Posted on February 4th, 2021by RMANY

Ep 48: Closing the Knowledge Gap Around Men's Reproductive Health with Rene Almeling

Fertility Forward Epsiode 48:

Resources regarding men's reproductive health are few and far between. We have such a deep association between women and reproduction, that men are often left out of the conversation entirely. Today's guest, Rene Almeling, is an Associate Professor of Sociology at Yale University with research and teaching interests in gender and medicine. Rene uses a range of qualitative, historical, and quantitative methods to examine questions about how biological bodies and cultural norms interact with scientific knowledge, medical markets, and individual experiences. She has also authored the book, Sex Cells, which offers a look at the American sperm and egg donor markets. Her new book, GUYnecology, explores why there is so little attention on men's reproductive health, offering insights into its influence on medical knowledge, health policy, and reproductive politics. Our conversation today unpacks some of the themes in this must-read work. We talk about a relatively emerging field of study, paternal effects, which examines the influence that sperm has on reproductive outcomes and hear what studies are showing. Information around men's reproductive health is vital because of the historical skewness toward maternal health knowledge generation. Rene also shares findings from her discussions with men for her book, the importance of including all bodies in reproductive health conversations, and where she sees this field of study heading. Join us today for this enlightening discussion.

Transcript of Episode 48

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.
Rena: So we are so excited to welcome to Fertility Forward today, Rene Almeling. She is an associate professor of sociology at Yale University with research and teaching interests in gender and medicine. Using a range of qualitative historical and quantitative methods, she examines questions about how biological bodies and cultural norms interact to influence scientific knowledge, medical markets, and individual experiences. She is the author of Sex Sells, an award-winning book that offers an inside look at the American market for egg donors and sperm donors. Her new book, GUYecology, examines why there's so little attention to men's reproductive health and analyzes how this gap affects medical knowledge, health policy, and reproductive politics. Professor Almeling has received funding for her research from the National Science Foundation and the Robert Wood Johnson Foundation. Her articles have appeared in American Sociological Review, Annual Review of Sociology, Journal of Health and Social Behavior and Gender and Society. She is a recipient of the Arthur Greer Memorial prize for outstanding scholarly research, one of Yale’s highest honors and holds courtesy appointments in American studies, the Yale school of Public Health Department of Health Policy and Management, and the Yale School of Medicine, section of the history of medicine. During the 2019 20 academic year, he was a fellow at the Center for Advanced Study in Behavioral Sciences at Stanford University. Thank you so much for taking the time to come on today, Rene. It is such a privilege to have you here, and I want to point out to everyone when someone first connected me with you and told me the names of your books there, that the titles are quite humorous because of the spelling. So Sex Cells, cells is spelled a C E L L S. And then the book that I really want to talk about today, GUYecology is G U Y and so at that, those are so clever and so I just, when someone showed them to me, I started laughing and I was so hoping to get you on because I figured anyone that wrote books with those titles would definitely be amazing and bring some humor to, you know, what is quite a serious topic.
Rene Almeling: Absolutely. Well, thank you so much for having me and yeah. The only downside of having punny book titles is that then you have to spell them out loud when you're doing podcast interviews.
Rena: Well, I think so, you know, we were talking a little bit briefly before and, you know, I mentioned it, I'm so I'm so happy to have someone on can really speak to kind of male factor because, you know, as we spoken about on the podcast before, you know, resources for men are few and far between, and, you know, if you think women go through this alone with shame and stigma and feeling isolated, I mean, you can bet for men it's that much more. So I guess what sort of prompted you to sort of delve into this, this field and this research?
Rene Almeling: Yeah, well, you know, I, my first book, which you mentioned was on egg donation and sperm donation. And so with the second book, I sort of went all in on the sperm is really what happened. I became interested in thinking about men's reproductive health as a topic that just hadn't received a whole lot of attention. When I started noticing, you know, newspaper articles and magazine articles, maybe 10 or 15 years ago, they started popping up with information about how men's health, you know, the health of their bodies, the age of their bodies prior to conception actually potentially had an impact on the health of their children. And I was just really surprised by that, especially because I'd been, you know, I spent about 20 years studying kind of reproductive health topics of all sorts, and just really posed the question for me of why did we not know that before? How did we not know that the age and health of men's bodies could affect everything from miscarriage rates to birth defects, to even childhood illnesses? And that's really what led me into the research for the book.
Rena: So I guess, can you touch upon that? I mean, what did you find in turn in terms of men's age and then leading to birth defects or miscarriage?
Rene Almeling: Yeah, so it's a relatively new body of research called paternal effects. So almost everybody is familiar with what would be labeled as maternal effects, which is, you know, as a woman ages, she's more likely to have a risk of down syndrome and other conditions for her children. She's more likely to have trouble getting pregnant and staying pregnant. And what they're finding now for paternal effects is that men's, their age, the health of their body, their toxic exposures which means everything from the chemicals they're exposed to at work at home and the environment that these things can damage sperm in such a way that the sperm can still result in pregnancy, but then the, the embryo and the fetus, and then the child that results from that sperm faces higher health risks. And so, because it's a relatively new area of research it's still very much, you know, very much information. So scientists are still trying to figure out exactly how much risk from which kinds of chemicals or exactly what is the relationship between paternal age and reproductive outcomes. But there's enough out there that, you know, scientists argue that men ought to be informed of some of these risks so that they can try to reduce them in whatever ways they can.
Rena: When we had we had Greg Summer on the, on the podcast before I talk about track. And so some of the things we talked about in terms of men's reproductive health or things like certain foods that you're eating, or maybe exposure to hot and cold. Are there any other sort of new things coming up in research that seems to play a role in this paternal effect?
Rene Almeling: Yeah. So in the third chapter of my book, I go into this in detail where I sort of track the origins of this particular branch of scientific research into paternal effects. And so it really starts in the sixties and seventies as people start being more concerned about environmental chemicals. So a lot of it is also research done in mice and so there's always that question of how much can you translate from mice to men and this condition in this circumstance, but the three different areas of risk really seem to arise from men's age. So with every passing year, as men get older, they are more likely to have new mutations in their sperm that are associated with health problems for their children, including such things as autism and schizophrenia bipolar disorder. And I think that the age data is probably the strongest of the three. The other two areas are toxic exposures. So things, everything from men smoking cigarettes. And so of course exposing their own bodies to chemicals through smoking, alcohol, illegal drugs, prescription drugs, but then also chemicals like pesticides paints, even things, you know, that scientific researchers themselves will work in laboratories with chemicals and working with reagents. And so, it's not just sort of low wage jobs where you have somebody working on landscaping and they're being exposed to pesticides. Also sometimes, dentists and doctors who are exposed to laughing gas, for example, you know, so there's a variety of different chemicals that have been investigated. The evidence on things like diet and exercise and BMI and particular foods, I think is the, the least developed and so, you know, there's just been more research showing that in particular heavy cigarette smoking and paternal age really does seem to be associated with these reproductive outcomes both in terms of miscarriage and birth defects, but also the children's own health. So this is a really important point and that you'll probably hear a lot about a variety of things that can affect sperm. But to take the next step and say, you know, the damage that is done to sperm, doesn't only affect its ability to fertilize an egg. It might also affect the resulting child. That's really the new information that's coming out with paternal effects.
Rena: Two questions come to my mind from that. So one is, you know, women, you know, we're told, okay, 35 is our kind of, you know, that's when our, you know, fertility starts to decline. That's the big sort of marker. So, you know, for men, is there a number that's popping up as sort of their decline too?
Rene Almeling: For men there's not the same sort of like here's the age you need to be concerned about. For men it's every passing year. So basically from the time they're 25 until the time they're 75, right? And of course we know that men who are much older can still have sperm that can result in pregnancy. But the question is that as men get older with these new mutations, they are at higher risk. And so people will sort of debate well, is it really, you know, if your risk as being a 55 or 60 year old man fathering a child, if your risk, risk of having a child with say schizophrenia doubles, that means it goes from 1% to 2%, right? So it's still very low. But there is an increased risk. I think the real sort of trick in this area is going to be to figure out how to put all the different factors together. So how does paternal age plus paternal exposures plus paternal behaviors all come together to produce any one individual's risk number? And then how do those factors interact with a maternal factors, with a woman's age and a woman's exposures and a woman's own behaviors? So there's a whole lot of work that remains to be done in this area and trying to fill in some of the details of these numbers.
Rena: That's so interesting. So, because that, to me sounds almost like, you know, so parallel to what we're told as females about our, our egg quality, right? Or egg quality and quantity that, you know, from the second we're born, we start to lose eggs. And so, but we're taught that men, you know, their sperm regenerate every 90 days. But the way you describe it as almost for men and women, that's such a parallel there, right? That men, there's not the 35 number, but it's just every year they're declining. Which to me sounds so parallel to what we're taught about eggs. So I guess then my question would be, how does that then, so if sperm regenerate every 90 days, you know, how does that sort of now all connect? You know, in these exposures, are they, is it something that I guess is prolonged and then affecting the new sperm as well?
Rene Alemling: Yeah. And so the, the actual sort of time of maturation for sperm is about 68 to 70 days plus or minus, you know, five or eight days. So it's really, you know, two and a half months that it takes a cell to grow inside the male body before it can ever exit and be associated with a pregnancy. And the thing that's so interesting and looking, part of what I did for the book was really look at the history of reproductive knowledge making. And for a long time, we have been able to separate out a women's fertility with women's reproductive outcomes, right? So the idea that you could as a woman get pregnant, but yet still have various kinds of exposures, or if you have maternal smoking or other kinds of environmental impacts, that that could affect the health of the pregnancy, but we didn't ever break that out for men. So for the longest time, scientists assume that if a sperm could fertilize an egg then it was healthy. And so that's the big, big sort of thought, you know, paradigm shift here is that scientists are now separating out a sperms ability to fertilize an egg from the health of that sperm. That that sperm can actually have genetic damage. And here we're not talking about the kind of mutations that you inherit from, you know, family members like Huntington's disease or Tay-Sachs, right? So men can absolutely be carriers of genetic mutations. But what we're talking about is the kind of damage to the DNA inside sperm that comes from age and health behaviors and what you're pointing to is, yeah, and part of why we didn't really wonder about the health of sperm is that it seemed like it was endlessly new. But what they're finding is yes, that two and a half, three month period is important for men's own bodily health, but it appears that even men's behavior earlier in life. So there's been some studies of men who started smoking when they were teenagers and then they get pregnant or they have a partner who gets pregnant 20 years later. That some of those early life exposures seem like they might be associated with reproductive outcomes even decades later. So it's not just that two and a half month period.
Rena: Wow. That's fascinating. If not a little bit frightening,
Rene Almeling: It's terrifying because what are you supposed to do about that?
Rena: Right. I mean, even, you know, I, I speak about my daughter on the podcast, you know, who's four. And so I think a lot, you know, even for her, am I putting her in clothes that might be affecting, you know, her ovarian reserve or her egg quality, you know, cause of chemicals or the stuff that she eats. And I try and walk this fine line between being this like overbearing helicopter parent and letting her, you know, have cake and wear clothes from normal places. But, you know, it's certainly something I think about. And, you know, I think that's the responsibility on, you know, parents or adults, you know, with kids to think about what they're doing. You know, is this going to then impact, you know, someone's reproductive health later in life? I think that's terrifying.
Rene Alemling: Yeah. Well, and I think it really points to a question about where is it that we should intervene on processes like this? So what you're describing is what, there's a sociologist named Norma Nora Mackendrick has called precautionary consumption. And so she writes about sort of the additional gendered labor, particularly on mothers who are often doing the shopping and the consumption to try to manage the potential chemicals that might be out there. But that this is a losing battle. And that really, you know, from a sociological perspective, if we are interested in improving reproductive health, that we're really going to see a lot of bang for our buck is by providing more health, more quality health care to a greater swath of the population. And so when you have public health approaches to ensuring that everybody has access to quality care, that we reduce the number of chemicals that are out there in the world, and that we have better regulation of chemicals, that all of these things will benefit everybody's health, you know, whether or not they're reproducing or whether or not their children. So that's really where both, you know, sociologists like Nora Mackendrick and I fall in terms of thinking about like how to approach this question which absolutely is terrifying. But also is not something that any one individual is going to be able to solve.
Rena: Sure. I mean, I certainly couldn't agree with that more, you know, even from makeup we use to containers, our food is in. There's so much to think about down to right pesticides or organic verse not organic, and there's so many labels. And I think so many people, they don't even, they don't even know where to begin. They don't even know what to ask. And so I think certainly educating the masses is what's so important. You know, I think there's a huge gap in the knowledge base and, you know, a lot of people, they just don't even know sort of small changes to make, to start living a healthy lifestyle and they don't need to be expensive changes or drastic changes. But people just aren't informed. So I'm so happy to hear that, you know, you're looking at this and, and, you know, she is as well, and hopefully people will start to be more informed just to take care of, you know, overall health in general.
Rene Almeling: Yeah, that was really, it was one of the things that in my interview. So for the book I interviewed 40 men from the general population. So I was really interested in sort of talking to average men from the community. So not men who were in fertility clinics or men who were sitting there thinking about the reproductive health for whatever reason, but just your average guys. And in these 40 interviews I was really struck by how little men knew about their own reproductive bodies, much less their reproductive health. So, you know, I asked them questions like, how would you define a man's role in reproduction? And how do you respond to learning some of this new information about paternal effects and really what came out of those interviews was a lot of them saying the last time I heard anything at all about my reproductive system was in high school and health class or a sex-ed class. Right? And now however many States in the United States don't even teach sex ed anymore. So men don't go to the doctor on a regular basis like women to get their reproductive organs examined. And the first time that they might talk to somebody about reproductive health is, is they are partnered with a woman and they have trouble getting pregnant. So this sort of basic knowledge about, you know, men's age and men's toxic exposures and their own health behaviors affecting their sperm is absolutely the sort of basic health information that we need to be getting out to a much broader public. And that's part of, that's really part of why I wrote the book.
Rena: What was one of the most surprising things that you found in your interviews of men? You know, besides what you just said, that they really just sort of had no kind of general knowledge base. Was there anything else that really stuck out?
Rene Almeling: Yeah. You know, I was, I really had no idea what kinds of answers I was going to get when I asked them to sort of talk about how they think about men's reproduction. And in part it's because it's just like scientists haven't studied men's reproductive health, social scientists haven't interviewed men about reproduction. If we interview people about pregnancy or birth or contraception or abortion, we go talk to women, right? So we too are, are sort of producing knowledge about women and reproduction and not producing knowledge about men and reproduction. So, so I had very few hypotheses which made the interest, the interviews super fun to do because every single one, I was just like, Oh my gosh, I can't believe that. But the thing that really kind of stuck out to me was just how interested men were in the information. So, you know, they sort of had an idea of their involvement of reproduction, you know, producing the sperm and having sex, being a dad. But most of them had never heard anything at all about their own age or their own behaviors and how that might effect their sperm or affect reproductive outcomes. And at the end of the interview, they would do things like, you know, I had actually, because there's no patient booklets about this, like the CDC doesn't produce anything, ASRM doesn't produce anything, the American Society for Reproductive Medicine. So I actually made my own, I made my own little healthy sperm leaflet and I would give it to them and say, you know, can you read through this and then walk me through your responses. And at the end of the interview, several of them would ask to take it with them so that they could share it with their friends. Or one of them had a son who was trying to get, you know, they were trying to get pregnant. And so there was just a real hunger and interest in the basic information, which I think, you know, makes me optimistic about the opportunities for public health messaging around us.
Rena: I love that. I mean it, and I think one of the things we briefly spoke about before recording was you know frustrated I get about the lack of resources for men. And I would say, you know, most of my patients, 98% are women. And you know, if you think women struggle with fertility and they're feeling isolated and alone and guilt and shame, I mean, with men, it's almost magnified. Because for women, at least I can give them support groups. I can give them resources. There's a lot more out there and it's continuing to grow. You know, one of my macro goals is to change the stigma surrounding infertility. But for men it's just, there's so little out there. And so I think it makes the experience so much harder and they suffer in so much more silence because, you know, for infertility cases, people think it's, you know, it's majority women who are infertile, but their male factor infertility is accounted for so many cases as well.
Rene Almeling: Yeah. I think the breakdown, the most recent breakdown I've seen as sort of a third female factor, a third male factor and a third unexplained. And so yeah, in that sense, the idea, well, and I'll, I'll just say that I, you know, you're in a position to probably hear a lot more of these stories than I am, but occasionally I'll hear from people who say, you know, that there was, you know, it's a heterosexual couple, the woman had gone through all kinds of fertility testing, all kinds of fertility screening. Sometimes she's even gone all the way through IVF before they even think to do a sperm count on the man or examine him in the most basic ways. So that too is a product of this broader historical dynamic that I'm talking about where when we think reproduction, we think about women's bodies. We're not asking questions about men's bodies. We're not studying men's bodies, we're not interviewing men. We have such an ingrained association between reproduction and women that it precludes us from even really posing questions about men's bodies, including in inside the clinic.
Rena: And I think, you know, I don't know if it's because, you know, women ultimately are the carrier of the baby and so there's this sort of disconnect, or, you know, maybe it's just as, you know, gender roles and sort of the traditional male female, you know? And I talk to patients a lot about how a lot of reproduction and thoughts surrounding it is almost biblical, you know, it goes back to Adam and Eve being put on earth to reproduce. And we feel that it's our biological innate right to reproduce. And if that's taken away from us, I mean, there's so much loss, there's so much grief, there's so much processing to do about that. And I love how, you know, the dialogue is changing a lot surrounding gender and gender roles and gender identity and, and all of that. And so I'm wondering if that will also end up causing some sort of shift to in this, you know, thinking around reproductive health and it being primarily, you know, female centric and how that's going to shift.
Rene Almeling: Yeah. So I think, you know, the way, what you just said, you know, the way that I put it in the book is that there is this association of reproduction both with women's bodies because bodies assigned female at birth are the ones that have historically been pregnant and given birth. So there is a biological component to how we think about reproduction as associated with women's bodies. But there's absolutely sort of a gendered understanding of women's roles as being associated with the family and childcare, and caring more, more broadly. So both the sort of biology and cultural aspects of womanhood and femininity are part of why we get that deep association between women and reproduction. But I think you're just absolutely to change a foot here in the sense that, you know, you have trans and non-gender conforming people who are starting to really question that tight association of gender identity and bodies. And so I've heard ,started to hear OBGYNs starts to talk about pregnant people instead of pregnant women, right? Because if you have somebody who was assigned female at birth, but no longer identifies as a woman and either is identifying as a transgender person or gender nonconforming, or non-binary that you have people potentially walking into a fertility clinic or looking for contraceptive care or even abortion care, who aren't necessarily women. And I think that that's hugely important for the reproductive health community to recognize. And it's starting to get reflected in language. And here, I think, you know, as we watch that reproductive health umbrella expand to include trans people that we can also expand it to include men, right? That when we think reproductive health, we should be thinking about all bodies and not just bodies of people who identify as women.
Rena: Mm. I love that. Yeah. I think, you know, I couldn't agree with that more and I think it's, you know, it's going to be so interesting to see how this unfolds, you know, as sort of, again, the dialogue changes and, you know, gender becomes much more fluid and how that's going to shift the conversation around, you know, sperm versus eggs and where that's going to take everything.
Rene Almeling: Yeah, absolutely.
Rena: And what about the emotional component? Did you speak with the men that you interviewed your sample size about that with them at all? Or did you come across that in any research? I saw, I have your book right here, when I was looking at it last night, there was a section I saw about kind of society and gender and a little touched a little bit upon, I think the emotional aspect.
Rene Almeling: Yeah. I didn't do too much with them mostly because I had recruited them from the general population. And actually, if anybody was undergoing fertility treatment, I purposely did not include them in the study. There were a few sociological and anthropological interview studies of men who were experiencing infertility, several books by Marcia and Horne who’s my colleague here at Yale in anthropology. And then by Liberty Barnes also has a book called Conceiving Masculinity. So, and then a really excellent one is Gay Becker, The Elusive Embryo. And I'm happy to send you those citations if you want to attach them to the podcast page. So those are really well done interview studies about men's experiences, the challenge that infertility poses to people's sort of beliefs about masculinity, the kinds of joking that often happens in fertility clinic to mask that embarrassment. So they have really lovely kind of ethnographic and interview data about that because I was interviewing men who, you know, my fliers actually didn't say anything about reproduction or sperm or fatherhood. I really wanted men who just were kind of, you know, from all walks of life, but had no particular interest in the topic. Cause I wanted to talk to sort of an average, average guy. And so in the end, you know, there were a couple of them who had had experiences with infertility, people who had become estranged from the children that they had. So emotionality did appear in the interviews, but not necessarily really focused on sort of the experience of reproduction that I would have expected if I had interviewed people about infertility.
Rena: That makes sense. I was wondering how you got your sample too.
Rene Almeling: Yeah, well, it was funny cause you know, for sociologists, when we do these sort of small in qualitative interview studies where you're going to go talk to 40 people, you're usually focused on a much more narrow swath of the population. Like, you know, in my previous book I wanted to interview sperm donors. And so then I went to sperm banks and I talked to sperm donors. But here I was looking for average men. And I had actually been sort of walking around the streets of New Haven and thinking about like, how am I going to find average men and there's men everywhere. I was like, shall I just stop people on the street and start talking to them about sperm, which I did not do So I ended up putting up flyers in a small, more Northeastern city asking for men to talk with me, to do an interview about life experiences. And so in doing those interviews, I, the first 20 minutes was really sort of about their childhood and their educational experiences and their experiences with work and family. So I sort of was talking to them about their life more generally in order to kind of pivot into these questions about family and reproduction and then eventually sperm.
Rena: Interesting. Where do you see sort of this field going in terms of any sort of testing or research or anything like that, did you sort of get a sense of where the field is going to go?
Rene Almeling: So I have, you know, I sort of spend the conclusion spinning out recommendations for a couple of different audiences. So there's a number of recommendations in there for reproductive healthcare providers. So clinicians who are working in everything from OBGYN to pediatrics and internal medicine. Because men aren't sort of going into the doctor on a regular basis like women are, I think that there's some real opportunities here for clinicians. You know, maybe that last pediatric appointment before somebody goes off to college or to join the military, you know, when they're 18 years old for their clinician to say, Hey, you know what, as you go forward just know that your own bodily health will affect your reproductive health, will affect your children's health. And so it's sort of planting some of these seeds. There's recommendations for high school teachers to incorporate some of this into the sex-ed and health curriculums. There's recommendations for the NIH, the CDC and the biomedical research community about some of the open questions here, how to have more residency training programs that talk about men's reproductive health. So there's sort of a number of different places. And I think because there's so little attention paid to men that there's just a lot of opportunity here for some pretty low hanging fruit in terms of basic things we can do that will help get the message out.
Rena: I mean, I think everyone should read those and take note, you know, one of the most common things I hear from patients is why didn't I know this before? Why did nobody tell me? I had no idea that my, you know, egg quality or quantity would start declining at 35? You know, I had no idea that these were my options. You know, I spent my whole life trying not to get pregnant. The only thing I learned was how to not get pregnant. Why did nobody tell me how hard it was going to be? And so I still hope that the dialogue starts sooner and people get educated sooner. You know, knowledge is power and the sooner we can educate both men and women about reproductive health and what to do to both prevent an unwanted pregnancy or to check your reproductive health. You know, getting checked earlier doesn't mean that you then have to conceive. But it means getting the information right to know, Oh, okay, I'm coming up, you know, I'm 22, but I'm having a super low AMH. You know, what does that mean for my future reproductive health? Do I need to look at now freezing my eggs now to try and preserve my fertility because this marker is coming up abnormal, right? Or for men to understand, okay, what I'm doing now, the lifestyle choices I'm making now may have a long-term impact on my paternal effect. So, you know, I think your recommendations are spot on and something we're all working to, you know, educate the masses about. I think it's so important because you know, my heart just breaks when I have patients come to me and say, if I had known, you know, I wouldn't be here. And it just, it's such a shame because, you know, and it's certainly a lot of things I wouldn't know unless I was in the field. Um, so I think, you know, the space overall really needs to change. So I'm so glad that you're putting the message out there too.
Rene Almeling: Yeah. Well, thank you so much for the opportunity to talk over some of the details and I just absolutely agree. I think there's, there's a lot of work to be done and it could end up having sort of enormous, enormously helpful sort of downstream effects for people.
Rena: Well, I think I know your book is fantastic. We'll post the info to that, um, in the show notes. And then I'd love to get you back on later to talk about Sex Cells and talk about the other book that you did, you know, another super important topic. So it was really such a thrill to have you on. And the way we like to conclude our podcast is on a note of positivity. So by each sharing a gratitude, so something that you are grateful for today.
Rene Almeling: I am sitting here very grateful for the prospect of a vaccine that is becoming more and more available in our country. And hopefully an administration, that will be even better at getting it out to more people and feeling hope about the future. So nothing related to sperm, but that's what I'm feeling gratitude for. And I just want to say, thanks also for the opportunity, it's been a real pleasure to talk to you and would love to come back.
Rena: Well, I love your gratitude. They, they don't have to be existential. I think, you know, it's the simple things. You know, I am just grateful to be here every day. I say I'm just grateful to be where I'm supposed to be, doing what I'm supposed to be doing, you know, keeping my calendar. So I am grateful that we scheduled this quite a while ago. I think over a month and it came to fruition, we're both here. Our kids are occupied, we got through the interview. And it was so lovely to, to meet you and definitely have you back on to talk about Sex Cells and so great to be connected with you and someone who is so like minded and putting out such important work. So I definitely recommend everyone check out your book. It's full of amazing research. You have some really cool illustrations in there as well, and really such a pleasure. So thank you.
Rene Almeling: All right. Thank you 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.

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