I never thought of, but it makes sense in terms of, it allowed more flexibility for people to meet with their doctors, but especially for men who have that, perhaps an added layer of, I don’t know if the word is embarrassment, but, you know, reservation, perhaps
Dr. Bar-Chama: There's a barrier. There's a barrier that exists, and this telehealth platform helps break that down. And also it personalizes what testing and their specific situation, right? So if someone has had a vasectomy, you know, I can talk to them about options with, you know, their partner and we can start providing the pros and cons of different models. Let's say there's a very poor semen analysis, right? And they're ready to do IVF. Okay, I'm not gonna delay that. My goal is to make things more efficient. So the, you know, the focus there is to, you know, to encourage that decision, to explore, you know, why is that happening? Is there a genetic reason? Is there a health issue? Is there, you know, we have to really also put into context and appreciate that part of our function as male reproductive specialists is to make sure we're not missing potentially life-threatening conditions. You know, I have patients who present with infertility and end up having testicular cancer or conditions like low testosterone, which we know has a huge impact on cognitive function, libido, sexual health, bone muscle mass. So we really wanna make sure that we're not missing something that is important for overall health, but at the same time, you know, not delay the technology that is available to achieve a healthy pregnancy sooner than later. And again, telehealth, you know, enables us to hone in, zone, you know, really focus on what this specific couple is experiencing, what their expectations are, and to support that effort that, you know, on the journey that they've embarked on.
Rena: Absolutely. And I think, you know, as you mentioned, I see all the time with men, I think there's such a mental barrier to seeking treatment. There's a lot of shame or fear involved. And so, you know, I think telehealth seems a lot less invasive than going into an office.
Dr. Bar-Chama: In my experience, it really is astonishing. You know, when I start the discussion, you know, we start talking, those barriers exist and, you know, 20 minutes, a half hour later, you know, you can see in their expression and their tone and how things have really just melted away and they are now, you know, really more engaging and more proactive and taking on more responsibility in terms of their lifestyle and moving forward with testing that they know is specific and to their, you know, to their case. It's astonishing to see and experience the pre telehealth dynamic and what happens during that process. And that's one of the most exciting parts of technologies. They really are effective.
Dara: So after obtaining that initial reproductive history, you said the second part was the semen analysis. Are there ways of being able to have the testing done at home and sending in? And what are the options and what are the things that you think still need to be done in an office?
Dr. Bar-Chama: Just as exciting as the telehealth advances has been the appreciation that this concept that someone has to go into a, you know, a facility, put themselves in an isolated room, you know, it may take two, three hours to get there and then, you know, produce a sample. You know, that model has not shifted or changed for decades. And we now can really, you know, have optimized technology to do two things. Number one is what we would describe as home testing, which is to get an initial assessment of once sperm count or motil sperm count. And those kits or those devices are over the counter. They can be shipped to your home. They don't require a physician's prescription. They're not overly expensive. And I'm not saying that they are as good as a formal semen analysis, but if there's a problem, it's nice to know about it right from the beginning. So, like I said, you know, we're all, you know, everyone is an expert, you know, testing at home, for example, you know, you did your covid test, you know how to read lines, you know, I mean, we've all been experts on these, you know, platforms and now there's a kit that does that to tell you if your sperm count is normal or not. Okay, and you just have to read the lines. There's even better technologies. There's what's called a home sperm test. Okay? So basically you put a small amount on a slide, you put it in this, you know, little compact camera, so to speak, which is connected by Bluetooth to your phone or to your computer. And all of a sudden, you know, you can see at home, you know, your sperm moving or not, and whether they're normal. And that's like, you know, and you can take a video of it and you can share it with your friends and you can send it to your doctor. But bottom line is if you decided at, you know, that day that you want to see motile sperm, you know, you can, and you don't need any prescription for that. But I think that those tests are good indicators that if there's a problem, you know about it right away. The other opportunity is what's called home collection, right? So basically, you know, we've been able to optimize the semen collection device. Okay. And what these advances have focused on is a couple of things. Number one is to keep the temperature intact, right? So we have insulation materials and packaging. Two is we put a small amount of media into the sample so it protects its pH and prevents it from undergoing decay. We've been able to isolate or minimize the dehydration process by, you know, decreasing surface tension. So there are many advances in this collection device that enable a couple of things to happen. Number one is if you collect it at home and you put it into these devices, you can bring it in within 3, 4, 5 hours. This notion that, oh, I collected after hop on the train, I have to get it in within an hour. That is, you know, very stressful. And some people can't get to a facility, you know, within an hour. And there's no reason not to utilize these platforms to give you that window of comfort and time. The other, you know, outcome of these, you know, new devices is that you can ship it. So you can collect a sample at home, put it into a mailing kit, and then ship it to a centralized lab, and they can do a semen analysis.
Rena: So they don't need, because usually when it's the collection here, it's like it has to be within an hour. So that it doesn't apply?
Dr. Bar-Chama: No. That's what this new technology enables us to do, is a, you can collect at home and bring it in within a couple of hours and it has not degraded and you can ship it and it can get somewhere within 24 or 36 hours and there too, they're getting a sample that has good motility and they can do a formal semen analysis and you never left your home, you never gave up a day's work. You didn't have to rush in and produce a sample on site or deliver it within a time constraint. It is a game changer. So when you go back to the, what is the initial evaluation of the male? The male does not ever have to leave his home. He can have, yeah, he can have a telehealth to review his history. He can provide a sample that we can ship to a, a centralized lab or, or have someone bring it in, you know, over a couple of hours. And it's, these two things compliment each other and really help, you know, us get the initial evaluation done efficiently.
Dara: Wow. These advancements are definitely game changers and accuracy. It sounds as though perhaps it may not be as accurate as what you would get in a hospital setting, however, still enough perhaps to give you an initial evaluation that if you need further testing, would that still need to be done in a…
Dr. Bar-Chama: I think, Dara, you hit it exactly right. Is that, you know, nothing is perfect. Okay. Right. And ultimately I may need to do a physical exam and certainly I would wanna do for the testing, whether it's blood work or genetic testing. But if everything, you know, but again, if we can get the evaluation of the mail done upfront and if there is a problem, we can do a telehealth and say, okay, you know what, I'm going to see you on one occasion and after we've spoken and after we've had maybe one analysis done, I know that the day I see you, we're gonna do all the tests that I need to do. Okay? So we're gonna schedule you for the exam and possibly an ultrasound and blood work and maybe a second semen analysis and other advanced testing. But it's all done in one concise visit because we've had the telehealth already and we've done one semen analysis in advance. So this coming in, you know, is really you know, and then once all that information comes, we can basically create a plan on what does the next three to six months look like for this couple. And that I think is one of really an important, you know, message for couples to have is, very often when people deal with fertility, they focus on one month at a time, right? Like, what are, you know, we tried this month, it didn't work, let's try again next month, what are we gonna do the next month? I, really, one of the things that I find helpful, and which is why I really encourage both the male and the female to come in together, is to kind of break away from that model and say, okay, what is your six month plan? Right? You know, how many more months do you want to try naturally? How many months do you want to do IUIs? Or if you're doing IVF and you want to create embryos, when do you want to do that? And very often when you switch to that process, it actually, you know, makes it less stressful because each month is not its own total event. You basically know that if it didn't work, we already thought this out and we've planned that, you know, we have one more IUI before we do IVF, where we're gonna try another two months naturally, and then we're gonna do the IUIs, but into growth to that type of planning is getting good information.
Rena: Absolutely. Those are always the steps I advise people to follow when they're really struggling. Okay. First you need to know, you need to have the facts, right? Then you have to have the plan, then you can kind of piece your life around that.
Dr. Bar-Chama: Right. And so the first step is getting good data, okay. And that's where telehealth and home semen analysis and all that so that we can start thinking about what your three to six month plan is. And the other thing that I always tell couples is, be flexible. Just because you created a six month strategy, you know, two months into it, three months into it, switch it up, decide that, you know, you wanna do X, Y, and Z.
Rena: Right. Maybe you wanna travel that month. Okay, fine. Take it off. You know?
Dr. Bar-Chama: Exactly. Be flexible, but within a structure that you're kind of planning ahead and like you guys just said, is a key for us to help you create a family building journey and a plan is good information so that we're able to work on that together with you.
Dara: I think that's great. Really good advice, the flexibility piece. But I was thinking this sounds that these at-home devices sound like a game changer. Are they costly?
Dr. Bar-Chama: Actually, not . I mean, they're really not. I mean, the old home sperm test I think is about, don't quote me on this, but it's somewhere around $70 for two semen analyses.
Dara: Oh, that's a lot less than I thought it would be.
Dr. Bar-Chama: Yeah. And then the sperm check, another one which uses this. And there's also, you know, very, very reasonable. And a home collected semen analysis where you ship it to a centralized lab is usually under $200.
Rena: Oh wow. That's great.
Dr. Bar-Chama: Yeah, that's, so
Rena: That's accessible. You know, I hate when people come on and share about tests and then we find out, you know, they're,
Dr. Bar-Chama: Yeah, no, no, it's, time is important. Getting a signal is important. You know, I'm a big advocate of, you know, being proactive. You know, there are tests for women that can be done without a prescription, you know, direct to consumer testing for me on both the male and female side has, you know, significant advantages. I appreciate that there are deficiencies and confusion and getting a signal early on I think is still worth it. And I think on the male side, we really have new technologies to support that.
Rena: I think too, and something that I've been thinking a lot about is, I listened to your talk, is, you know, I have a lot of couples that have religious accommodations or considerations when doing fertility testing. And something that is often a struggle is the male sample. And you know, I've had so many patients, you know, they've had to stay in a hotel the day before a test to go to the sample, and then it's a whole thing because of accommodating, you know, the religious observance and the requirements. And so this being able to do in your home is, I mean, I think you're skirting all of those barriers. So it really is just making it that much more accessible.
Dr. Bar-Chama: And I, I will add another feature to these new devices, which is there is some preliminary data that not only are you maintaining and preserving the quality of the sample and enable you to have, you know, increased transport time, which is either several hours, you know, or even overnight. There is some suggestion that that sample actually may perform better when you do IUIs and better fertilization rates and better embryo quality. Again, that is small numbers, but I think to me, the take home messages, I don't necessarily look for it as an advantage, but rather if it's doing the same as an onsite collection, you know, the convenience is tremendous.
Dara: Speaking of devices, I I, one more question in terms of, so I believe you said there is a device to collect semen that can help with quality and motility. What about for fertility preservation? Is there anything new in terms of advancements with that?
Dr. Bar-Chama: So many of the entities that do home semen collection also enable you to send the sample in and have it frozen.
Dara: That's great. So it's not just for testing purposes per se.
Dr. Bar-Chama: It's not just analysis. So for example, we can have that sample sent to a centralized facility for prior preservation. We can also now have home collection for advanced sperm testing, like DNA fragmentation. Okay. So, you know, think about it, we really, you know, if someone is, you know, in a hospital or, you know, hours away from a fertility center and diagnosed with cancer or needs to have emergent fertility preservation, they can get this kit, ship it, freeze it, and those services are available and been optimized.
Dara: That's incredible.
Rena: And I was just gonna say before, so has the intake process changed in terms when you enter fertility clinic, you know, to me it makes so much sense for you come in if you're a heterosexual couple, and not only does the woman, you know, have a consult and an intake with a reproductive endocrinologist, but the man in parallel has an intake and consult with a urologist. Is that now kind of how it's done on the norm or we're not there yet?
Dr. Bar-Chama: Yeah, I think we're getting there because certainly, you know, you know, if a couple's been trying for let's, hypothetically they're, you know, she's 38 and they've been trying for a year and they're very anxious. You really want to not delay, you know, the process. So, and at the same time you wanna make sure you're not, you know, you're addressing if there's a male factor, the cause and optimization. And so I think that, you know, the telehealth and home collection is really critical for us to, you know, support the reproductive endocrinologist's path and, you know, work synergistically. You know, I think the patient coupled experience is enhanced when we're not delaying things. I think that all that is really an evolving and maturing process. And I think I would just say, you know, that even when you do IVF and you do ICSI, what we're realizing, you know, is that sperm quality also matters. So we're seeing a lot of couples who have done an IVF cycle. The eggs, you know, look great, but the fertilization rate is suboptimal or the normal embryos created. And, and the question is, is what is the male contribution to this? How do we, you know, optimize that? And so I think that very often we are asked to evaluate the male after, you know, that experience. Also, you know, we see that there's a male factor for recurrent pregnancy loss. So there are tests that we now do, you know, to look at the male in more depth and that involves potentially doing a carrier type on the male if there's a recurrent pregnancy loss to go ahead and look at sperm quality beyond the standard semen analysis such as DNA fragmentation, which as I mentioned, is also a test that can be done through home collection and shipped to a facility. And then if it is an issue, right? If there are sperm quality, you know components to the IVF cycle, the goal is to try to improve that semen quality. And so we have different technologies that are now available to hopefully get a better outcome. So for example, if there's poor sperm quality as demonstrated by an abnormal DNA fragmentation assay, options exist, such as getting testicular sperm, where we feel that that sperm closer to the source may have better quality. There is a new technology using microfluidic processing. So you're putting the sample into a chamber that essentially is like an obstacle course that the sperm have to get through those microfluidic barriers. And the sample in the sperm that we see at the end of this process is of a much better quality. It has less DNA fragmentation than the sample that was put in initially. And so we would recommend this, this is another example of new technologies that we utilize to get better sperm quality that would hopefully function better in IVF and normal embryo creation. And we do that often. We add that microfluidic chamber to many cycles when we feel that we need to get better sperm quality.
Dara: Brilliant that there's so many options. I'm sure there's more that could be done down the road. Is there anything that you in particular wanna see more of or something different that can really be helpful?
Dr. Bar-Chama: You know, it's exciting because, you know, reproductive medicine constantly challenges itself. I mean, if you, how I practiced today is, is different than how I practiced two years ago, five years ago, 10 years ago, 20 years ago. So I'm dating myself, but you know, I mean this is really just, you know, I'll give you an example. For example, you know, men who produce a semen sample where there's no sperm at all, right? It's called azoospermia. And, and the standard approach is to have the andrology lab, you know, possibly spin that sample down and look at the pellet if there is something there to see if there's any sperm at all. And if there wasn't, these men, many of them would undergo surgery, extensive microscopic testicular sperm procedures, to see if we can find sperm in the testicle. What we do and others is not stop at that junction, but rather say, well, you know what? We're gonna take that sample and we're gonna put it through what's called an extended sperm search. So initially there was no sperm, they might have spun it, they didn't see any sperm, but if we do an extended sperm search where the embryologists may spend 3, 4, 5 hours looking through that sample, do you know that in about 30 to 40% of those men who initially had no sperm, we end up finding sperm. So 30 to 40% of these men, you know, do not need to undergo an extensive testicular surgery.
Dr. Bar-Chama: And then we have new technologies on what to do if we find isolated motile sperm. So the, the challenge of how to freeze small numbers of sperm, it's been an achilles heel because we wouldn't, you know, not everything you freeze survives. But now we have special dishes and special techniques where we can isolate 5 or 10 motile sperm, okay, after hours of searching and put it in these special, you know, dishes. We use sperm vd, but these are specially designed dishes that are able to freeze very small numbers of these sperm and we can then retrieve it and then use that for IVF. So, you know, how we manage and handle very low sperm concentrations has also benefited tremendously from new technologies and platforms that make our, you know, what we can offer patients dramatically better than it was just five, five years ago.
Dara: That's incredible. It sounds like a lot more, a lot more options, a lot more availability. I'm just thrilled also to hear, I thought that these tests would be really costly and it seems as though they are not all, all too expensive and to allow more accessibility and more ease and hopefully less fear and stress for people. That's huge.
Dr. Bar-Chama: Yeah. Yeah. It's very exciting. And I think we're just gonna keep getting, you know, more efficient, more focused, more accommodating, you know, get couples to understand their fertility status early on and hopefully, you know, identify, you know, interventions and pathways that result in pregnancies sooner than later.
Rena: This is amazing and it's so exciting to hear now and I can't even, you know, wait to hear what will happen in the next few years. I mean, the technology is just changing so fast and quickly and, and making everything just so much easier and efficient for everyone, which is incredible.
Dr. Bar-Chama: It's exciting.
Rena: Well, we are so lucky to have you at RMA to refer patients to, to bring your mind and expertise. And thank you so much for taking the time to come on our podcast to share with our listeners. I, I think that this will really bring hope to so many people. This is really making everything, you know, just so much more accessible and easy and what a gift it is to have you come on, share your time and experience with us. So thank you so much.
Dr. Bar-Chama: Thank you so much for having me.
Dara: So how do we end our podcast is words of gratitude. You probably know this by now. So Dr. Bar-Chama, what are you grateful for at this very moment?
Dr. Bar-Chama: I'm most grateful that I'm in an environment where new technologies are embraced. That we always focus on what we can do better to help couples achieve their family building goals. And I think it takes a village and a community to bring these resources and advances to fruition and to make them actionable. And so I really am grateful to my colleagues and you guys for promoting all this and everything really makes a difference in the long run for the couples we take care of.
Rena: Love that. Dara, what about you?
Dara: I'm gonna piggyback on that, Dr. Car-Chama. I was gonna say I appreciate in challenging moments and challenging, you know, times like covid, how sometimes it could bring upon some beautiful things. I think it really did push people to find other ways to help people out, to access care. And I think it really did push a lot of these companies to come up with, you know, more accessible testing and better care ultimately, hopefully for people. I'm really grateful for something that's challenging. Something good came out of it. What about you, Rena?
Rena: Yeah, I would say, yeah, kind of piggybacking on the both of yours. I mean, this was one of the episodes where I really thought a lot about a bunch of the patients that I have currently and over the years and how this technology will really make such a difference. You know, as I've heard them really struggle about the sample and either getting the male to do it or the considerations around religion that come with it and how to figure out how to jump through those, what really are barriers for people. and is huge and going to make such a difference. So, so grateful for that advancements in science and technology and to be able to work with such a fabulous team.
Dara: So grateful for your guidance, your expertise, and for coming on and being here today. Thank you.
Dr. Bar-Chama: My pleasure. Take care.
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.