The Truth About Male Infertility & Low Testosterone | World’s Leading Men’s Health Doctor

26:40The other way of looking at it is it's not going to do any harm to lose weight or try and lose weight. But studies again are interesting, aren't they, about weight? because if you look at weight in itself, but on the other hand, if you look at, it's really fascinating. If you look at, for example, operations to lose weight, so gastric stapling operations, the impact on fertility is quite limited. You would have thought that losing weight and doing these type of operations, you would improve fertility, but studies are very controversial about that. What's more interesting, losing weight naturally.

27:15We did a study looking at an NHS diet, which interestingly improved semen parameters, potentially improving or reducing oxidative stress, which causes DNA. And it would be really interesting to see, for example, the drugs that are used in the weight loss drugs, injections at the moment, and JARRA, etc. And their potential, reproductive potential as well, and effects on testosterone. So I think that's a really interesting area that we'll begin to see evolve for the future over the next one to two years. And there will be studies looking at that and the potential effects of these weight-losing drugs on reproductive health, which will be fascinating.

27:52Wow, that's really interesting. Well, you mentioned a term that people might not, well, might not be too familiar with, oxidative stress. And I immediately think of antioxidants being a nutritionist here, which is basically why we get people to eat lots of fruits and vegetables. Looking at the nutrient profile to help fertility for men, women, I think we're pretty aware of what's important for our fertility. we'll look at understanding taking folate when we want to conceive and coq10 could be really helpful for us but i don't think men and i might be seeking out a term here because i'm not a man but are as aware of their nutritional status when looking at their fertility i know that you've done a lot of research here what would you recommend for somebody who wants to improve their fertility or their sperm quality or in general not testosterone yet because we'll get to that i That's a separate conversation.

28:39How would you get them to look at their nutrient profile and do supplements help? Yeah, it's a really good question. Do supplements help? I think the, I mean, if you look at data, yes is the answer of individual studies, but you've got to then look at the quality of those studies, going back to what we were talking about, quality of science, meta-analytical data. So often we use meta-analysis to look at all of this. So if you look at meta-analytical data, you can drill down on certain, We talked about Q10, carnitine, for example, vitamin E, C, selenium, zinc. But what's interesting is one of the best studies probably was called a MOXIE study, which is a Scandinavian study, which is a prospective study.

29:20And one of the very few prospective studies of looking at sperm DNA damage and semen parameters, which actually showed no major benefit. But if you then take the whole data in meta-analysis, which is what it does, it looks at pooled data when you look at a meta-analysis, there is a benefit for some of these. But the data, again, is what we would term as weak because there's not that many randomized controlled studies looking at outcome. And in particular, you can look at data and it can say, we've got an improvement in semen parameters. But a lot of data isn't controlled, so you don't have a control group because semen parameters do fluctuate.

29:54So this is one inherent problem or variability in studies. And also at the end of the day, should you be looking at pregnancy rates or pregnancy outcomes? And there are analyses which are much more rigid, Cochrane analyses, which have shown some benefit of antioxidants in that setting. DNA is another issue. There is some evidence equally there is, as we mentioned that study, contradictory evidence suggesting the effects of antioxidants on DNA damage as well. But I think the problem underlying all of this is a lack of focus in terms of research and driving research in these directions, basically.

30:33because that's what you need, is you need more robust data to support practice. And I think that's where we lack that evidence base or science in the context of male infertility. I'm interrupting for one moment to ask one small favor. Please subscribe to the show. This helps it grow more than you know. And I'm so bad at asking this from you. I'm so bad at thinking about this. But you know my goal is 100 ,000 to get to on YouTube. and I really want to bring you more content and better guests and bigger episodes and we can only do that with your help together. So please do hit subscribe. Thank you.

31:11I'm thinking about people that want to try and actively do something for their health. As I'm hearing this, do you think people, because it doesn't feel like it's harmful with certain, I want to say multivitamins, but you know, vitamin E, yes, it can on high levels be actually more detrimental. but thinking about risk versus benefits if people wanted to dial down on looking at certain supplements to take or how they should be approaching their nutrient profile what advice would you give i think the the benefits out outweigh the risks yeah as we know and this like you mentioned importantly about vitamin e yeah okay so i think that they do so it's you know you can say and probably a nutritional pharmacologist would shoot me down but i would say that the risks do outweigh the benefits, it's not going to cause you major harm.

31:59But I think the question of course is, is it going to do any good? Possibly is all you can say based upon the data that we have. So if it's not going to do any harm, then it's reasonable to do that. I think nutritionally it's important, because I'm talking to a nutritionist anyway, but I think it's important, you know, the Mediterranean diet, I think it's important to lose weight, to exercise, and to do all these things that are important. Stopping smoking, not drinking as much. caffeine very important as well interestingly and caffeine important for dna interestingly which is a rather unusual thing to kind of pick out because you kind of look at it and say but again caffeine you know uh reduction or caffeine has been associated with dna damage to sperm so but again you look at it and there must be some other biological factors or genetic factors as which might predispose, which nobody's ever looked at, is are different patients more susceptible in their reproductive health to oxidative stress?

32:59That's one area which will be fascinating to look at. Is there an abnormality there? Because if you look at other people's lifestyle, you always hear, don't you, that he was taking drugs, he was overweight, smoking like a chimney, drank lots of booze, and he managed to have ten kids, and there I am with a waist of 32 inches, and I don't smoke, I don't drink, I don't do anything bad and I can't conceive. There's got to be other factors involved, not just environmental. There has to be genetic factors as well. Yeah, I also can imagine within that stress must be quite a big factor. And before I go on to the stress, I just want you to repeat those nutrients that you studied.

33:40Coenzyme, yeah, Q10, carnitine, vitamin E, C, selenium, zinc. These are ones that classically... These are the ones to be really aware of. And I'm just thinking if people are going to go and have a blood test, there are certain levels that they may feel like. Is vitamin D a big player in this? I think that's quite an important vitamin to speak about. Again, there's some evidence of vitamin D, isn't it? But a lot of these are animal-based studies as well, which is a problem, and therefore translating. We've got to remember, and that's one of the problems we have actually. It's good you mention it, because if you look at animal studies, animals are more sensitive to toxins, animals are more sensitive to drugs, compared to humans.

34:13So that's where it's difficult in terms of the translational. science in terms of extrapolating that to human beings, basically. So I think that those would be reasonable. Again... One thing that does deplete nutrients that I know, speaking as nutritionist, is stress. Stress has a massive impact on our physiology. And I don't think that we look at it as acutely as we should when it comes to fertility. Do you see a lot of people walking into your clinic that suffer with high stress, and that could be linked to fertility problems? Yeah, hugely. We live in a society that is, It's a busy world, and it's a busy society, and it's a society that doesn't take any prisoners, really.

34:53And I think that often people can't switch off, and often people can't stress. I mean, the nearest thing you can do, because you can't objectively measure stress in terms of fertility directly, that would be difficult. But take, for example, as part of the reproductive potential, is erections, or male erections. I mean, stress is a major factor for psychological stress, for erectile dysfunction. for example. So in the same way, we've got to think physiologically about the effects. We don't know enough about stress and male limited, but I'm sure it does have a role, without a doubt. But there are two aspects of stress.

35:29One is obviously you're trying for a child. You're not conceiving. It's stressful. It's difficult. You see and you look around you, people of the same age as you, and if you're in your 30s, for example, and you go into christenings, you go into weddings, and you see all these kids around you. Patients often talk to me about that and say it's one of the biggest stress, and they begin to slowly marginalize themselves socially from people because they don't want to have contact with children. That's really sad to see as well. And that's also what does happen. Then you look at the stress of a job.

35:58A lot of the time, people have very stressful lives, stressful jobs, financially, many, many factors, relationship issues. And the third thing, of course, is that relationship issue, isn't it? Ultimately, the way that fertility can impact upon the relationship with your partner as well and how relationships can break down. And you do see that sadly in relationships. And so I think there are multiple components or facets to the stress. It's not just stress within the environment or the world you live in socially, but it's also about the process of infertility and what it causes because it can have profound effects on relationships and people's wellbeing.

36:35Do you talk a lot to patients about this aspect when they come through the door on how to manage their stress levels? Honestly, to a degree, but not really. Not as much as I should. Because, again, it's that kind of pressurised, isn't it? I mean, what we would want to offer is holistic care. But the trouble is that within the confines of restricted times, resource, it's very difficult. And also, we don't have that infrastructure. There are fertility specialists out there who deal with the psychological counselling and aspects of that. But more often, of course, is, you know, So IVF units, for example, have a counsellor who's really more talking about donor sperm, for example, and not talking more holistically about the psychological well-being of the patient and how that's impacted and how that's affected.

37:20Because you do see it when you're in clinic and you detect that stress between a couple. And it's not their form. It's just they also need guidance as well. And I think we don't really deal with stress very well as a medical fraternity. And I think we should be. And we should have that resource as well because it does affect people's mental health, you know, and it will impact upon relationships and at worst will result in people ending the relationships. Yeah, absolutely. Well, I think it was really interesting going back to earlier when you were saying about women's kind of big markers of 35, 37 and 40.

37:58And egg freezing now has become very common among women, especially in their 30s. But now there's a lot of conversation around freezing sperm. And Chris Williamson, who's a big podcaster as well, has spoken openly about this, that he's actually frozen his sperm at 36. And I wanted to talk to you about fertility preservation. Should we encourage it for men as similarly as we do to women? And, you know, what's kind of the outcomes? Because I'm quite aware of if a woman freezes their egg solely on their own, there's less of a likelihood to get pregnant than freezing it with an embryo because of the throwing process, and then we have to see if they, obviously the embryo connects properly.

38:38Is there, what's the risks versus benefits? Like, is it quite a high likelihood that if you freeze your sperm, you could then go into IVF? Like, what's your thoughts around this? I mean, sperm freezing for, let's say, for lifestyle reasons is not something I would particularly encourage. I mean, it's individual choice, isn't it, really? If you want to do that and you feel more comfortable. I mean, the context that we tend to freeze sperm in, for example, is patients preoperatively having certain types of cancer chemotherapy treatments where it's mandatory to freeze sperm in terms of the effects or the negative impact of these various treatments like chemotherapy, radiotherapy, removal of testes for testes cancer on sperm production.

39:24So that's one group of patients. The other group of patients may be that you're faced in clinic with a patient who may have a very low sperm count because sperm counts can appear and disappear, that you might want to freeze. The concept of freezing for a man who gets older, I'm not sure that I would particularly advocate or believe that is something that I would say to patients to do outside of those indications that we talked about. I think it's about individual choice. If you feel happier doing that, fine. We know there is a decline, but we also talked about DNA as a sperm. Preserving sperm at a younger age, fine, you might get better sperm quality in terms of DNA at a younger age than you would if you're older.

40:06But then we go back to what we were talking about earlier, and even pre-interview about the concept of societal pressure. We tend to have children at a later age now, and society is moving towards that. And is this just is this just a result of that rather than a necessary indication to do that? I mean, I think there's different arguments about this, but I don't think that one can say that you're going to freeze sperm in your late 30s because if you have a child at 45, then my sperm count might be much worse. We don't know that. But if it's something you want to do, you feel comfortable with that, then fine.

40:46But it's not something that I would be particularly going out there advocating. Really? Okay, that's interesting. Well, let's go into testosterone because I think that's a really important topic, especially for men right now. Can men naturally, without treatment medication, naturally increase their testosterone levels? And how should men be looking at this themselves? Well, testosterone is important for cognitive health, mental health, argument about depression. It's also important as we talked about weight, we talked about cardiovascular disease, and its association with metabolic syndrome, erectile function, libido, and there are many studies showing its association and importance for general well-being.

41:26To try and improve it naturally, there are things you can do. I'm not a great proponent of so-called natural testosterone products. The evidence base of them is very limited. Data is very weak supporting them. But if you look at the concept of central adipocicity, men who are overweight or obese have a lower testosterone. because of this concept of testosterone conversion into oestrogens, which might then impact upon the brain axis, which then reduces testosterone or other chemicals called leptins produced as well, which interact with that axis and causing something called secondary hypogonadism.

42:03But reducing weight, for example, natural weight reduction might improve your testosterone levels by one to two points or nanomoles per litre. But we've also got to analyse what do we mean by low testosterone? What is low testosterone? Because ultimately you're not going to treat somebody who is asymptomatic, who doesn't have symptoms, but you might nowadays because of the associated metabolic syndrome. Men are normally what we term as hypogonadal. They have symptoms of hypogonadalism, low testosterone, and also biochemical evidence of low testosterone. You should be treating both hand in hand.

42:39But if you look at guidelines, guidelines vary about what levels you should treat, and that's really where it gets very difficult. And there are lots of kind of myths out of it. But we formulated some guidelines for a guidelines group that I worked for. And we said that if your testosterone is less than 8 and you have symptoms, you're definitely hypergonad or you could consider testosterone placement. 8 to 12 is borderline. And above 12, which is the total testosterone, then you're okay, basically. The problem is we've got this very gray group between 8 to 12 where people talk about measuring free testosterone as well.

43:13But I think if I got a patient who, for example, has 8 to 12, I'd probably be initially saying to him, look, we can try lifestyle modification in terms of losing weight, exercising to try and increase testosterone levels. Sleep as well is important because sleep can also improve testosterone levels in studies as well. So, but then what comes first, chicken or the egg, because testosterone can cause, as we know, problems in terms of sleeping as well. So you've got to weigh that up. So I think that there are some natural ways to do it to answer the question in a long-winded way. Well, I want to talk about a supplement that's going off, I think, a lot online right now, all the things that I've been looking at, which is Tonga Ali.

43:56Now, you just mentioned that toge testosterone and free testosterone, which people might not know the difference between those two. But it's very interesting. There's a lot of people talking about Tonga Ali helping boost free testosterone. by significantly quite a lot. Is it worth taking this? Is it harmful? What's the risk versus the benefits? And what's the difference between free testosterone and total testosterone that you were just mentioning? So the first difference is total testosterone is the total amount of testosterone in your body that is bound to proteins, including something called albumin and SHBG, or sex hormone binding globulin.

44:34Free testosterone is that the body uses. It's free. It's within the plasma. So again, there's this whole issue about what's important is your total testosterone, your free testosterone, your total testosterone. Your free can vary. It's also very difficult to measure free testosterone bioassays as well. So I think if I was going to comment, and I don't know enough in all honesty about Tongali, nor have I, nor would I want to comment too much if I'm honest with you about it, Sarah. But I think that you have to be careful about data analysis and be careful about hype and careful about data that people, because that's what we've got to rely on, evidence-based scientifically.

45:16If it's not harmful, fine. I don't see a problem in it. But on the other hand, I think we want to see more studies, more evidence-based, controlled studies. We want to see more science. That's really what you want to, and what I'd be saying to people about it. so before we speak about trt which i really want to talk about because you mentioned there that actually it can be detrimental to fertility um this is a really interesting picture that i've kind of collated from speaking to a few people before this episode and it's kind of in relation to testosterone so men's roles are changing generally um men are being told to be maybe more in their feminine more connected to their emotions women are becoming more educated are taking on more CEO roles.

46:01So, you know, traditional roles are naturally shaping and shifting a bit, which is great. And if three people said to me before the show, is it because men's roles are changing in society that it's impacting their testosterone levels? And could that be impacting fertility? Which I just thought was a really interesting observation that I wanted to put to Possibly, but I think that there are, I mean, biologically, physiologically, there is, testosterone is the kind of male hormone, isn't it, really? I don't personally think there's enough data surrounding that concept, but open to any concept, really, nowadays, to kind of explore it.

46:47So I don't think there's enough data to support that, but equally, we wouldn't have thought, you know, years ago about certain diseases and conditions that would be caused by certain things. So I think there's a lot to learn, isn't there? Yeah, I mean, it was just a very interesting thought that if you're thinking about the drop in sperm quality since the 70s and how much men's roles are changing since then, it's an interesting thought to think, well, we're putting men more in their feminine as their testosterone. Possibly, but then how does it affect testosterone? But yeah, sure, sure. So let's talk about TRT, because I think this is something that's been spoken about a lot online.

47:21When should people look at this as a treatment? and when should they not look at this as a treatment? What's the risk versus the benefits of TRT therapy? Sure. I think one of the problems about TRT is the concept that it is used more and more recreationally. Now, historically, and I think probably one of the negative factors about science is that we now know that testosterone has less harmful effects than what it used to in terms of exogenous or testosterone that's given either in injections or in the form of gels. I mean, we used to talk about the risk of prostate cancer, for example, where we now believe that it doesn't cause prostate cancer per se.

48:04Okay, so given it doesn't cause prostate cancer if you don't have prostate cancer. The other thing about it is that there used to be this issue of cardiovascular disease, a higher risk of cardiovascular disease, oddly, with testosterone, taking exogenous testosterone. We now believe from studies done that it doesn't. So it's become more and more acceptable that it's a safe treatment, especially now with more data emerging. We talked about metabolic syndrome and low testosterone association with longevity as well. So if we look at testosterone replacement therapy itself, there are various forms, but which patients are indicated?

48:43Well, I think that's if patients are symptomatic that we talked about earlier and have truly biochemical evidence of low testosterone. The group of patients we talk about, if your total testosterone is normal, above 12, you don't need testosterone placement therapy. Because there's also this concept, isn't it, that people sell and say, my testosterone could have been 20-odd when I was in my 20s. It's now 12. That's halved, so therefore I need it. That's not correct. I mean, ultimately, it's about these thresholds and these values. There have been studies that have done that show what these thresholds mean in terms of symptoms.

49:21So, testosterone, there are two different types. You've got to go back to basics. Two different types of hypogonadism or low testosterone. One is secondary, which can include late onset, which is the commonest one, the so-called male menopause, if we talk about that. So once you fall below the age of 50, certainly, testosterone levels fall and can fall significantly. The other group is the primary hypogandalism. So, men who have an intrinsic problem with their testicles, might have had chemotherapy, radiotherapy, surgery, twists of the testicle, cancers of the testicle, where there's primarily a problem with the function of the testicle.

50:00So, there's two different types. You've got to differentiate that. So, it's important to see a clinician and differentiate that, rather than just starting testosterone placement therapy. You want to know, why is my testosterone low? And also, screen you for other types of problems, like we talked about dyslipidemias, we talked about prediabetes or type 2 diabetes that can occur as well. So it's also important to look at all of that as well as lifestyle. So the type of patient that you would treat are patients genuinely biochemically with low testosterone who after you've gone through a comprehensive testing and trying to differentiate the two different types.

50:38So those patients who have generally low testosterone with symptoms And those are usually, in clinical practice, the late onset group of patients. In other words, the so-called male andropause or menopause as well. TRT generally is safe. There are some contraindications, for example, active prostate cancer, for example. Patients who have breast cancer, which is very rare. Patients who may have too much thickened blood, so-called polycythemia as well. And patients who may have heart failure as well. But generally speaking, it's a safe drug, which therefore means that one of the problems, of course, is it's often used as a recreational type of drug, that kind of image, social perception, concept of men, you know, who are muscular and strong.

51:25And that's the image that people want. That's more of a societal perception and more the problem in terms of the media in portraying what is a male, an ideal male. And I think that's kind of one of the problems that we face. Because we've got to remember, as you just said, that testosterone itself can have a negative impact on your sperm. Although we need testosterone, paradoxically, intratesticular testosterone for your sperm production, testosterone itself exogenous inhibits the brain hormones called FSH, which drives sperm production. So it suppresses it. So therefore, it acts like a male contraceptive.

51:59So this concept of taking it now, and that's kind of emerged over many years, but we still don't fully understand the full cycle of that. And there are also various other types of treatment people have tried, of course, which we can talk about. So I think anyone who hasn't had a child yet or is looking for fertility, it's really not a good idea to be doing TRT. No, and although it's reversible in the vast majority, but in some patients it's not reversible. Yeah. Androgen abuse, as we call it. And a certain number of patients don't recover their axis. There are other drugs that people can use. Generally, patients who have hypogonadism or low testosterone can give things such off-label treatments, which should be prescribed by a specialist, I add, as well, but often aren't, actually.

52:45This is kind of the gym environment. Drugs such as Clomid or HCG, which act differently. They boost your endogenous or your own body's testosterone rather than relying on an exogenous form. But exactly what you just said is that if you're thinking of having children, you shouldn't really be starting TRT or considering TRT. Something I found really interesting when I was looking at testosterone levels in men is that testosterone levels seem to drop after men have children. and I saw a study that said men with the highest levels of testosterone were more likely to become committed partners and fathers at which point they showed steeper drops in their testosterone than did their single childless counterparts.

53:29I found that quite interesting. I haven't seen that study but my comment would be that if you're in a relationship and it's a good relationship invariably it's probably going to be a long-term relationship and where I'm coming to is that if you've had kids invariably you've been in that relationship for a while so therefore you're going to be older so therefore is it just an age dependent factor yeah that testosterone drops as we know as you get older yeah so if you think you're going to have kids if you if we're having kids in our 30s you might have a 10 year old and eight year old you can be in your 40s and testosterone might be dropping that's the way I would look at it that's really interesting because I was thinking is it the body saying no more children it could be.

54:09Biologically, you know, it could be. We don't know enough, do we, about it? Why do women, you know, in terms of their ovarian reserve by 40 become, it's very difficult, isn't it? Why is that? Why should it switch off? I mean, that's really kind of an evolutionary discussion, isn't it? Yeah, I mean, that's one question that I think about a lot. But it's an interesting concept because you don't look at it in men, do we? We don't look at it in men. I think everything around children and fertility is always anchored towards women. And men just seem to, I think, it's just not conceptually spoken about at all.

54:43But I do think it is becoming now, I think men are becoming so much more aware of their health, they're becoming much more conscious of their health. And as you said, I think, you know, looking back at the 1970s, people weren't having children later. And so now we are, we're wanting to try and become more acutely aware of things that we can actively do, that are, as you said, also living in an environment that has so many more endocrine disruptors around us all the time, especially even living in London, in built-up cities. I'd also find that quite interesting. I haven't listened to data for this podcast, but I'd love to know if there is reduced fertility rates in cities in more than rural areas.

55:21Do you know if that's a thing? I can't tell you offhand, but there are studies which potentially show that. What about America versus Europe? Because I also know there's more tighter regulations of what can get passed in Europe. Yeah, and you talked to me about political and regulatory capacity. I can't tell you offhand about that either. But that's the kind of work we need doing, you know, in terms of rural areas, in terms of is it a first world problem or is it a third world problem as well? And we need comparative studies to look at that. Yeah, because I know the regulations here in the EU are much, much tighter than regulations in America.

55:56And I know there's a lot of conversation right now, especially with everything that's happening over there, with people wanting to change that policy to make it harder to make it similar to you, which will also have an impact on fertility. And that's the kind of wider issue that is out of the individual's hands when it comes to this, I think. So thinking overall from a male who is listening to this, whether they're experiencing infertility, whether they're just curious about fertility for longevity or for children. What would you say is one of the most important concepts for that person, this individual right now, to be taking away from today's conversation, how they can support their health in this way?

56:39I think the basics of good health, basically. Eat well, live well, be happy, try and take out stress, exercise. We talked about Mediterranean and diet, not to overindulge in alcohol, stop smoking, recreational drugs, don't take TRT as a recreational use. All those things are important. I think if you want to get checked, you should get checked. Don't be scared of checking. I mean, there are companies now that do home delivery kits for similar analysis. It's a bit difficult. If you say to somebody, you've got to go to a lab for a test, it's kind of embarrassing, isn't it? It's very embarrassing to go and have to do that.

57:23And so therefore, I think there are people, specialists who can help you as well. I think that's really important to be aware of. And there are things you need to think about in terms of your general health. It's not just about your sperm count as well. So I'd be saying that get yourself checked out. You can do a sperm test very easily. Either you can get it online or you can go to a lab. There are many, many out there. But I think it's also putting it into context as well of your partner's age as well. and make sure that you don't leave it too late. And if you're thinking about kids, start early.

57:57And ultimately, it depends on your own lifestyle, but ultimately do get tested if need be. But I don't think we should be scaring people into all of this. I think it's also about choice and people's choice. And ultimately, we do live in a society that we are older and having children at an older age as well. but get if you need testing and go and see a specialist yeah and that there are things that you can actively do absolutely you know and there are things that you can change and you empower yourself take control and i think it is quite simple to do a sperm test remember we said it's not just a sperm test it's not the whole picture but it gives you an idea of your fertility potential sucks thank you so much for coming on to live well be well today i always leave with a final question um which i'm looking forward to your answer which is what does live well be well mean to you mine is a bit different i think um i think to live well is to try and live healthily as you can we all like a glass of champagne and we all like to do things that are bad for us um and i think it's basically getting a balance i think it's a balance of your own health and psychological well-being.

59:11You can't always be strict in terms of your diet. You've got to have some vice in life and you've got to enjoy yourself as well, but get the balance right. And as long as you have insight into that and you can change that and modify that, then that's fine. Joy is such an important word, I think, in health today. So I'm really glad that you said that. Great. Thank you. Thank you so much. Pleasure.

59:40Thank you.