How Women Can Improve Their Fertility & Hormone Health | Dr. Natalie Crawford

0:00 Everybody should get an AMH test.

0:01 I think it's a very important marker.

0:03 If you are listening to this and you want kids one day,

0:06 ask your doctor for this test.

0:08 It is not a test of egg quality.

0:10 And we talked about what egg quality is, right?

0:11 Genetics and egg competency.

0:14 But it is a check of how many eggs you have and that knowledge

0:18 can be really impactful for how you view your future and your plan.

0:22 Welcome to the Huberman Lab Podcast where we

0:24 discuss science [music] and science-based tools for everyday life.

0:31 I'm Andrew Huberman and I'm a professor

0:33 of neurobiology and ophthalmology at Stanford School of Medicine.

0:37 My guest today is Dr.

0:38 Natalie Crawford.

0:39 Dr.

0:39 Natalie Crawford is a double board

0:41 certified physician specializing in obstetrics and gynecology,

0:44 fertility, and reproductive health.

0:46 Today we discuss the actionable steps that all women can take to improve

0:51 their reproductive and hormone health both

0:53 to enhance probability of successful pregnancy,

0:56 but also because fertility and hormone health

0:58 are strong correlates of general health and longevity.

1:01 Dr.

1:01 Crawford shares what all women, regardless of age or reproductive goals,

1:05 can do to enhance their health using lifestyle, nutrition, supplementation,

1:10 and prescription medical tools that she indeed uses in her practice.

1:14 We also have a very honest discussion

1:16 about biological versus chronological age and fertility.

1:19 Why age is not just a number,

1:21 but also why it is that many women do successfully conceive in their 40s.

1:26 Of course, there's a lot of information online nowadays about women's hormones,

1:30 fertility, and health.

1:31 Today, thanks to Dr.

1:32 Crawford, you'll learn what is known and documented and what she has

1:36 herself consistently observed clinically in her practice

1:39 about women's health and fertility.

1:41 Few, if any, people have Dr.

1:43 Crawford's training, clinical acumen, understanding of the new research,

1:47 and incredible ability to communicate the well

1:49 and lesser-known actionable steps for improving female health.

1:53 Dr.

1:53 Crawford also has a new book out entitled The Fertility Formula:

1:57 Take Control of Your Reproductive Future,

1:59 which again focuses on reproductive health,

2:01 but also hormone health and how both of those things

2:04 impact female health in the short and long term.

2:07 Before we begin, I'd like to emphasize that this podcast

2:09 is separate from my teaching and research roles at Stanford.

2:12 It is, however, a part of my desire and effort to bring zero

2:15 cost to consumer information about science

2:17 and science-related tools to the general public.

2:19 In keeping with that theme, today's episode does include sponsors.

2:23 And now for my discussion with Dr.

2:24 Natalie Crawford.

2:26 Dr.

2:26 Natalie Crawford, welcome back.

2:28 Thank you so much for having me.

2:29 I'm thrilled to be here.

2:30 And congratulations on your new book, The Fertility Formula.

2:34 It's no small feat to complete a book and it's and it's especially

2:38 a big feat to complete a book that offers people so much advice,

2:41 not just people who want to get pregnant,

2:45 but also looking at things through the lens

2:47 of fertility as an important health metric.

2:50 Yes.

2:50 Thank you so much.

2:51 You know what goes into writing a book and it's always been this aspirational

2:55 goal of mine and after educating and talking

2:58 about fertility with patients and people online,

3:00 it's been something I've wanted to do,

3:02 but I will say it is a much bigger feat to go through it,

3:06 to work with editors, to try to refine within your word count.

3:10 I was, you know, I was 20,000 words over and try to bring it back in.

3:13 So, thank you for having me and for holding it up

3:16 and reading it early and sharing your endorsement for it, too.

3:19 That means so much.

3:20 Yeah, I I'm insisting, as much as one can insist,

3:23 that various people in my life read this book,

3:26 um, including family members and other people because, again,

3:29 it's not just about people who want

3:31 to have children or who already have children,

3:34 but fertility as a way of kind of knowing where

3:37 one is in their health arc and their life arc.

3:40 Um, so if you don't mind, um,

3:43 how should people think about fertility purely as uh a read-out of health?

3:48 I mean, what just how do you how do you frame

3:49 this for like if somebody comes to you and says, "Listen,

3:52 they have kids or they don't want kids or they're not sure if they want kids,

3:55 but um, why use fertility as a lens on general health?

4:02 Yeah, fertility is a health marker and I love that you bring

4:05 that up the top of the episode here because so often patients,

4:09 women specifically, think fertility is only the ability to get pregnant.

4:13 We really simplify it into this one phase of life.

4:16 But if we want to zoom out,

4:18 your fertility is a sign that you have good hormonal health, good cellular,

4:21 good metabolic health because it takes

4:24 so many different moving parts to ovulate,

4:27 for an egg to allow a sperm to fertilize, to implant, to get pregnant.

4:31 But also your hormonal health and the ovarian

4:33 function is really going to impact your entire life,

4:36 how you feel on a day-to-day as a woman.

4:39 But if we want to be really specific, if you have infertility,

4:43 you have increased rates of metabolic syndrome,

4:46 cancer, heart attack, stroke, and dying early.

4:50 So, those are extremely scary statistics and you know,

4:53 I had my own infertility journey, so I fall into this category.

4:57 But the reason why is not that infertility causes any of those things directly.

5:02 It's that for most people, it's one of the first warning signs that something

5:06 is not right in their body and that there's

5:08 higher levels of chronic inflammation or insulin resistance

5:12 that we know can impact long-term health outcomes.

5:16 For women who are still of reproductive age,

5:19 and I realize there's no strict cut-off,

5:21 um, we can and and certainly will talk about what are the measures,

5:26 direct and indirect, of fertility that, um,

5:28 can give them a window into their kind of health span risk factors,

5:32 life span risk factors.

5:34 For women that have already reached menopause or in perimenopause,

5:38 um, how should they think about fertility as a health marker?

5:42 Meaning, if somebody is has passed the point

5:45 where they can safely, um, get pregnant, Mhm.

5:49 does that mean that their periods are no longer informative?

5:52 I imagine their periods features about their menstrual

5:54 cycle are still very informative about their general health.

5:58 As long as you're having a menstrual cycle,

6:00 it is a sign that you're ovulating and you theoretically could get pregnant.

6:04 So, I think it's really important to say that even in perimenopause,

6:07 which is the transitional time between having regular,

6:10 appropriate hormonal function,

6:12 that reliable characteristic of the ovary responding to the brain,

6:16 this is the transition time as you're starting to get to a lower

6:18 egg count that you will eventually start to see some cycle changes,

6:22 but you also have a lot of hormone dysfunction.

6:25 But you can still get pregnant and in fact,

6:26 I see a fair amount of patients who said,

6:29 "I thought I was past that stage of my life

6:31 based on my age." But if you're still having periods,

6:34 it's a really important window into your hormonal health.

6:39 It can tell you a lot about your body,

6:41 especially if you know when you ovulate and we

6:43 can look at the distinct phases of the cycle,

6:46 the follicular phase and the luteal phase.

6:49 When we're a little bit past this, menopause by definition,

6:52 which I hate, is 12 months without a period.

6:54 So, menopause is one single day in time.

6:56 Really, it means you've been in ovarian failure

6:58 for 12 months before you'll magically get this diagnosis.

7:02 But menopause at its purest is ovarian failure.

7:05 The ovaries no longer have the capability to respond to the brain signals.

7:09 You're not going to make estrogen or progesterone anymore.

7:12 At that time, a woman's metabolic health completely changes,

7:15 but the age of which you went through

7:16 menopause really can impact your reproductive health outcomes long-term.

7:21 And some of the characteristics you might have had in your cycle

7:25 when we look backwards can inform us some about your cellular health now.

7:29 So, it's still really important to think back and move forward.

7:32 And then on a bigger scale,

7:35 we're seeing the tide turn on hormone replacement therapy

7:37 and I know that's not what this entire episode's about,

7:39 but as a reproductive endocrinologist, I love estrogen.

7:42 I love hormones.

7:44 And I think it's really important for women to know

7:45 that you can start hormone replacement therapy at any time.

7:48 So, even though long time ago we felt really

7:51 comfortable starting it right at the time of menopause,

7:55 we're starting to see benefits starting in the perimenopausal period.

7:58 We see a benefit starting at once you have menopause,

8:02 but I think it's a disservice to women to make them have no period,

8:06 ovarian failure for 12 months, no estrogen, feel terrible,

8:10 before we'll allow them to have hormone replacement therapy.

8:14 Yeah, this is such an important theme and and if I may,

8:17 um, I I realize I have to be very careful,

8:21 uh, to not draw parallels to men's hormonal health when

8:25 talking about women's hormonal health because it's not a one-for-one.

8:28 They're very distinct processes.

8:30 On the other hand, I think thematically, what I'm about to say, I believe holds.

8:34 So, hopefully it won't upset too many people, which is,

8:37 you know, for many years now, um, for reasons that, uh,

8:42 are unfair, um, hormone replacement therapy was sort of became

8:49 widely available for men before it became widely available for women.

8:52 Uh, there are reasons for this.

8:54 We don't have to go into it, but they're they're the kind of obvious ones.

8:56 Um, uh, that things were pushed to market more quickly and and so forth.

9:01 But there's been this idea, you know,

9:03 should and there it's usually testosterone replacement therapy, right?

9:07 Um, and there was this idea that unless

9:10 somebody fell below 300 ng/dL for for a male, that they weren't, um, uh,

9:17 that they shouldn't get testosterone replacement therapy.

9:19 Now it's kind of understood that if somebody chooses,

9:22 they can usually find a doctor that if they're the low end of normal,

9:26 they can push to the high end of normal or to the middle

9:28 of the of the range so that they can get their symptoms away and and just feel,

9:33 right, to optimize within the normal range.

9:34 That's sort of And so,

9:36 I'm relieved to hear that you're saying the same is true for women.

9:39 And I'm relieved to hear it because I think that having

9:42 these strict cut-offs of like no periods for a year,

9:44 well, I mean, it could take a long time to reach that.

9:47 I mean, what if it's, you know, two periods per year, right?

9:50 Does that mean that that person doesn't deserve the therapy,

9:52 which is what essentially what I think you're saying.

9:54 So, the R in hormone replacement is the dangerous letter

9:57 in my opinion because there is this notion of augmenting hormones.

10:03 Exactly.

10:03 Okay, so for forgive me for going long,

10:04 but I think the two situations it would be

10:06 great if both women and men could augment their hormones

10:10 to be at the high end of normal or wherever

10:12 puts them in a place where they're not experiencing symptoms.

10:14 Absolutely.

10:15 We know that as humans,

10:17 we now have longer lifespans, we outlive our reproductive hormones,

10:20 yet they are essential for our day-to-day function and to feel our best,

10:24 and we should at least be given the opportunity to have our symptoms evaluated,

10:29 to be offered hormone therapy if we want it,

10:32 and to not have to have these harsh cutoffs,

10:35 especially for something that can be so protective long-term.

10:39 I mean, for women we see it be cardioprotective,

10:41 it can help lower the risk of Alzheimer's disease,

10:43 of course it can be protective for your bones.

10:46 So, I love this greater discussion,

10:48 and it really stems from learning about your body,

10:51 knowing what's normal so you can advocate for what's not normal,

10:55 and really feeling like you have your own

10:56 agency over your health and your own future.

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13:34 I wish that um the medical profession um

13:37 could agree on nomenclature that included hormone replacement,

13:41 the R, replacement therapy for people that are out of range.

13:45 You know, they're two too low, out of the normal reference range.

13:49 Hormone augmentation therapy um for people

13:51 that want to push within the normal range.

13:54 And then of course, there's super physiological stuff,

13:56 and that's kind of how all of this got here was

13:58 there were a bunch of mainly guys taking tons of anabolic steroids,

14:03 and then estrogen's a steroid, you know, testosterone's a steroid,

14:06 and then it just became a long road to get to this point

14:10 where people like you are able to even talk about this, right?

14:13 I mean, I think 10 years ago, I think the medical profession was not

14:16 open to the idea that a 40-year-old woman,

14:19 for instance, who had not yet undergone menopause by the strict definition,

14:23 would take estrogen.

14:24 It was seen as a risk as opposed to a benefit.

14:26 Isn't it interesting?

14:27 And, you know, by professional organizations,

14:30 they would even call it menopausal hormone therapy,

14:33 MHT, not even just hormone replacement therapy.

14:36 And I talk about this a lot with my patients,

14:37 the difference in replacing a hormone we'll use in an embryo transfer cycle.

14:42 If I'm going to give you estrogen,

14:44 you haven't ovulated, I now have to replace your progesterone.

14:47 I have to give it in a certain format

14:49 that it can get to high enough levels versus supplementing.

14:52 Your body's making some,

14:53 and we're supplementing that or augmenting it like you said to get

14:57 it to the appropriate level or to make sure we have enough.

15:01 I've given hormone therapy for a long time, right?

15:03 I've been out of practice for over 10 years,

15:05 and what's so interesting is that we'll use premature ovarian failure.

15:08 So, going into ovarian failure before age 40,

15:12 well accepted that these women need hormone replacement even

15:16 when they still have the low end of hormonal function.

15:19 So, in this population,

15:20 we've been doing it for a really long time, but for menopause,

15:24 it's been and so frowned upon because of the WHI

15:27 and fear-based tactics about what would happen with hormone replacement.

15:31 So, it's interesting, and I'm really glad to see the tide is turning,

15:35 and we're really allowing people to stand up for themselves,

15:40 to also know what's normal within their body, which sounds so common,

15:45 but if we think about it, many women have been dismissed and gaslit for so long.

15:50 And if you go to your doctor and you

15:52 talk about your painful periods or your irregular

15:54 cycles or your bloating that you have with your period

15:56 and some of these red flag warning signs,

15:59 the spotting, the this, and it gets pushed to the side,

16:02 when you start to go through actual hormonal change later,

16:05 it's really hard to then believe yourself.

16:09 And so, I think it's really important, you know,

16:12 I have a whole chapter in the book about how to learn to track your cycle

16:15 and your ovulation and really learn to see the red flags your body gives you,

16:19 not just if you want to get pregnant now,

16:20 but to know that your hormones are really functioning as they should,

16:24 and that's going to help you stand up

16:25 for yourself later when you're in this transitional period,

16:28 because perimenopause or diminished ovarian reserve like

16:31 we call it in the fertility world, I mean, that can last 5 to 10 years.

16:34 That can be a really long transitional period that women are going through,

16:38 and they deserve support if they're not feeling their best.

16:41 Are all um now I want to call it hormone augmentation,

16:45 hormone let's just call it hormone replacement for for sake of uh simplicity.

16:49 Um hormone therapies uh for women,

16:52 do they always start with estrogen when it comes to trying

16:56 to encourage fertility or push fertility or well-being out into um more years?

17:02 That's an interesting question.

17:04 I think when it comes to hormone replacement therapy in general,

17:07 we've got estrogen, progesterone, testosterone.

17:10 Most women when they start not reliably making estrogen,

17:13 that's when they really start to feel bad.

17:15 And so, typically some type of estrogen replacement,

17:18 and there's many different ways, right?

17:19 There's patches, there's pills, there's vaginal inserts, there's vaginal cream,

17:23 often helps some of the symptoms they're having.

17:26 But, progesterone alone or in combination can be a big player.

17:29 Progesterone also is not made if you're not ovulating well,

17:33 so there's this tandem where often you need both of them,

17:36 but I have some perimenopausal patients who feel great on just progesterone.

17:41 To me, testosterone's the last one we add to the mix,

17:44 and it will always depend on clinical scenario.

17:46 There's nuance.

17:48 Estrogen and testosterone can convert back and forth,

17:50 so for most women, if they are adequately being replaced on estrogen,

17:55 and they still have functioning ovaries,

17:56 so in this transitional period, they tend to not need testosterone.

18:00 But, that's never 100% of the time.

18:03 I think greater to your question about how is there a way

18:06 for us to extend the ovarian lifespan is a really good one.

18:11 We know that women who go into ovarian failure early,

18:13 so when we look at that, we call it POI,

18:15 the premature ovarian insufficiency group,

18:18 their ovaries have more inflammatory markers,

18:20 they have more chronic inflammation and fibrosis inside the ovary.

18:23 There's a higher prevalence with autoimmune

18:25 disease or chronic inflammatory disorders.

18:28 So, I think there's also something to be said,

18:30 despite having not having the perfect paper to sit here and say

18:33 that we know a variety of different things that increase chronic inflammation,

18:39 cause you to have a lower egg count,

18:41 and are associated with earlier menopause or earlier ovarian failure,

18:44 that paying attention to these factors earlier in your life,

18:47 whether it's controlling an autoimmune disease,

18:50 earlier diagnosis of Hashimoto's, whether it's treating your endometriosis,

18:55 or cultivating a lifestyle that's decreasing inflammation, right?

18:59 Avoiding certain toxins, eating anti-inflammatory foods, the type of exercise,

19:03 and how we deal with those lifestyle tenants,

19:05 that that likely has the capability to extend

19:08 our ovarian lifespan to the degree that it can.

19:11 I know these days people are very concerned about plastics, Yeah.

19:15 and you mentioned toxins, so I was going to get to this later,

19:18 but I'll just ask now.

19:19 How concerned are you about plastic water bottles and um I mean,

19:24 we can't avoid exposure to plastics, and I think one thing that Dr.

19:28 Rhonda Patrick has done nicely is to highlight the fact that the really small,

19:32 hence microplastics, are really the ones that we worry about

19:35 the most because they can get into so many tissues,

19:37 but we're constantly ingesting plastic.

19:39 Some of them are just excreted um because they're big,

19:42 but some of them get into our cells, right?

19:45 Are there any data that have you or observational um data that have

19:49 you genuinely concerned that plastics are

19:53 becoming more of an issue vis-a-vis fertility.

19:57 There definitely is concern.

19:59 I always want to frame this and you did a nice job of it,

20:01 so I'll I'll double down.

20:03 The goal when we talk about toxin avoidance is you can't avoid everything.

20:07 You cannot avoid every toxin in this world,

20:09 nor should we try to have this all or nothing mentality,

20:12 which is what so many people do.

20:14 Oh, if I can't avoid it, I just will totally ignore it then in general.

20:19 When we want to think about toxins,

20:20 there's many different mechanisms why plastics can be harmful.

20:23 When it comes to microplastics as you mentioned,

20:25 we know they can accumulate in the ovary.

20:27 So, if we want to be really transparent and simple,

20:30 your ovaries must function in order for you to make estrogen and progesterone,

20:35 in order for you to ovulate, in order for you to get pregnant.

20:38 So, if microplastics can accumulate inside the ovary,

20:42 that's obviously detrimental towards fertility or ovarian function.

20:47 On a greater scale, we know that some of the endocrine disrupting

20:51 chemicals that are in plastics have been associated with worse IVF outcomes,

20:55 lower live birth rates, longer time to pregnancy.

20:58 And these are population-based cohort studies,

21:00 so there's no randomized control trial.

21:02 So, we have to limit it.

21:05 And there's some truth to the fact

21:06 that people who might be more exposed to plastics

21:09 may have other lifestyle factors such as we

21:13 know plastics can also be in food wrappers, right?

21:16 So, maybe they have more of an ultra-processed food diet.

21:18 So, it's never one specific thing.

21:21 But I look at all of these lifestyle

21:24 factors and I include toxins as one of them.

21:27 These are all either contributing

21:28 to your inflammatory burden or they're helping you.

21:30 And when we start thinking about optimal hormonal health and fertility,

21:35 it is your decision every single day.

21:37 Am I drinking water out of this cup or out of a plastic bottle?

21:40 Am I going to lift weights, do nothing?

21:42 Am I going to run?

21:43 How much sleep am I going to get?

21:45 What foods am I going to eat?

21:47 How do I deal with stress?

21:49 And these choices, even though one single one

21:51 is not going to make it or break it,

21:52 together they can add up to that inflammatory

21:55 burden or they can help decrease it.

21:57 And that chronic inflammation does in fact

21:59 matter to your fertility and does worry me.

22:02 I realize I'm jumping jumping around here a bit,

22:04 but um in just thinking about what seems to be on a lot of people's minds,

22:08 I took a informal poll of some people heading into this cuz

22:12 obviously I I only know my own experience as a male.

22:14 So, to a number of women,

22:18 I asked the question um you know, what what are you wondering about?

22:21 And a common question was um it seems that for some women,

22:27 if they've been pregnant once before,

22:30 uh they have it in mind that it's going to be

22:32 easy for them to get pregnant again later or easier.

22:36 And of course, they understand the logic

22:37 that they were younger before by definition, even if it's a year, right?

22:41 Um and that fertility drops off with time.

22:44 But there seems to be this um kind of belief uh that if one was pregnant before,

22:51 that it's going to be possible to get pregnant again

22:53 within the normal windows of biological windows for getting pregnant.

22:58 Is there any evidence that having been pregnant

23:01 before makes it easier to get pregnant again?

23:04 That's separate from the fact that obviously, they were pregnant before.

23:07 I realize that's a convoluted question,

23:09 but it's not a perfect experiment, right?

23:11 Because they've been pregnant before, obviously they can get pregnant.

23:13 If they haven't, the control group is not a very Yeah.

23:17 uh it it's not a good control group for an experiment.

23:20 But for within the person, if they've been pregnant before,

23:23 can they exhale a little bit that yes, they can get pregnant?

23:27 I did fellowship research with the primary investigator on a large cohort study,

23:32 one of the biggest ones we have on natural fertility,

23:34 and this study was called time to conceive.

23:36 And it was looking at women who did not have a history of infertility,

23:39 who were trying to get pregnant, who were 30 and older.

23:41 And then we looked at different variables of them.

23:44 And one of the most startling pieces of data

23:46 is that there's a huge age-related impact of fertility, right?

23:50 This data set set the standards for the numbers that we quote.

23:54 Meaning, if I will sit here and say if you're

23:55 trying to get pregnant with your first child and you're 30,

23:59 you'll have a 20% chance per month, right?

24:01 The finest point we look

24:03 at in natural fertility studies is called fecundability,

24:06 the probability of pregnancy per month.

24:08 But as you age, when you're 35 to 36, that number will be 11 to 12% per month.

24:13 At age 38, it'll be 5% per month.

24:16 And at 40 and beyond, it'll be 3% per month.

24:19 Importantly, for the person hearing this, none of those numbers are zero.

24:23 And so, by no means do we mean you can't get pregnant.

24:25 But in the group who had a child before

24:28 and were trying to conceive with the same partner,

24:30 that number stayed between 18 to 20% up till age 37.

24:34 And then it dropped.

24:36 So, we do see that there is

24:38 this protective benefit for a multitude of reasons, right?

24:41 You conceived with that person, so they had sperm, right?

24:44 Sometimes I find out some patients,

24:46 the male partner has no sperm and we didn't know all that time they were trying.

24:50 Goodness.

24:50 Right?

24:50 Oh, I've had patients try for years, be dismissed by their doctor.

24:54 Because men and women mistakenly think

24:56 that because there's semen, there's sperm.

24:58 Exactly.

24:58 There's ejaculate, so there must be sperm inside of it.

25:02 And then when we find out there's none, it's it's heartbreaking.

25:05 It's a big reason why we can segue and say one of the things

25:09 I really hate the most right now about my field is that by definition,

25:15 infertility is a failure.

25:16 And we don't even recommend testing or screening or talk

25:20 about a preventive approach at all until you have failed.

25:24 Yet if we look at the population, say okay,

25:26 the definition of infertility is trying to get pregnant for 12 months.

25:29 And then once you've reached that point, well now we'll check a semen analysis.

25:33 Now we'll do an anatomical investigation.

25:35 Now we'll check your ovarian reserve.

25:37 Now we will discuss if you're ovulating.

25:40 So, we're making you go through this period of time where you're trying and yes,

25:45 maybe the majority of people will get pregnant.

25:48 But most people who do will get pregnant the first 6 months.

25:51 So, 72% of people will get pregnant in that first 6 months of trying

25:55 and only 13% will get pregnant in the next 6 months of trying.

25:59 That's why if you're 35 and older,

26:01 we will shorten that testing interval down to 6 months.

26:04 But sitting across from so many people who've tried and tried,

26:07 went to their doctor, their doctor said, "Oh, you're fine.

26:11 You're young.

26:12 You're this, you're that." Forced them to try longer and fail.

26:15 And then to find out fallopian tubes were blocked.

26:18 They had a birth defect of the uterus.

26:20 He had no sperm.

26:21 She had low ovarian reserve.

26:23 And they would have intervened differently back

26:25 at time period A had they had that data.

26:28 Really makes me feel like we have to switch how

26:30 we approach infertility in the world where infertility rates are rising,

26:35 women are waiting later to get pregnant.

26:38 It doesn't really make sense to make people

26:40 fail first before we'll even do an investigation.

26:43 We should test things and if it's all normal,

26:45 maybe you do just go try your 6 or 12 months.

26:49 We would capture people who don't get pregnant and be

26:52 able to help them at a sooner time period, which is so valuable.

26:56 So, to your origin question, there is data that having a child previously puts

27:01 you statistically at a higher chance of getting pregnant again.

27:06 But secondary infertility is real.

27:08 This is where you've gotten pregnant before and now

27:10 you're having a hard time conceiving your second child.

27:13 I want to acknowledge that it's really hard

27:15 for people who walk it because they weren't expecting it.

27:19 They're a little underprepared for it because they said, "Oh,

27:22 I got pregnant so fast before." They come

27:24 into it just assuming it will be as easy.

27:28 They watch their children have a longer age gap,

27:30 a bigger age gap than they wanted.

27:31 But also, they don't really fit into the community.

27:33 Meaning, there's a really robust infertility

27:35 community and they support each other.

27:38 And so many patients who have secondary infertility say they feel caught

27:41 in between feeling guilty that their child's not enough for wanting more.

27:46 Of course, they're thankful for their child,

27:48 but not really fitting into that category.

27:51 Yet also simultaneously feeling left behind their friend group

27:56 or their family group or watching their family start to look differently.

28:00 And so, even in women who've had a prior child, age does become impactful.

28:04 It's not the only variable.

28:06 We also see that, you know, sperm counts change with age.

28:09 So, your partner's sperm count will change with age.

28:11 We see egg quality starts to change with age,

28:13 largely because metabolic health changes with age as well.

28:17 And then we see things like endometriosis and adenomyosis,

28:20 which are tincture of time diseases.

28:22 It's simply you've had more time,

28:24 so there's a higher probability that these diseases could be present.

28:28 So, I think it's important to say yes,

28:30 you can probably take a sigh of relief that most likely,

28:34 you won't have trouble again.

28:35 But if you've been trying those 6 months after and you're not pregnant,

28:39 I would say kind of at the longest, go and get an evaluation.

28:42 And if you're a little bit older, maybe started your journey a little bit later,

28:46 it's never too early to get an evaluation for anybody at any

28:48 time cuz you can't make decisions on data you don't know.

28:52 I'm a big fan of knowing the data and then making the choice that's right

28:55 for you and your circumstance versus taking population-based

28:59 data and just applying it to every single person.

29:02 Yeah, all excellent points.

29:03 And um with respect to the sperm testing,

29:06 since clearly there are men who think they're making sperm and they're not,

29:11 um there are at-home tests of that as well.

29:14 So, once again, men have it a little bit easier.

29:16 They can do it at home.

29:17 Although, I don't know how high quality the at-home tests are.

29:19 There are some that are just telling you,

29:21 almost like a pregnancy test, plus minus, are sperm present, are sperm not?

29:25 Of course, that's not really telling you the full picture.

29:27 There are those some mail-in tests that go

29:29 to a true lab that we would even take as valid.

29:32 So, it's a it's called a CLIA certified lab, CLIA, for somebody listening.

29:36 And you can find some of these online mail-in sperm tests and collect a sample.

29:39 They send you the whole kit, you mail it off.

29:41 It's very valid.

29:42 And you get all the sperm parameters that we would then look for.

29:45 So, that's a great way to get data yourself and not have

29:49 to have your doctor tell you no or go to a fertility clinic.

29:52 I mean, we'll do a semen analysis for anybody who calls and most clinics will.

29:56 It's usually earlier that patients are getting roadblocked,

29:59 whether it's their PCP or their regular OBGYN.

30:02 They're getting dismissed and just oh, just try first, it's probably fine.

30:06 Mhm.

30:06 You mentioned that if a woman has had a successful

30:09 pregnancy that the probability of getting

30:11 pregnant again is significantly higher, although with the caveats you mentioned.

30:15 Is there any data about if someone has

30:18 been pregnant and either terminated or lost the pregnancy,

30:21 whether or not that's related to ability to get pregnant again later?

30:24 It's a good question.

30:25 Most of the data that exists is looking at prior live birth.

30:27 So, I think there's a couple things if you've

30:30 gotten pregnant regardless of the outcome of that pregnancy,

30:33 if it's with the same partner,

30:35 we can feel confident that they had sperm present.

30:37 So, that's already one leg up over never getting pregnant.

30:41 If it was an intrauterine pregnancy,

30:43 we know at least one fallopian tube was functioning.

30:46 So, that's also in the camp of we're checking some

30:49 mental boxes of some of the things that we think about.

30:52 And we know your body could accept an embryo implanting at least to some degree.

30:55 The top cause of pregnancy loss is going to be random genetic abnormality.

31:00 This wasn't the right embryo or the embryo didn't

31:02 have the right capacity or capability to truly implant.

31:07 So, I think that should give you some sigh of relief that it's

31:10 probably going to be a little bit easier because certain boxes are checked.

31:15 I think it's also really important to say I mean,

31:17 I had four pregnancy losses myself.

31:19 I don't know if you know this.

31:19 So, I had four pregnancy losses.

31:21 Yeah.

31:21 I mean, and and by the way, could I really appreciate the personal story

31:26 uh sharing in the book because it um

31:29 it really clearly was in service to your patients and to the to the reader.

31:34 And even as a male who can't relate certainly to certain aspects

31:38 of all this, um it was it was not only very moving,

31:42 but it was it was really a testament to just how that sort

31:46 of thing lands and then the process of trying to sort out what's real.

31:50 And it just made me even more

31:51 grateful for the the other information because otherwise,

31:55 I mean, it would sort of be like if I'm talking about ovarian health, right?

31:58 Which I've I've talked about on podcast, but yeah, with all the caveats,

32:02 you know, that that how but of course, how could I possibly know?

32:05 So, the your personal experience well the reader and I,

32:09 you know, feel feel and felt for you in in reading it.

32:12 It is it is super impactful because people there's a level

32:15 of trust that just comes from somebody who's been through that whole jungle.

32:18 Thank you.

32:20 I'll try not to cry on this show about it,

32:21 which is funny cuz it's so long ago, right?

32:23 I have two children now.

32:25 Had them after this journey.

32:27 And it was terrible for so many different reasons.

32:31 Of course, going through pregnancy loss is an emotional roller coaster.

32:35 I started to have a lot of self-blame against myself.

32:38 I felt like it was my own body, something was wrong.

32:41 And professionally, what I was unprepared for is I was This was

32:46 the end of OBGYN and then

32:47 the beginning of my reproductive endocrinology fellowship.

32:50 So, I felt like how am I going to be a fertility doctor,

32:54 Andrew, if I can't even get myself pregnant?

32:56 Right?

32:56 The professional impact of how it made me view myself and my space,

33:02 I was so unprepared for, right?

33:04 We especially in an era where you separate your personal and professional life,

33:08 which is, you know, what was 100% accepted back then.

33:12 You know, my last pregnancy loss was an ectopic pregnancy.

33:14 My fertility nurse had to give me my methotrexate shot.

33:17 I mean, everybody knew about it.

33:20 And I felt like a really big failure.

33:23 And when I sought help to say it'll happen, just relax,

33:27 there's nothing you can do or even just do IVF,

33:31 felt so dismissive of what I felt like was true as the patient experience.

33:37 Say, well, what about this symptom or what about this question?

33:40 And just really, really pushed aside.

33:41 And I'll be honest, it made my whole career is different because of it,

33:46 which isn't it interesting how sometimes things happen to us that are not ideal.

33:51 And that can be really terrible.

33:52 I have the two kids I'm meant to have,

33:55 but also I have forever viewed fertility differently.

33:58 In fact, all my fellowship research was on natural

34:01 fertility because of it cuz I said at the core, I want to know why some people

34:05 get pregnant naturally and why other people don't.

34:07 Like I really want to know that.

34:09 I want to do epidemiologic research.

34:11 I got a master's in clinical research

34:12 because that research is very complicated to understand.

34:16 And most fellows do an IVF lab project, which is great,

34:19 but it's a lot more of a controlled environment.

34:22 And then I've been so passionate about talking about it since then.

34:25 And so, I think to walk back what I wanted

34:28 to say though is if you've gone through pregnancy loss,

34:30 I don't want to ever dismiss how terrible that experience is.

34:34 And sometimes it can feel that way by me

34:36 sitting here as a professional and saying oh,

34:39 you had a pregnancy loss, so that could be a good sign for the future.

34:42 Mhm.

34:42 And I don't want anybody to ever feel that hearing it,

34:45 but it does tell us that certain systems are intact.

34:48 On the other hand, after two pregnancy losses, you need an evaluation.

34:52 The evaluation is for certain blood tests, a semen analysis,

34:56 a sperm fragmentation, and a uterine and tubal evaluation.

35:00 That can be moved up to one if you had heavy blood loss,

35:05 you know, needed a D&C procedure, if your periods have changed afterward,

35:09 if anything was really off, you can always get tested.

35:13 And we never want to be in the world where we used

35:15 to make women go through three pregnancy

35:17 losses before they would get an evaluation.

35:19 And I fell into that camp.

35:20 After two, I said, shouldn't we do tests?

35:24 I'm starting to fall off the curve here.

35:25 Isn't something wrong?

35:27 And I was told, you need to have

35:28 another pregnancy loss before we'll do those tests.

35:31 And that's the worst thing,

35:32 the worst feeling that I had to fail again to a certain

35:36 degree and lose a pregnancy before they would even investigate why.

35:40 Yeah, that this theme it seems of like it's only

35:44 menopause when you haven't had a period for a year,

35:46 you have to have two pregnancy losses and then

35:47 we can put you into this category of like oh,

35:50 amenable for treatment.

35:52 I mean, it's so it's um something really backwards about all of that.

35:56 I imagine with your book and um you being public facing with health information

36:00 and hopefully others um with you in your field that eventually this will change.

36:05 I mean, I if I were to draw the parallel to psychiatry, which isn't a fair one.

36:08 I mean, should someone really have to um be waking

36:11 up at 3:00 in the morning for an entire year

36:13 and have no uh hope for the future and be

36:16 near suicidal before they get whatever the adequate treatment is?

36:20 or whatever is going on.

36:21 It doesn't [clears throat] it doesn't make sense.

36:23 I don't think it serves us.

36:25 And I will say this, too.

36:26 And we're starting to see a change.

36:29 My big lofty hope for the book is that it changes the entire field of fertility.

36:34 Like I understand why OBGYN used to take care of this.

36:38 And then at some point they said, some people have infertility,

36:41 let's draw a line in the sand and have some people specialize in this, right?

36:45 And I had 3 years of training in that after OBGYN.

36:49 But at the same point, it doesn't make sense to practice that way.

36:53 It doesn't make sense to force people to fail.

36:56 And I might tell you, hey,

36:57 the greatest likelihood is all the tests will come back normal.

37:00 But we should do them because sometimes it doesn't, right?

37:04 If I look across somebody who has recurrent pregnancy loss,

37:06 I say, 80% of the time, every test will come back normal.

37:09 But 20% is is a big number.

37:12 That's a lot of people who maybe it's a simple medication,

37:16 maybe it's a procedure,

37:17 something can markedly change what they're going through.

37:21 And in the same breath,

37:22 and the 80% really need specialized care because what's really

37:26 going on if we don't have an easy test for it.

37:29 So, I agree with you.

37:29 I think the whole field needs to change.

37:31 I think we need change how we define terms, how we address women,

37:35 how we approach reproductive health and hormones and fertility.

37:38 And really in a more proactive patient-centric approach.

37:42 And women and men are driving this really by talking about it.

37:46 10 years ago when I started on social media, nobody talked about fertility.

37:50 And patients who did had nameless, faceless accounts.

37:54 And now you see celebrities talking about IVF, talking about endometriosis,

37:59 talking about their termination for genetic reasons or whatever happened.

38:04 And those stories are so powerful to drop the stigma,

38:08 but also highlight how wrong it is that we force women

38:11 to fail before we'll even evaluate what's going on, let alone treat.

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39:41 One theme that I heard over and over again was um women would say, "Okay,

39:49 they thought that they might have been pregnant before

39:51 or they knew they had been pregnant once before." Circumstances varied,

39:55 but they sort of had it in mind that they could get pregnant at some point.

39:58 And that their mom had one either them or a sibling let's

40:04 say at like age 42 or 43 and they're in good health themselves.

40:10 And so they had it have in mind that there's time.

40:14 I think this is not uncommon.

40:17 And given that life is very expensive,

40:20 most people in the world seem to be underpaid nowadays.

40:23 And people are waiting longer to get married and have children.

40:28 And the other common narrative that I was

40:32 hearing was that there people that want kids, but they it's under the well,

40:36 if I found the right person, I would do it,

40:38 but otherwise I wouldn't do it on my Yeah.

40:40 That's not always the case,

40:41 but it's it's pretty it's a it's a it's a common theme, right?

40:45 So for those women, which I think is quite a few,

40:48 whether or not they're in their 20s or their 30s or their 40s,

40:52 what sorts of things do you recommend they would

40:54 add to that rather just kind of real life analysis?

40:57 Those are not meaningless metrics like how would

41:00 one's mother had a a child or for instance.

41:03 But things have changed.

41:05 Microplastics, maybe certain things have gotten better, right?

41:07 We're no longer eating margarine.

41:08 I'm I'm not trying to be facetious Yeah.

41:10 here.

41:10 I think that there's so many variables.

41:12 People are living longer, yet there are more environmental toxins perhaps.

41:16 I mean people are smoking less.

41:17 So it the Are they though?

41:19 Are they?

41:20 We'll talk about nicotine for sure.

41:22 So for those women in their let's say 20s, 30s, and early 40s Yeah.

41:29 What's the level of urgency that they get certain

41:32 things checked out and what should they get checked out?

41:34 Oh, and I should say that they'll say that they're having regular periods.

41:38 I'd love to answer it and I'm going

41:39 to, but for the person who's maybe coming to this discussion let me

41:44 let's explain egg quality really quickly cuz it really is going

41:46 to tie into what we can test and what we cannot.

41:49 As you know well, women are born with all the eggs they're ever going to have.

41:52 The eggs are kept I like to think about it

41:54 as in a vault inside your ovary and so they're stored there.

41:57 You have the most eggs when you're 5 months old inside your mom.

42:00 You have 6 to 7 million eggs.

42:02 By the time that you're born, you have 1 to 2 million.

42:04 By the time you start your first period, you have half a million.

42:07 So you lose eggs over time.

42:09 A lot of the determination of that starting number will be influenced some

42:13 by genetics and some from your mom's health while she's pregnant with you.

42:16 Things she's exposed to, her current disease state.

42:19 What I want people to think about is every single month you are losing eggs.

42:23 So I like to imagine and describe to my patients

42:25 a group of eggs is coming out of the vault.

42:27 Each egg grows inside a small fluid-filled structure called a follicle.

42:30 The brain sends out follicle-stimulating hormone or FSH,

42:34 well-named, gets a follicle to grow.

42:36 As the follicle grows, it makes estrogen.

42:38 This is called the follicular phase.

42:40 Estrogen levels talk back to the brain.

42:42 Remember that the brain does not see what's happening anywhere in the body.

42:46 It is simply waiting for the hormone signal.

42:48 That's what hormones are.

42:50 They're communication signals.

42:51 I like to think about it like text messages between friends.

42:54 When estrogen is high enough for long enough,

42:56 200 picograms for 50 hours and that's the level

43:00 it'll tell the brain it's time to ovulate.

43:02 The brain will send out a surge of LH.

43:05 Follicle will then rupture.

43:06 Egg will be released.

43:08 It only has 24 hours to be fertilized,

43:10 but that follicle will actually reform and become the corpus luteum.

43:14 Now we're entering to the back half of the cycle called the luteal phase.

43:17 The corpus luteum makes progesterone stimulated from LH pulses from the brain.

43:22 So then it makes progesterone pulses throughout the luteal phase.

43:26 Can only live for about 2 weeks unless a pregnancy occurs.

43:30 When you have an embryo come in and implant,

43:32 it makes HCG, the pregnancy hormone we check in a pregnancy test.

43:36 Fun nerdy fact, HCG and LH share a receptor.

43:39 So HCG comes into the corpus luteum

43:41 and now stimulates a constant production of progesterone.

43:44 But if that doesn't happen, corpus luteum will die,

43:47 progesterone will drop, and you'll get a period.

43:50 Okay.

43:51 Also back to the vault, you have a different number of eggs that come

43:54 out every month that is proportional to how many remain.

43:57 So when you are younger, when you have more eggs,

44:00 more eggs come out of the vault every month.

44:02 As you get older and you have fewer eggs, fewer come out every month.

44:06 That explains why you go from 6 to 7 million to 1 to 2 million and why

44:10 you go from 1 to 2 million to half

44:11 a million because you had more, you're losing more.

44:15 At some point everybody will be out of eggs, right?

44:18 We're going to call that ovarian failure

44:20 and not menopause for the sake of our discussion,

44:22 but so everybody will go into ovarian failure.

44:25 Now the timeline once you have your your clock is now up.

44:29 Because at that point there's no more eggs,

44:30 you cannot get pregnant with your own genetic child.

44:34 You still have a functioning uterus.

44:36 It's just not being stimulated.

44:38 So importantly, those women can get pregnant with donor eggs or donor embryos.

44:42 They can still carry a pregnancy.

44:44 That's sometime a myth that people think about.

44:47 But once you're out of eggs, that's kind of the end of your clock.

44:50 Now two things are happening with time

44:53 that are really important because your eggs are inside

44:55 that vault inside your ovary is that they absorb the wear and tear of your life.

45:00 And your egg has many different functions.

45:02 It has to respond to hormone signals and make estrogen,

45:06 make progesterone, and ovulate.

45:08 The mitochondria inside the egg, which everybody knows the mitochondria,

45:11 the powerhouse of the cell, gets exclusively passed on to the embryo.

45:15 It completely controls embryo growth and development.

45:19 In fact, the male genome doesn't even

45:20 kick in until day three after fertilization.

45:22 All those first few days are 100% maternal.

45:26 The egg also has a hold the chromosomes in correct position.

45:30 So an interesting fact is that inside the egg,

45:32 it is frozen in metaphase of meiosis two for whatever reason.

45:37 And so the chromosomes have met in the middle and they're held

45:39 apart by those meiotic spindles and they do not separate until you ovulate.

45:43 And so then you get your egg that has all we think about as your 23 X.

45:47 The other part goes into a polar body.

45:50 Okay, this means that when you're 25,

45:52 your eggs have only been held in metaphase for 25 years.

45:55 Your chromosomes are for the most part still in the right position.

45:58 Your proteins are strong that are holding them apart.

46:01 Most people have better generalized metabolic health.

46:04 Their mitochondria are stronger.

46:06 When you are 40 40 years have passed.

46:10 We've asked those chromosomes to hold there longer.

46:12 And we say if I have a line of kindergarteners

46:14 and I ask them to stand for 40 years, like somebody's going to get out of line.

46:17 So tincture of time adds up.

46:19 But the other thing that happens as we get older is as a population,

46:22 we get more metabolically unhealthy.

46:24 So we see more chronic inflammation, more insulin resistance, more obesity.

46:29 And all of those factors influence oxidative stress,

46:32 mitochondrial health, DNA damage.

46:35 They can damage the meiotic spindles holding those chromosomes apart.

46:39 So we also see more genetic abnormalities as we age,

46:43 but that is worsening as metabolic health worsens, too.

46:47 Okay.

46:48 We don't have a direct test for egg quality.

46:50 That's what we call egg quality.

46:52 Genetic normalcy and egg competency.

46:54 How good are the mitochondria?

46:56 Can it do its job?

46:58 We approximate it to age.

47:00 Which has some faults because not all 40-year-olds are created equal.

47:04 When we think about ovarian reserve, this is how many eggs you have remaining.

47:08 So this is how many eggs are inside the vault.

47:11 And we can approximate it with a blood test called AMH.

47:14 AMH stands for anti-Müllerian hormone.

47:16 It's made from the granulosa cells that surround each follicle.

47:19 So in its purest form, more eggs inside the vault, more come out, more AMH.

47:25 Fewer eggs in the vault, fewer come out, lower AMH.

47:28 Not a perfect test.

47:29 The vault also is not perfect,

47:31 so there's some month-to-month variability in how many exactly get sent out.

47:35 And in prolonged periods of not ovulating, AMH can be suppressed,

47:40 whether it's from birth control pills,

47:41 pregnancy, postpartum, whatever the reason is.

47:44 So AMH is imperfect, but it is something and it's a very simple blood test.

47:49 It's not telling us if you can get pregnant or not,

47:52 but it is telling us how many eggs do we have outside the vault.

47:56 And the way I like to frame this is that every woman who wants

48:00 to have children or understand her own

48:02 reproductive timeline should get an AMH checked.

48:06 That is against medical advice,

48:08 meaning the American College of OBGYN says that women

48:11 should not get an AMH checked unless they have infertility.

48:14 Okay, this is wild to me, right?

48:16 I mean to me as well.

48:17 I mean it just seems like like this failure criteria

48:21 it just seems so it seems just very extreme and unnecessary.

48:26 Unless there's some hidden agenda to try

48:28 and prevent people from maintaining fertility

48:30 or having children because and that doesn't square with at least my assumptions.

48:36 The idea here is that it can be really stressful.

48:39 This is what they say in their document.

48:40 American College of OBGYN,

48:41 it can be very stressful for a woman to find out

48:43 she has a low AMH and that it doesn't predict fertility.

48:48 And there's some truth to that.

48:49 So let's think about I have two 30-year-olds.

48:52 One has 20 eggs outside the vault, which would be age-related norm,

48:56 and one has five eggs outside the vault.

48:58 Well, if every single other factor is

49:00 the same and they each are ovulating one egg,

49:03 they have the same chance of getting pregnant, right?

49:05 So that's not a faulty statement.

49:08 However, the person who has five eggs will not have as long to grow her family.

49:12 She will not get as many eggs if we're doing advanced treatment like egg

49:16 freezing or IVF because I can only get the eggs outside the vault to grow.

49:20 So it's hugely impactful for what your journey may look like in treatment.

49:24 But more so than that, Andrew,

49:26 so many of the causes of a low AMH directly contribute to infertility.

49:31 Things like autoimmune disease,

49:33 insulin resistance, endometriosis, smoking cigarettes.

49:37 So if there are factors, some of which you can control,

49:40 some of which you can treat.

49:43 If I have a woman who has a low AMH,

49:46 I'm not going to sit here and say, "Okay, well, you can still get pregnant,

49:48 no worries." I'm going to say, "I don't know that you'll have infertility,

49:51 but some of the reasons your AMH is low can cause infertility.

49:55 You will get fewer eggs if we're freezing your eggs or doing IVF.

49:58 You will go into menopause earlier.

50:00 So, we need not wait, right?

50:02 To your point, the woman who's 20, 30,

50:04 40 thinking about this, she might make a very different decision when

50:09 she knows she's really faced with a timeline that is less than ideal.

50:14 And why should we allow time to be making that decision

50:17 for us instead of at least playing an active role?

50:20 I sit across from women every day find out they have a low AMH,

50:22 and I say this, like, let's do the investigation to see if we can find out why.

50:26 Probably 50% of the time we find an autoimmune disease.

50:30 I can't reverse the clock, but I can slow down the rate of inflammation, right?

50:34 If say [clears throat] if it's Hashimoto's,

50:36 suddenly we can do thyroid replacement, we can work on decreasing inflammation.

50:39 If inflammation harms our ovary, maybe we can slow down that rate of egg loss.

50:45 At least she's being treated and probably feeling better

50:47 and will have improved fertility outcomes because her Hashimoto's is treated.

50:50 So, we should look at why.

50:51 Why is it low?

50:53 And treating that why very well may impact fertility.

50:56 We also might say, what should we do about this?

50:58 You know, I have a lot of couples who are partnered

51:01 who are just waiting for the right time to get pregnant.

51:04 So, sometimes we say, well, we could get pregnant, but I'm in medical training,

51:09 I'm going to law school, I'm doing XYZ, it's not a good time.

51:13 Well, when faced with their perfect time, they may not have eggs anymore.

51:17 Suddenly, we reevaluate where we are, and there's no one right answer.

51:21 We might choose to try to get pregnant now.

51:23 If we don't have a partner, we might buy donor sperm and try to get pregnant.

51:26 Maybe we freeze eggs.

51:28 Maybe we freeze embryos.

51:29 Maybe we do none of those things, but we made the active choice, right?

51:33 Sitting here saying,

51:34 "I chose not to pursue treatment knowing my AMH was low and that I might

51:39 be in ovarian failure at the point when I was planning to have a family,

51:43 and I know that" makes the journey so much easier to walk because you made

51:47 that active choice from a place of a knowledge

51:49 that was your autonomous decision versus saying,

51:53 "I asked my doctor for an AMH test 5 years ago.

51:56 They told me it wasn't medically recommended because I don't have infertility,

52:00 and had I known that information then,

52:01 I might have done something different." Well,

52:04 that was the longest discussion to say everybody should get an AMH.

52:07 I think it's a very important marker.

52:09 It's a newer-ish test.

52:11 We've only been checking it for about the past 10 years.

52:14 It's not a perfect test.

52:15 I don't have the nomogram for exactly how it should drop over time,

52:19 and I like to think about it as categories.

52:21 Normal, above average, below average, critically low.

52:25 And based on your category, we should probably talk and do different things.

52:29 If you are listening to this and you want kids one day,

52:32 ask your doctor for this test.

52:34 If they say no, you can order it yourself at a LabCorp request,

52:38 many of the online platforms like Function Health,

52:41 you can have an AMH checked through them.

52:43 You can ask your doctor for it and say, "Well, if it's low,

52:46 I know I'll talk to a fertility doctor to find out more

52:49 information." Or call a fertility clinic

52:51 and just say you want fertility testing.

52:53 The end.

52:54 Okay, I think it's such an important [clears throat] marker.

52:56 It is not a test of egg quality.

52:58 You know, we talked about what egg quality is, right?

53:00 Genetics and egg competency, but it is a check of how many eggs you have,

53:05 and that knowledge can be really impactful

53:08 for how you view your future and your plan.

53:10 So, I think everybody should get an AMH.

53:12 I think we've got to learn to track our cycle,

53:14 and I know you said in the vignette that these women have regular cycles.

53:20 Having a regular period is really good.

53:22 It's much better than having an irregular period,

53:25 but knowing when you ovulate and tracking ovulation is a much more sensitive

53:30 health marker than simply when you bleed or when you have a period.

53:34 Because tracking ovulation is going to allow us to know how

53:37 long is your luteal phase and how long is your follicular phase.

53:41 And ovulation disorders progress through a very predictable pattern,

53:45 and we know this well.

53:47 The first stage of an ovulation disorder is a luteal phase defect,

53:51 meaning a shortening of your luteal phase.

53:53 So, you're ovulating, but the brain and ovary have a miscommunication,

53:58 and we don't make progesterone long enough to sustain the luteal phase.

54:02 Less than 11 days is a short luteal phase, but you'll still have regular cycles.

54:07 So, if I sit across from somebody and I just say,

54:09 "Are your cycles regular?" and they say yes,

54:12 and we carry on, I've missed the fact

54:14 that they actually have a shortened luteal phase,

54:17 and that warrants further investigation.

54:19 Prolactin, thyroid, AMH, PCOS, looking at different causes.

54:25 The second stage of ovulation disorder is a long luteal phase.

54:29 Takes the ovary longer to actually respond to the FSH stimulus from the brain,

54:35 and then from there we'll progress into irregularity

54:38 and true amenorrhea or absence of periods, but those first stages,

54:43 you might miss the little red flag warning sign that something's

54:47 wrong inside your body because you're just tracking when your bleed is,

54:50 and it's every 34 days, so you think it's normal,

54:54 but if we were looking at when you actually ovulated, we have more data.

54:58 So, learning to track ovulation as opposed to just cycle tracking,

55:03 I think is one of the most important skills a woman

55:05 can have for learning to listen to her own hormonal cues.

55:11 Amazing.

55:12 Um just I don't say that lightly.

55:14 You just explained egg quality, the biology of the of the ovulation cycle,

55:19 and how it links to the actionables, and um I'm just struck.

55:22 It's awesome.

55:24 Um And it has me asking a couple of practical questions.

55:29 Um some people will have insurance, some won't.

55:31 What's the cost of an AMH test?

55:33 Let's assume insurance doesn't cover it.

55:36 Um and they just have to go completely out of pocket.

55:38 Uh and before you answer, I will say whatever it is,

55:41 I think it should probably be compared against what it would

55:44 be to try and um I don't want to say rescue,

55:47 but but to not take the test, and then,

55:50 you know, 3 years later you're trying to harvest eggs.

55:52 It could be multiple cycles because you you

55:54 realize it was only five eggs per you know,

55:57 per month as opposed to age match, right?

56:00 15, right?

56:00 Exactly.

56:01 So, um so, are we talking hundreds of dollars, thousands?

56:05 $79.

56:07 a $79 test, and I I feel really strongly about this.

56:13 I do not view myself as the gatekeeper of information about your body.

56:17 Do you want hormone levels checked?

56:18 Do you want an AMH?

56:19 I do not think that is the role of a physician.

56:21 I know I can say your insurance doesn't cover it.

56:24 You can make the decision if $79 is worth it to you,

56:27 but in the age of information,

56:29 where that's an easy test to do, every lab runs it,

56:32 and it's relatively inexpensive compared to freezing your eggs or IVF.

56:37 I mean, right?

56:38 Multitudes.

56:39 $79.

56:39 We're throwing a fit over a $79 test.

56:43 Wow.

56:44 Um [cough and clears throat]

56:46 I I'm going to make sure that message goes far and wide.

56:49 Um because I you know,

56:49 I thought you were going to say maybe in the high hundreds or thousands,

56:52 which for some people is going to be, you know, prohibitively expensive.

56:55 Yes, I So, get AMH checked.

56:57 I think I'll avoid going into too

56:59 much editorializing here because I'm really just interested

57:01 in in how you view this, but how you describe the the sort of the the way

57:06 your field has a originated and where it's headed reminds me a little bit

57:11 of I remember in the '80s there was

57:12 a genetic testing was starting to become possible.

57:16 And a lot of it was happening at Stanford.

57:17 I happen to grow up near campus,

57:18 and I remember hearing you could get tested for like Huntington's disease,

57:21 which is it can be a devastating disease.

57:24 Um and the idea was people don't want to know.

57:27 People don't want to know.

57:28 I think everything I've I've observed, I can't speak for everyone,

57:31 but everything I've observed about people's interest

57:34 in their own health and genetics and what

57:37 genetics does and doesn't mean tells me

57:39 that people are actually much more interested,

57:43 and they're much smarter than let's just call it the traditional medical field,

57:47 certainly medical genetic testing, gave them credit for.

57:51 It's like people aren't idiots.

57:52 You can sit someone down and say, "Hey, listen, you have this gene.

57:55 There's an X probability.

57:56 Here's the things you can do to protect yourself." And but there

57:59 was this assumption like people don't want to know because now they're going

58:01 to live in dread and their life is going to be destroyed

58:04 if they know they're going to get

58:05 full-blown Huntington's or something like that.

58:07 It's so paternalistic.

58:08 It's actually I mean, it borders on unethical.

58:12 Um people are smart.

58:13 People can take in information,

58:15 and they can make decisions that don't necessarily

58:17 crater them on the basis of just knowledge.

58:20 I mean, it feels like we sort of treat people like children,

58:23 like little children.

58:24 And even little children would probably want to know certain things.

58:27 Although you don't want to give them genetic information,

58:29 but certain things like, "Hey, you have a challenge with X, Y, and Z,

58:33 and you can overcome it in the following ways." Technology's advanced.

58:37 It has.

58:37 How we counsel and how we approach health care needs to advance also,

58:42 meaning we don't live in a universal health care system.

58:45 We don't have only X dollars to spend on every single patient.

58:48 And in certain circumstances,

58:49 when that's the case or a patient has limited money,

58:51 we do have to make very judicious decisions about the best use of those dollars.

58:57 But for the majority of people who will be listening

58:59 to this, they are willing to spend money on their health,

59:03 and it shouldn't be a society or a physician or somebody standing

59:06 in the way of getting data that can dramatically impact your life.

59:10 And because you mentioned Huntington's, I should say, right?

59:13 Autosomal dominant disorder.

59:14 People have very strong feelings on if they want to know they have it or not,

59:17 and I've had patients because we can test for this with IVF.

59:21 So, we do genetic testing of embryos,

59:23 and we often do screening to see if the chromosomes are in the right position,

59:27 which we talked about for age, that can be really beneficial.

59:30 We can do single gene testing as well,

59:32 PGT-M for monogenetic diseases and Huntington's is one of them.

59:36 And I've had some patients say, I my mom had Huntington's.

59:41 It was the worst experience to watch her go through that.

59:43 I would love to test my embryos,

59:45 but I I've committed to myself that I don't want to know if I have it or not.

59:49 Okay?

59:50 And I think it's really important just to mention that disease to say,

59:53 we can blind test you.

59:55 You you know, we can you can make a probe to see if you carry it or not.

59:59 You don't have to know and we can still test the embryos.

1:00:02 And I've had a few patients who then themselves did not want to know,

1:00:05 but we went through the steps to make a probe in case they did.

1:00:08 In both cases, the patient did carry it, didn't find out that they did,

1:00:12 but they could assuredly transfer an embryo

1:00:14 that did not have it because often they

1:00:16 these people have felt so strongly watching

1:00:19 a family member die from a terrible progressive disease.

1:00:22 They've said children are not in the cards for me.

1:00:26 Or I'm not going to have genetic kids.

1:00:27 Or sometimes they'll come to me saying,

1:00:29 we have to use an egg donor or sperm donor

1:00:31 because I might carry this and don't want to know.

1:00:34 So, again, it's the idea that that should be

1:00:37 your own individual choice whether you want to know or not,

1:00:40 but it shouldn't be the society or somebody else putting this roadblock up.

1:00:44 And it's such an antiquated approach in the era of technology

1:00:48 and access where you really can get so many data points.

1:00:53 Why should somebody be making the decision

1:00:55 on if that information's valuable to you?

1:00:57 Yeah, and I think with blood testing, the price coming down, um,

1:01:01 it seems to me maybe it's just the circles I

1:01:03 run in that people want more information as opposed to less.

1:01:05 But I'm glad that you raised this um these cases

1:01:08 where people don't want to know certain certain amounts of information.

1:01:12 Um one thing that well, I'll just pose this as a question.

1:01:17 How many women out there,

1:01:19 um do you think know if I'll have to be careful how I word this.

1:01:26 If doing a egg harvest cycle um decreases their ovarian reserve or not.

1:01:33 The majority of patients that I sit across from will tell me,

1:01:38 I'm afraid to freeze my eggs or do IVF

1:01:40 because I don't want to go into menopause earlier.

1:01:43 So, the myth that doing that is going to tap into the vault and pull out

1:01:48 eggs is inaccurate and a fear that really

1:01:51 does need to be busted because it doesn't.

1:01:54 It's a limitation of the science that I can

1:01:56 only get the eggs outside the vault to grow.

1:01:58 If I could tap into the vault, it would change the game.

1:02:01 But right now I am limited by the eggs you give me,

1:02:05 the number of them controlled by whatever's outside the vault.

1:02:08 We in IVF, we just give FSH, same hormone your brain makes,

1:02:11 trying to stimulate more than one egg to grow.

1:02:14 Your body doesn't want to have five kids or 12 kids or 20 kids,

1:02:18 so it has checks and balances to prevent that from happening.

1:02:21 I, however, would like every egg outside the vault to grow because in nature,

1:02:25 you will ovulate one and everything else will die.

1:02:28 You are constantly losing eggs no matter what.

1:02:32 When you're pregnant, when you're breastfeeding, when you're on birth control,

1:02:34 before you start your first period, constantly losing them.

1:02:38 I cannot change that right now.

1:02:40 So, doing IVF or egg freezing is not going to decrease your ovarian reserve.

1:02:44 It is simply going to influence one month

1:02:46 in time trying to not have all those eggs die.

1:02:49 And I think the myth is that um by doing a cycle

1:02:53 of of egg freezing that you're taking more eggs from your reserve.

1:02:58 Um but as you pointed out, women are losing the same number of eggs

1:03:01 each month or follicles each month regardless.

1:03:04 You're maximizing on that process by just maturing more

1:03:08 and taking them as opposed to letting them die.

1:03:11 Exactly.

1:03:11 We are not running out of eggs early.

1:03:14 I think it's just based on again, nobody understands basic biology,

1:03:17 so we think in our brain, I'm just losing that one egg since I'm ovulating.

1:03:21 We're not thinking about all of the ones

1:03:23 that were sent out of the vault who weren't chosen.

1:03:26 Yeah, and [clears throat] I think people will also assume um because

1:03:28 they haven't been told that if you do an egg, you know,

1:03:32 if you stimulate for more to mature that you're somehow

1:03:35 um taking away from eggs that you would have had,

1:03:38 you know, stuck around somehow.

1:03:40 Uh so, we're we're hitting we're at you

1:03:41 we're saying the same thing three different ways.

1:03:43 you're giving I mean, it's fascinating to me if you think

1:03:46 about it because we are allowing the possibility

1:03:48 for you to have children in your family that likely you would not, right?

1:03:53 Because if you were to get pregnant naturally that month,

1:03:55 the greatest probability is it would just be one that you would ovulate.

1:03:58 Yeah, for IVF, we can sometimes take one month's

1:04:01 group of eggs in time and have a couple

1:04:03 different embryos and those become a couple children

1:04:05 for you that you have from this one exact cohort.

1:04:08 I think it's so fascinating.

1:04:10 You know, early IVF days, I mean, IVF is not that old.

1:04:14 It's only been around like 46 years.

1:04:16 I think the oldest IVF babies we didn't have gonadotropins.

1:04:20 We didn't have FSH um that was, you know, synthetic or purified.

1:04:24 And so, we couldn't get multiple eggs to grow.

1:04:26 So, original IVF patients had to go live

1:04:30 at their IVF clinic and they had urinary-based

1:04:33 hormone measurements done every day so they could

1:04:36 try to gauge when as estradiol was rising,

1:04:39 when they were getting closer to ovulation.

1:04:42 And in those days, this is just science,

1:04:44 they went and they did abdominal surgery to aspirate the egg.

1:04:46 Now we do a vaginal egg retrieval where

1:04:48 we take a needle attached to a vaginal ultrasound.

1:04:50 It's a minimally invasive procedure.

1:04:52 But back in the origin IVF studies,

1:04:54 they had to go and do an abdominal incision to put a needle

1:04:57 in the one single follicle to get the follicular fluid and the egg out.

1:05:01 So, it was very low odds of working.

1:05:04 It was crazy to even think of, but the advent of gonadotropins,

1:05:08 the ability to it first started by purifying FSH and LH and be

1:05:12 able to give that to people to stimulate more than one egg,

1:05:15 understanding this concept that there's so many more

1:05:17 eggs that you have outside the vault every month,

1:05:20 that has changed the game and is such an amazing advancement

1:05:23 in science that we can leverage that physiology for egg freezing or IVF.

1:05:29 Uh very practical uh question.

1:05:32 Um it's clear that the younger that a woman is,

1:05:35 the the more eggs that uh could be uh frozen in a given cycle.

1:05:39 But I think it's fair to say that many people,

1:05:42 either because of finances or life circumstances,

1:05:46 that could be not having a partner and wanting a partner before having kids,

1:05:49 this sort of thing, um are waiting.

1:05:52 They're just waiting.

1:05:53 What stands between um us now in the United

1:05:58 States and egg freezing being covered by insurance 100%.

1:06:04 I don't hold any superpowers, but there are, you know,

1:06:06 there are pretty powerful ways to lobby um all the administrations

1:06:11 regardless of who happens to be in office when that actually happens.

1:06:13 I mean, it is possible, right?

1:06:15 That the the phone is a powerful tool.

1:06:17 Advocacy is a powerful tool.

1:06:18 I do think that um things can happen um if there's a lot of advocacy.

1:06:24 So, um first question is, you know, what would that require?

1:06:29 And um is that a good idea?

1:06:32 I am a fan of knowledge and options.

1:06:34 And egg freezing is not a guarantee.

1:06:35 So, you know, how I pose it to patients is,

1:06:38 we are going to keep the door of opportunity open longer for you.

1:06:41 And that is our goal.

1:06:42 If we want to compartmentalize it as some

1:06:45 people will falsely sit across from me and say,

1:06:47 oh, egg freezing's an insurance policy for my fertility.

1:06:51 And it's not cuz an insurance policy always pays off,

1:06:54 but it's an investment in my fertility.

1:06:56 Like investing in the stock market.

1:06:57 Like probably will pay off,

1:06:59 but it depends on external factors that we don't have yet, right?

1:07:02 So, the ROI is yet to be determined,

1:07:04 but in general considered to be a good thing.

1:07:08 I think it would be absolutely incredible to be

1:07:10 in a place where egg freezing could be covered.

1:07:12 And you know, there's definitely countries where it is.

1:07:15 That they have said with the birth rate is dropping,

1:07:17 we want to keep the reproductive lifespan open for some patients.

1:07:21 We want to offer this.

1:07:22 I think to be honest and transparent,

1:07:25 the number one restriction against that that we see as a field right now is

1:07:30 the camp of people who are ethically or morally

1:07:32 opposed to IVF for reasons of embryo disposition.

1:07:38 [clears throat] Embryo disposition.

1:07:39 the personhood of an embryo.

1:07:40 Is an embryo a person?

1:07:42 I see because embryos that are not used

1:07:45 are going to be either kept frozen or discarded.

1:07:47 And to those people, that's seen as essentially killing a baby.

1:07:51 Correct.

1:07:52 Right, that's their that's their view.

1:07:53 Yeah, and and we should acknowledge that.

1:07:55 I have many patients right now who are donating embryos,

1:07:57 you know, when they are done with their family,

1:07:58 which is an amazing way to kind of pass forward

1:08:02 the opportunity and for other couples to have a family.

1:08:06 And I also just want to say at the top of this is that IVF is incredible.

1:08:10 17 million babies have been born in this world because of IVF.

1:08:14 So, I think this technology's great.

1:08:16 Does that mean everybody has to do IVF?

1:08:17 No.

1:08:18 You are allowed to have your own feelings

1:08:21 and decisions about anything that you do, IVF included.

1:08:25 And there's often things we can do within

1:08:27 the procedure for patients who might have religious or ethical

1:08:31 concerns to limit the number of embryos that we

1:08:34 make or only transfer embryos that are created.

1:08:36 And that's important to know to bring that up if that's your line

1:08:40 in the sand is that we can often do things differently based on your beliefs.

1:08:45 It might be less efficient.

1:08:47 It might cost more money.

1:08:48 It might have a lower rate of success.

1:08:50 But I've had patients walk that road

1:08:52 and that's the way it felt comfortable to them.

1:08:54 In this country, there's a camp and that's not too political.

1:08:57 Um they're really pushing something called restorative

1:08:59 reproductive medicine and they're opposing a lot

1:09:01 of the American Society for Reproductive Medicine's um

1:09:05 attempt to get fertility treatment and fertility preservation covered.

1:09:09 And their rationale, even though a lot of RRM, I'm a huge fan of.

1:09:13 It's about teaching women cycle tracking and getting

1:09:15 to the root cause and really supporting understanding your fertility.

1:09:19 Like bullet point 10 on their list is that IVF is unethical.

1:09:23 But these people are ostensibly pro-child.

1:09:25 So, that I sorry.

1:09:27 I'm I'm not a pro- my political stance, I people often speculate.

1:09:29 Like, I'll be really honest, I don't like politics and I'm very disappointed

1:09:34 in the current state of politics um on both

1:09:37 sides and I try and go issue by issue

1:09:39 and I realize that itself is a controversial statement.

1:09:41 You're supposed to take a hard stance for or against,

1:09:43 but I think that as a biologist, um I look at certain things and I go,

1:09:48 "All right." Like, and I look at other things and go,

1:09:50 "Oh my goodness, like like what Stone Age are we living in?" And so,

1:09:53 I think that um to argue uh whatever it is that one

1:09:57 believes about it seems to me that IVF, at least to me,

1:10:02 maybe I just I'm too uh through my own lens,

1:10:06 but the whole notion of freezing eggs

1:10:08 and creating embryos seems very pro-child to me.

1:10:11 So, it doesn't square with with number 10 on this list.

1:10:14 with you.

1:10:16 I agree with you and I think a lot of the people

1:10:17 who are a fan of ARM might actually agree with you and I,

1:10:21 but there's definitely people who are very adamantly opposed to IVF

1:10:24 who put number 10 in there because they have a different agenda.

1:10:27 Okay.

1:10:28 I'm a fertility doctor, right?

1:10:29 I want as many people to have a family as they desire.

1:10:33 I want you to fulfill your life's dreams.

1:10:36 If having a child is a part of it,

1:10:37 I want to do everything I can to help you have that.

1:10:40 I am not here to sell IVF or force IVF.

1:10:44 I, at the end of the day, it impacts me zero what you individually choose to do.

1:10:48 But I believe that across the board, people deserve the tools in the toolbox.

1:10:53 They deserve to be presented with all the choices.

1:10:55 We could try Clomid, we could try IUI, we could try surgery, we could try IVF.

1:11:00 Oh, you're getting older, we could freeze your eggs.

1:11:02 There's just more tools, there's more opportunities.

1:11:04 And then based on your circumstance, your financial,

1:11:07 your beliefs, you should be allowed to choose.

1:11:10 I feel very adamantly that one's own beliefs that cause you to want to put it

1:11:15 at number 10 on the list should not be the beliefs that we enforce on everybody,

1:11:20 especially when we know that IVF can be so

1:11:23 powerful to help so many people have a family.

1:11:27 It should be something that is offered

1:11:29 to you if indicated and you get the choice.

1:11:31 And so, back to the origin, it would be incredible to live in a world,

1:11:37 a country where egg freezing was offered to women as we

1:11:41 do see people are waiting longer to start their families.

1:11:44 It would allow more people to feel less pressure,

1:11:47 less pressure with a partnership and on their relationship,

1:11:49 not to feel like, "Oh,

1:11:50 this better work out because my clock is ticking." And be able to really

1:11:54 feel like they could chase one dream and not at the expense of another.

1:11:59 I think we're further in this country than we want to admit from that.

1:12:01 We can't even get fertility treatments covered for patients with cancer

1:12:05 when we know that chemotherapy is going to deplete their ovarian reserve.

1:12:10 We have some states that we can't even get egg freezing covered for them.

1:12:14 So, this is state by state?

1:12:15 This is state by state right now.

1:12:17 We would We would love federal protection for everybody.

1:12:20 We would love to be able to see I don't know, to me that's my litmus.

1:12:24 What your state or your country would do for patients who have cancer,

1:12:28 you know, are are in this position.

1:12:30 And if we're not even willing to move to help them,

1:12:33 the idea that we could cover it for everybody,

1:12:36 we're still ages away from that, I think.

1:12:39 Yeah, because uh it's not I don't know if

1:12:41 what we're talking about is forcing anyone to do anything.

1:12:45 Um nor is it necessarily the destruction of an embryo.

1:12:49 I mean, it's there is a world where

1:12:50 the embryos are created and kept frozen, right?

1:12:52 There is a there is no uh Yeah.

1:12:55 We call that embryo banking.

1:12:56 I mean, to specify maybe for somebody who doesn't understand, right?

1:12:58 Egg freezing, getting those eggs outside the vault to grow,

1:13:01 taking them out of your body and we freeze them right there at the egg state.

1:13:05 Making an embryo is going to be thawing that egg, fertilizing it with sperm,

1:13:11 letting it grow out to the implantation stage, which is day five or six.

1:13:14 Not every egg will survive, fertilize, grow.

1:13:17 There's a ton of attrition in culture.

1:13:19 So, 90% of eggs survive the freeze-thaw.

1:13:22 75% will fertilize.

1:13:25 50% will make it to the implantation stage and then not

1:13:28 everyone will be genetically normal based on your age and other factors.

1:13:31 And then even a genetically normal embryo only has a 65% chance of live birth.

1:13:36 Like, the science has come far, but we're not there all the way.

1:13:40 With that being said,

1:13:41 they do morally really feel like an embryo could be a potential life

1:13:45 and they do struggle with what to do if they have leftover embryos.

1:13:50 And I have some patients who've told me,

1:13:51 "Every embryo we make, we're going to transfer." Okay,

1:13:54 well, we want to be really mindful what we do in that circumstance.

1:13:57 And even though it's unlikely,

1:13:59 I have a patient right now with four children and one embryo in the freezer

1:14:02 cuz we froze five knowing that everyone

1:14:05 shouldn't implant based on that 65% number, but we've gone four for four.

1:14:09 Okay?

1:14:10 So, like we have to know that if that's what we're doing,

1:14:12 we're prepared for how the data may fall

1:14:15 because data just helps us guide decisions, right?

1:14:17 Especially when it comes to live birth, it's a zero or 100.

1:14:19 It happens or doesn't.

1:14:21 Now, if I freeze them as eggs for some patients who

1:14:24 have really strong beliefs and they are afraid of that number five,

1:14:27 we might take more time or time more money, but we might say,

1:14:30 "Let's thaw them and only fertilize two." Leave everything else frozen.

1:14:34 And then whatever makes it embryo, we can transfer.

1:14:36 And yes, that's not a cost-effective way to go

1:14:39 through the process cuz we might be having to pay

1:14:41 for thawing and the fertilization and the transfer more times

1:14:45 because there may be nothing to transfer based on that attrition.

1:14:48 It can let some patients say, "Okay, I feel better with that process." So,

1:14:53 just freezing eggs, to your point, isn't not making embryos, right?

1:14:57 And there's different things we can choose along

1:14:59 the way to make an individual person feel comfortable,

1:15:02 but we shouldn't be dictating how the field has to function.

1:15:06 I think it would be incredible if we could encourage egg freezing earlier.

1:15:09 I think it would open the door of opportunity.

1:15:12 And not everybody who freezes eggs will need them,

1:15:14 but the peace of mind knowing that there's

1:15:16 a chance is really impactful on the human mind.

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1:16:38 So, in insurance I would think would want to do

1:16:43 this because um covering all the other stuff is expensive, too.

1:16:48 Most insurance doesn't cover IVF.

1:16:51 You're not wrong, right?

1:16:52 In principle, if I freeze a 25-year-old's eggs,

1:16:55 I will have three times as many eggs to work with, you know,

1:16:59 than I would if she's going through IVF when she's 37.

1:17:03 So, if I'm going to pay for her to do IVF at 37,

1:17:05 it'll take so many more cycles, I'll spend so much more money.

1:17:08 That one cycle of egg freezing is

1:17:10 much more cost-effective if I'm covering them both,

1:17:14 but we don't even cover the latter.

1:17:16 So, many times patients, this is such a hard stretch for everybody.

1:17:21 And look, the technology is incredible.

1:17:25 As somebody who has an IVF lab,

1:17:27 as somebody who keeps embryos on site, it's I mean, it's outrageously expensive.

1:17:32 I mean, our generator alone is like a million dollars, right?

1:17:35 Because if the power goes out, like what do we have to keep going?

1:17:39 We always say, "If there's zombies coming,

1:17:40 like come to the clinic." The technology to keep up with all the advancements,

1:17:46 to have trained embryologists, I mean,

1:17:48 their micro-manipulation skills, it's impressive.

1:17:51 So, it costs money to run a lab like that that will provide results.

1:17:54 So, the process and the technology is really, really expensive.

1:17:57 That being said, like I shouldn't be the one sitting here

1:18:00 making assumptions again on what you're going to do with your money.

1:18:03 And if somebody's in a position where they know

1:18:06 their egg count's low and they should freeze their eggs

1:18:09 because they're not partnered or they're not ready

1:18:11 to get pregnant and they don't have the financial resources,

1:18:16 we can sometimes find more money, right?

1:18:18 We make decisions every day when it comes to money.

1:18:19 We can't find more time.

1:18:21 We can't find more eggs or more ovary.

1:18:23 So again, this idea that, "Well, what are they going to do about it if

1:18:26 they find out they have a low AMH?" Or, "Oh,

1:18:27 they can't afford to freeze their eggs anyway." Or, "Oh,

1:18:30 it's too expensive." We all make individual

1:18:33 choices on how we leverage our different resources,

1:18:36 which I consider to be your time,

1:18:37 your money, your physical energy, and your emotional energy.

1:18:41 And every day, you're leveraging them.

1:18:43 But when it comes to reproductive health, having a family,

1:18:46 like I I feel strongly, you feel strongly,

1:18:48 which I love, that we should be giving more access

1:18:51 and more options to people so that they can pursue this.

1:18:54 So, the arguments are across the board, too.

1:18:56 Like, why not check an AMH in somebody who's younger?

1:18:58 Well, they can't afford egg freezing anyway,

1:19:00 so what are they going to do about it?

1:19:02 Again, like we shouldn't be making the assumptions of what somebody

1:19:05 will or will not do with their resources or with their data.

1:19:09 We should be ones helping them get the data and interpret the data,

1:19:12 understand what resources or options exist,

1:19:15 and then the individual has what they need to make the decision.

1:19:20 In the Bay Area where there a of tech companies,

1:19:23 um there's a uh my understanding is there's a an opportunity

1:19:28 at many of these companies for female employees to freeze their eggs.

1:19:31 That landed much more controversial than I thought it would.

1:19:35 Isn't it crazy?

1:19:35 Um because the the assumption, the sort of uh to some people uh

1:19:41 the tacit message there is "Don't have kids now.

1:19:44 Work work work work like crazy and then have them later, right?" But

1:19:49 having known some people that work there and froze

1:19:51 their eggs in their um late 20s or early 30s, I think they would say,

1:19:56 the ones I know would say, "I'm really grateful that I did that um

1:19:59 and that the company I worked for paid for it.

1:20:01 And they got to keep their eggs even

1:20:02 though they don't work for the company anymore.

1:20:04 So there's that.

1:20:05 But it was kind of interesting.

1:20:06 So anyway, we're getting kind of we are.

1:20:08 But what we are finding is that Yeah, what data supports is that when companies

1:20:14 do leverage a fertility package in their benefits,

1:20:18 they retain employees longer, employees are happier,

1:20:22 and more people utilize the service than would without it.

1:20:25 Meaning people freeze their eggs when

1:20:26 it's offered to them through their company,

1:20:28 and that gives them that peace of mind.

1:20:31 Understanding is not everything,

1:20:32 but they feel more comfortable exploring bigger opportunities,

1:20:36 and they are grateful to the company.

1:20:38 They stay with the company longer because

1:20:40 that is an investment in your employees.

1:20:42 I think it's incredible.

1:20:43 In Austin, right, a lot of these tech companies have second homes.

1:20:45 So we see a lot of these patients also.

1:20:47 And I do think that has changed game

1:20:50 for so many people to be able to have access.

1:20:53 Because for many it's not ethical or moral, it's financial.

1:20:58 The often the time when you would freeze your eggs,

1:21:00 when it would give you the highest rate of return,

1:21:02 you don't have the resources to do so.

1:21:05 So having a company that's able to come

1:21:06 in and do that is really I think impactful.

1:21:10 I wish more companies would do that.

1:21:11 Maybe we can change their minds.

1:21:12 I tend to get pretty loud and pretty consistently

1:21:14 loud about the things that uh I believe in.

1:21:17 Once I understand the landscape, so I I plan to be vocal about it.

1:21:21 Um for what it's worth.

1:21:22 Uh you mentioned that birth control can

1:21:24 reduce AMH levels um on a month-to-month basis.

1:21:28 Is there and we should define birth control cuz it's such a broad category.

1:21:33 Um but is there any evidence that taking hormonal birth control

1:21:38 can lower chances of pregnancy when somebody comes off birth control?

1:21:44 In my friendships and knowledge space, my um and this isn't I have a friend.

1:21:50 I just I know a number of people who have kids now who um were on birth control,

1:21:54 came off birth control, and got pregnant right away.

1:21:56 Right.

1:21:56 So I think a lot of people assume that's how it works.

1:21:59 But are there any uh good examples of how certain forms of birth

1:22:02 control can actually suppress fertility in women

1:22:06 long after women come off birth control?

1:22:08 Excellent question.

1:22:08 Okay, let's break the data down from big to little.

1:22:11 Number one, big studies looking at all different types of contraception,

1:22:14 no higher rate of infertility,

1:22:16 again defined as failure to get pregnant at 12 months.

1:22:20 So you come off your contraception at 12 months later when we look,

1:22:23 there's no higher rate of infertility than

1:22:24 we would have on the population based level.

1:22:26 So that data leads us to comfortably

1:22:28 say birth control is not causing infertility.

1:22:31 Now if we go and we look more nuanced at different types of contraception.

1:22:35 If you look at the birth control pill, what most people are talking about,

1:22:38 the birth control pill is a combination of synthetic estrogen,

1:22:42 ethanol estradiol, and a type of progesterone or a progestin.

1:22:45 These work by telling the brain, essentially tricking it,

1:22:49 so the brain doesn't send out FSH or LH.

1:22:51 And as we described earlier, those are important in getting you to ovulate.

1:22:54 So you don't ovulate when you have taking the birth control pill,

1:22:57 and that's why it's a very effective contraceptive choice.

1:23:00 However, the half-life of the birth control pill is only 28 hours.

1:23:03 So it's actually quite short.

1:23:05 So you can miss even just one pill and you could ovulate.

1:23:08 So when you stop the birth control pill,

1:23:10 your period should come back that next month.

1:23:13 So immediately you should have resumption of ovulation.

1:23:17 A couple of problems with this one is

1:23:20 that the birth control pill has some valid medical uses,

1:23:25 has some non-valid ones, but very often,

1:23:27 especially in the generation of women that we see right now,

1:23:30 they were given the pill potentially for a valid

1:23:33 medical reason without any investigation of what it was.

1:23:36 So maybe a woman had irregular cycles or some acne, and her doctor said,

1:23:39 "Well, here, take the birth control pill, it will help." And it did help.

1:23:43 But just based on that history, I would sit here and say,

1:23:45 "I bet she has PCOS." And the woman though never was told,

1:23:50 "I think you have PCOS.

1:23:52 Here's what it is.

1:23:53 You probably will not ovulate when you stop the birth control,

1:23:55 and your acne will come back, and you should talk to a fertility doctor,

1:23:58 and here's lifestyle things we can do

1:24:00 to decrease insulin resistance." Never had that discussion.

1:24:03 [clears throat] So in her mind, had some symptoms, started the pill.

1:24:06 Those symptoms resolved.

1:24:07 Now we stop the pill and we're not getting pregnant,

1:24:09 and we have irregular cycles, and we start to blame the pill as the reason why,

1:24:14 instead of understanding that the pill was maybe

1:24:16 masking it or treating certain aspects of it.

1:24:18 So we do see failure to get to a diagnosis

1:24:22 in women who were prescribed the birth control pill young,

1:24:25 and then with the idea I'm going to stop the pill and get pregnant right away.

1:24:28 What I like to say is you're not ovulating on the pill.

1:24:31 If ovulation and knowing when you ovulate is one of your most

1:24:34 sensitive health markers and really essential

1:24:36 information in trying to get pregnant.

1:24:38 If you are trying to get pregnant, the egg only lives for 24 hours.

1:24:42 The fertile window is the 5 days before and the day of ovulation.

1:24:46 Meaning sperm can live in the reproductive tract for up to 5 days.

1:24:49 Most will stay around for 2 days.

1:24:52 That's why the 2 days before and the day of ovulation have

1:24:54 a 20 to 30% chance of getting pregnant compared to a 0 day,

1:24:58 the day after ovulation, 0%.

1:25:00 So very defined fertile window.

1:25:02 So if you know when you're ovulating and you target intercourse,

1:25:05 you're going to have higher odds and get pregnant faster.

1:25:07 Data supports that very much so.

1:25:10 But you don't know how to track your ovulation cuz you've been on the pill.

1:25:13 So you don't know how to do that.

1:25:15 So I recommend that you stop the pill three to six months before

1:25:18 you're really wanting to start your family so you can track your cycle,

1:25:21 learn to detect ovulation.

1:25:23 And if you do have an abnormality,

1:25:25 you're not now six months of trying or one year of trying before it's evaluated,

1:25:29 you can say, "Oh, I can't detect ovulation or my cycles are irregular.

1:25:33 Let me go get that investigated now so we're not kind of behind

1:25:37 in our own timeline." The progesterone IUD is

1:25:41 another one that we talk about a lot.

1:25:42 The progesterone IUD is local progesterone that is placed inside the uterus.

1:25:46 There's different types that can release progesterone in different amounts.

1:25:50 It typically suppresses ovulation in the first 2 years,

1:25:53 but then progesterone levels drop and it tends not to suppress ovulation,

1:25:57 but that chronic progesterone exposure thins the endometrial lining

1:26:01 to the degree that many women do not have periods anymore.

1:26:05 That can be great if you don't like having a period.

1:26:08 That can decrease the chance of anemia or menstrual cramping.

1:26:11 So it can be very lifestyle positive during those years.

1:26:15 But when you stop the IUD, we do see a change in endometrial receptivity

1:26:19 at least for 6 months after it's been removed,

1:26:22 and it can take time to build that lining back up.

1:26:25 So I always recommend that a progesterone IUD is removed

1:26:27 at least 6 months before you want to get pregnant.

1:26:30 Give the endometrium time to rebuild and regrow,

1:26:33 and then you'll have better odds at conceiving.

1:26:36 We do see a little bit of lower pregnancy rates in those first

1:26:40 6 months of conceiving in women coming off of the IUD.

1:26:43 More of them are getting pregnant in the back 6 months.

1:26:45 So kind of shift your own timeline.

1:26:48 And the birth control thing that's always important to mention

1:26:50 in this conversation is one that's not as common,

1:26:52 but it's the Depo-Provera shot.

1:26:54 So this is a high-dose intramuscular progesterone

1:26:56 shot that can prevent ovulation for 3 months.

1:26:59 On population based levels, to use it as an effective contraceptive,

1:27:03 must get every 3 months.

1:27:04 But one single dose can prevent ovulation for 18 months.

1:27:09 So this is that one exception where if you

1:27:11 want to get pregnant potentially in the next 2 years,

1:27:15 please don't get Depo-Provera.

1:27:17 Great.

1:27:17 Incredibly thorough and clear.

1:27:20 Is there any evidence one way or the other that intentional

1:27:23 termination of a pregnancy can disrupt chances of getting pregnant again later?

1:27:28 No study supports that having a termination

1:27:30 is going to negatively impact your fertility later.

1:27:33 One caveat I just want to mention is that any intrauterine procedure

1:27:37 has the potential to damage the endometrium and result in scar tissue.

1:27:41 So that could be having an IUD,

1:27:43 could be having a fibroid removed, could be a prior C-section,

1:27:46 it could be a prior D&C because you had a pregnancy loss,

1:27:49 it could be from a termination.

1:27:51 Where we see the greatest risk in all of these circumstances

1:27:54 is from heavy bleeding or from an infection associated with it.

1:27:59 So in general, most terminations are done early, very routine.

1:28:03 Where we are fearful is when they are accessed in non-safe environments,

1:28:08 we're seeing more infection or heavy bleeding,

1:28:10 or even when women are having to travel statewide to access care,

1:28:14 and they're getting the procedure done later with a higher risk of complication.

1:28:18 In Texas, where I practice, there's obviously an abortion ban,

1:28:21 and so women who need an elective termination for a medical reason,

1:28:25 I had one patient who's been very open about her story.

1:28:29 Her baby had anencephaly.

1:28:30 So she went through IVF and had a baby that had no brain develop.

1:28:35 And they made the decision that they wanted

1:28:36 to terminate that pregnancy since that's not compatible with life.

1:28:39 They don't want to have to carry the entire pregnancy.

1:28:41 They had to travel out of state to access care.

1:28:44 Their first appointment was canceled.

1:28:46 So they had to make another one in a different state.

1:28:49 Took them much longer than they wanted, had the procedure much later.

1:28:53 And then she had residual scar tissue inside

1:28:55 her uterus that was because it was done

1:28:57 at a later term that we then had to fix before she could get pregnant again.

1:29:01 So I think it's just important to say that across

1:29:03 the board any intrauterine procedure poses a little bit of a risk.

1:29:07 No matter what it is, if your periods are different afterward,

1:29:10 the hallmark sign is going to be a lighter cycle.

1:29:12 So no matter what thing on that list you had done,

1:29:14 if your cycle is now lighter afterward,

1:29:17 I am worried there could be scarring inside the uterus,

1:29:20 and we'd rather evaluate that in the clinic.

1:29:22 We can do a saline sonogram to just check and make

1:29:24 sure there's no scar tissue because that will impact your fertility.

1:29:28 Thank you.

1:29:29 Um some practical questions about metabolic health,

1:29:35 mitochondrial health, and egg quality.

1:29:36 Let's do it.

1:29:38 Um in your book you go into this in some degree of detail,

1:29:40 but um when you think about the things

1:29:43 that can really um help support egg quality, aside from age, Yeah.

1:29:49 um in fact, I should say at any age,

1:29:51 uh what are the you know, sort of top contour of those?

1:29:56 Um you mentioned inflammation is the enemy,

1:29:58 but inflammation happens all the time, and we can't avoid it.

1:30:02 Um but we can certainly avoid exacerbating it.

1:30:04 So, what are the things that people can do, not do, and take?

1:30:08 We can do the inverse of that.

1:30:10 Do, not do, and take.

1:30:11 Okay.

1:30:12 So, yes, inflammation is prevalent in our world,

1:30:16 and the goal is not to avoid all of it.

1:30:18 In fact, acute inflammation is required for conception, right?

1:30:23 We need acute inflammation with ovulation.

1:30:25 If we just think real physiology, a follicle is rupturing,

1:30:31 allowing the egg to be released and then reforming.

1:30:33 Like, we need our acute inflammatory response to allow that to happen.

1:30:36 To the degree that if women take NSAIDs around the time of ovulation,

1:30:39 Advil, ibuprofen, Aleve, they'll prevent the follicle from rupturing.

1:30:44 Really?

1:30:44 Yes, so they'll go through the hormonal changes of ovulation,

1:30:47 but the egg will not be released.

1:30:49 So, that's why we recommend, and you know, fun fact or important to know,

1:30:53 if you're trying to get pregnant,

1:30:54 you can take those medications only when you're on your period.

1:30:57 So, period cramping, fine, but we don't want you taking them for the rest

1:31:00 of the cycle because you can prevent ovulation from occurring.

1:31:03 How many people in your experience you think know that?

1:31:06 I don't think very many, honestly, right?

1:31:09 Which is which is one it's sort of like banner across the sky.

1:31:12 Like, these you're not going to lose eggs by doing a a free cycle,

1:31:15 collecting free cycle, the um I mean,

1:31:18 Basic facts about our biology that we are never taught.

1:31:21 So, if somebody's trying to get pregnant, NSAIDs can be problematic.

1:31:24 They can be problematic.

1:31:25 They can prevent the egg from being released with ovulation.

1:31:28 So, I think that this is important because I will sometimes have patients say,

1:31:32 "Well, if inflammation's bad, can I just take medicine for it?" Right?

1:31:36 Like, that in our brain might make sense.

1:31:39 And I always want to say,

1:31:39 "Your immune system is essential for ovulation and also for implantation." So,

1:31:43 I can't I don't want to turn off your immune system.

1:31:46 What I want to do though is not have

1:31:48 it be so burdened with what we call chronic inflammation,

1:31:50 that constant activation, where it can't even do the job that we need it to do.

1:31:55 So, I like to think about this as that inflammatory burden,

1:31:58 and it's so we're all exposed to some,

1:32:00 but how do we to your degree make it better?

1:32:03 How do we add to it and make it worse?

1:32:06 And really framing ourselves so that we can cultivate and I

1:32:08 like to think about it as resilience within your body.

1:32:12 I mean, you're going to be exposed to inflammation.

1:32:14 Life is going to throw things at you,

1:32:16 but you want to cultivate these best practices of your life

1:32:19 so that you are reducing inflammation to the degree that you had,

1:32:23 and this goes hand in hand with insulin resistance, which we'll get into.

1:32:26 And I usually divide it into like what I call my five non-negotiables of sleep,

1:32:30 stress, muscle, food, and toxins.

1:32:33 And thinking about how we leverage these to our benefit by giving

1:32:37 people the knowledge that they can if they understand their bodies,

1:32:43 they can then be empowered to make choices that are in line with their goals.

1:32:48 And so, I really I'll just want to say really importantly,

1:32:51 I hate the narrative that there's nothing you can do for your fertility

1:32:53 or that it's all luck because the truth is even if we can't control everything,

1:32:58 we have a huge control over our metabolic and cellular health,

1:33:02 which as we just said plays a huge role

1:33:04 in our ability to get pregnant for both men and women.

1:33:07 So, taking control of what we can,

1:33:10 I think is really important information and one person can

1:33:13 take with that and make the choices they want to make.

1:33:16 But the worst thing that I hear every

1:33:17 single day is people sitting across from me saying,

1:33:19 "Gosh, I wish I'd known that information.

1:33:22 I would have made a different decision." Why do

1:33:24 we make people go through a failed IVF cycle, they have no embryos form,

1:33:28 and only then do they make lifestyle changes when we know

1:33:30 the lifespan of a sperm is 90 days and sperm are so sensitive.

1:33:34 And then we know that even though eggs are in your body your whole life,

1:33:37 the 60 days before you get pregnant is when

1:33:40 the egg is most susceptible to the world around you.

1:33:42 So, this is this time period that I like to call trimester zero,

1:33:46 the time before you're getting pregnant where the choices you

1:33:49 make can influence your egg and sperm quality the most.

1:33:52 And what you said earlier, if we're making them even earlier in life,

1:33:55 can we influence ovarian function longer?

1:33:57 I think there is good thought to that.

1:33:59 But how do we leverage these choices and diving into them?

1:34:03 Number one for me is sleep, and I think that this is an important one

1:34:06 because it can leverage that inflammatory burden in both ways,

1:34:08 and I know you're a big fan of sleep,

1:34:10 so this isn't going to take much to convince you.

1:34:12 When you sleep, this is when your body's

1:34:14 going to get rid of some excess chronic inflammation,

1:34:16 lowers our inflammatory markers.

1:34:19 We know that when we get less sleep,

1:34:22 it's going to cause us to have more cellular stress, more oxidative stress.

1:34:26 Your gonadotropins, so FSH and LH,

1:34:28 are released from the brain in the early morning hours.

1:34:31 So, when you don't sleep long enough,

1:34:33 you're not going to have the same hormonal response.

1:34:35 And we know really directly, men who get less sleep,

1:34:38 they have lower testosterone levels and lower sperm counts.

1:34:41 Women who get less sleep get fewer eggs at IVF cycle.

1:34:45 And we see that if you say you have poor sleep,

1:34:48 you have double the rate of infertility.

1:34:49 If you just objectively say, "Yeah,

1:34:50 I have poor sleep," you have double the rate.

1:34:53 And that people who are not sleeping well,

1:34:56 either partner, it will take them longer to get pregnant.

1:34:58 They have lower fecundability, that month-to-month pregnancy rate.

1:35:01 So, it's not just me sitting over here saying, "Oh, yeah,

1:35:03 you need to sleep better." Like, your physiology is meant to sleep.

1:35:07 It is a sign to your brain,

1:35:09 if we go back and we view that hypothalamic response as central command station,

1:35:14 looking for clues that your life is stable enough,

1:35:18 you're healthy enough to carry a pregnancy for a woman,

1:35:20 which is a huge metabolic spend.

1:35:23 It's looking to make sure you're taking care of yourself primarily,

1:35:26 and sleep is one of the most powerful markers that we can move.

1:35:30 7 to 9 hours.

1:35:31 Most women need closer to 7 and 1/2, especially in the luteal phase.

1:35:35 Making progesterone is a big body spend.

1:35:38 We really have to cultivate better sleep.

1:35:41 You know, all the things you talk about.

1:35:42 Dark room, sound machine, a sleep mask, a cooler temperature.

1:35:46 Takes two to tango, so if you sleep in the bed with somebody,

1:35:49 they need to be on board.

1:35:50 You need to go to bed at the same time,

1:35:51 you need to have similar sleep practices.

1:35:53 And we know that day-to-day consistency is also impactful in fertility.

1:35:58 So, not just the length of time,

1:35:59 but really having that good circadian rhythm is so important for your hormones.

1:36:04 Melatonin is obviously released before you go to bed.

1:36:07 Slow doses of melatonin supplementation can impact fertility,

1:36:10 so doses of 1 to 3 mg 30 minutes before you

1:36:13 go to bed can improve your odds of getting pregnant as well,

1:36:17 can improve egg quality.

1:36:19 And we know that naturally you make more melatonin when you ovulate

1:36:22 to kind of counter some of the oxidative stress to the ovary.

1:36:25 Really have to be careful though,

1:36:26 a lot of over-the-counter products have like 10 times the amount of melatonin,

1:36:29 so I always want to tread lightly with that one in recommending it to patients.

1:36:33 Often a pediatric dose is like 1 mg,

1:36:35 and that's the perfect amount just to augment.

1:36:38 Again, we're not trying to replace your body's melatonin.

1:36:40 We want to augment it and kind of help

1:36:42 your body I always like to think about like a toddler,

1:36:44 really get good consistency with your wind-down

1:36:47 routine so that you can get enough sleep.

1:36:49 I don't want to disrupt your flow,

1:36:50 but if a woman is already sleeping well, should she take melatonin?

1:36:54 I would say for the average person, probably don't need to.

1:36:57 I would say the exception to the rule would

1:36:59 be that if we know we have increased chronic inflammation,

1:37:01 maybe we have endometriosis or an inflammatory autoimmune disease,

1:37:05 or we're going through IVF with unexplained infertility,

1:37:08 or ever been kind of told you have quote bad egg quality,

1:37:12 then the anti-inflammatory properties of it might be advantageous.

1:37:16 Since NSAIDs can disrupt the inflammation requirement for ovulation,

1:37:22 um I'm curious about other things

1:37:24 that are known to potently reduce inflammation.

1:37:27 Um I I think enough terrible things have been said about

1:37:30 cold plunges um that we don't need to add any more,

1:37:32 but we're seeking reality here.

1:37:35 Uh and I don't have and despite common belief,

1:37:37 I don't have anything inherently attached to cold plunges.

1:37:40 I do them sometimes,

1:37:41 but we know that one shouldn't do them after resistance training um or any

1:37:45 kind of exercise where you want the inflammation

1:37:48 to get the adaptation to the exercise.

1:37:49 We know that.

1:37:50 And it's a pretty potent inhibitor of inflammation.

1:37:53 So, is there any reason to think that in the time where

1:37:56 somebody's trying to conceive that perhaps they should avoid the cold plunge?

1:37:59 I usually recommend against them for reasons stated here.

1:38:02 I think there's very few things we have that are going to really

1:38:05 turn off that acute inflammatory response to the degree that NSAIDs do,

1:38:09 but we should proceed with caution in doing those things.

1:38:12 Most everything else is trying to just

1:38:15 get rid of the excess inflammation we have,

1:38:17 but if something's dampening down into that acute inflammatory response,

1:38:20 then I think we have to be a lot more judicious in saying, "Yeah,

1:38:23 go for this." So, I'm not a fan of cold plunges when trying to get pregnant.

1:38:27 A lot of people will be very happy to hear that cuz I don't Unlike the sauna,

1:38:31 nobody likes the cold plunge.

1:38:32 I hate a cold plunge.

1:38:33 I tried it I tried it one time, and that was one time too many.

1:38:36 I would say if you if you like it, great.

1:38:38 If you think you benefit, great, but otherwise, don't worry about it.

1:38:41 Um one thing that's commonly used is um curcumin.

1:38:44 Yeah.

1:38:45 And it's a pretty potent anti-inflammatory.

1:38:47 Do you recommend people stay away from Let's not cooking with curcumin,

1:38:51 but the high-dose curcumin that comes in a lot of of supplements.

1:38:55 usually recommend it in a supplement form.

1:38:56 Like, I I I never recommend it.

1:38:58 I think if you have a doctor who's giving it for very specific purpose,

1:39:01 you might be a unique person who

1:39:03 has excess inflammation they're trying to target,

1:39:06 but that's not something that I recommend.

1:39:07 But cooking with it is fine.

1:39:09 NAD and NR are I get asked about them thousands of times

1:39:14 per week and I'm more or less a fan of NR

1:39:18 or NMN if one is trying to I don't know I don't

1:39:21 think it will extend lifespan but it does seem to at least

1:39:24 in my experience increase energy these kinds of things um but it's

1:39:29 NR in particular there's data that it can be very anti-inflammatory so if

1:39:33 a woman is trying to conceive should she stay away from NMN

1:39:36 NAD and NR cuz I often see it listed in in fertility protocols.

1:39:41 Animal data looks like NAD and NMN can

1:39:44 be advantageous especially for unexplained infertility which to be

1:39:49 clear is different than I just want to get

1:39:51 pregnant right in unexplained infertility you're not conceiving we

1:39:54 do the basic test anatomy ovulation ovarian reserve

1:39:58 semen analysis they're all fine so I view

1:40:00 that as chronic inflammation unless proven otherwise and so

1:40:04 that's a unique situation that patients may have potential benefit.

1:40:10 But unlike certain things across the population

1:40:12 that we can feel really comfortable recommending I

1:40:15 don't recommend that to everybody so I think

1:40:16 that there might be utility in certain subgroups

1:40:20 who are kind of really falling off

1:40:22 the curve and we think there's excess inflammation

1:40:24 that it could make sense for so I don't ever say no and I sometimes use it.

1:40:28 But on like the flip hand we could say

1:40:29 like CoQ10 which has robust human data that is advantageous

1:40:34 without a negative benefit that's an easier place to leverage

1:40:37 your supplement dollars if you're going to spend cuz most

1:40:40 of us don't want to spend endless amounts on all

1:40:42 the things that we can craft for our supplement

1:40:44 list but the human data is yet yet to be

1:40:46 out although animal data looks promising for the right patients.

1:40:50 I'm glad you mentioned coenzyme Q10 CoQ10 and L-carnitine are the two

1:40:55 at least I'm aware of there's some decent data on supporting sperm

1:40:59 and egg quality so do you encourage patients to start taking that what

1:41:04 60 days before trying to conceive and then continuing that through pregnancy?

1:41:08 We usually stop CoQ10 in pregnancy just because of lack

1:41:11 of data we're very cautious in pregnancy of not

1:41:15 exposing you to anything additional you may not need

1:41:18 so we just want to be really mindful of that.

1:41:21 But I think it's in my like everybody should take before you get

1:41:24 pregnant yep at your trimester zero your hey we want to get pregnant

1:41:27 soon we should take a prenatal vitamin that has folic acid we should

1:41:30 take CoQ10 we should take omega-3 fatty acids we should take vitamin D.

1:41:35 These are all going to optimize make giving

1:41:37 you the nutrients you need for a pregnancy

1:41:39 helping support my good mitochondrial health which is

1:41:41 important for egg quality without risk of harm

1:41:45 to any of these specific supplements so these are

1:41:47 the universal we're trying and then for sperm

1:41:50 health L-carnitine we like a lot and then

1:41:52 zinc and selenium can have benefits as well.

1:41:55 I know you cover specifics in the book so

1:41:57 we'll we'll leave it to people to find it there.

1:42:00 everybody who's like very curious based on disease state and and more info.

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1:43:15 I'm sure there are sort of standards and a lot of communication in your field

1:43:20 about you know how many follicles to try and mature if one does IVF

1:43:26 and or is pulling eggs I don't know if that's the right term forgive me there

1:43:31 it is again I you know it's pulling eggs taking eggs out carefully and for sake

1:43:37 of freezing or fertilization um but how

1:43:41 much conversation is there at the various meetings

1:43:43 and in the journals about things like

1:43:45 coenzyme Q10 L-carnitine I'm not trying to punch

1:43:48 holes in these I'm obviously a big fan of supplements and my friends joke

1:43:51 when people ask me which supplements do you take they just shout all of them

1:43:55 he takes all of them which is not true I don't take all of them

1:43:57 but I've been experimenting with them since I was in my teens and they're

1:44:00 not the be-all end-all but some work

1:44:02 so how much conversation is there about things

1:44:05 like coenzyme Q10 L-carnitine is there a consensus

1:44:09 or is there sort of a distribution

1:44:10 of old school new school and I am very curious not trying to be political

1:44:15 or politically correct whether or not this divides

1:44:18 on male female fertility docs or like

1:44:22 the culture within a field often tells us a lot so I'm not asking you

1:44:26 to throw any of your colleagues under the bus but if you have to No.

1:44:32 [laughter]

1:44:31 I will say this over the past 10 years we've seen a huge change in how we

1:44:36 talk about fertility even at meetings you know

1:44:38 the first ASRM which is the American Society for Reproductive

1:44:42 Meeting that I went to was probably 15 16 years ago and it's was so IVF heavy

1:44:48 now to be fair like the science was rapidly

1:44:51 evolving like genetic testing was just introduced for embryos

1:44:54 but as we also see more patients

1:44:57 and the general public really curious about well what can

1:45:00 I do and I think this is such a good question because I look at people and say

1:45:04 IVF is incredible but I can only work with the eggs and sperm you give me so

1:45:07 come to the table with the best eggs

1:45:09 and sperm you can right control all of these variables.

1:45:12 That public curiosity drives research to a degree

1:45:18 because if you're hearing it from your patients

1:45:20 that's the formation of research questions right what

1:45:22 we're looking at now granted all data that exists

1:45:25 is is limited in its own form right

1:45:27 in general we look at cohort studies of course

1:45:29 people who tend to take CoQ10 have other

1:45:32 advantageous lifestyle factors than people who do not.

1:45:35 When we do randomized control trials though which

1:45:37 we often do in the IVF subset because we

1:45:39 can look at more distinct criteria I can

1:45:42 say well how many how many eggs were mature

1:45:45 or how many embryos formed or how many were

1:45:47 genetically normal or the pregnancy rate per embryo transfer

1:45:51 which is a little bit of a finer point

1:45:52 than just how many people got pregnant per month.

1:45:55 We definitely see robust data that certain supplementation CoQ10 vitamin

1:45:59 D omega-3 fatty acids those are clearly associated with improved

1:46:03 reproductive outcomes and I we're starting to see more I

1:46:06 don't want to say fringe but of the specifics right inositol

1:46:09 for PCOS decreases insulin resistance

1:46:11 huge benefit N-acetylcysteine for endometriosis

1:46:15 or chronic inflammatory disease so we're seeing more interest

1:46:19 in the nuance it's a hard question on the field I

1:46:21 think there's definitely an old school versus a new school approach.

1:46:24 I've always been slightly controversial because I've always been educating

1:46:30 I think at the end of the day my job's not

1:46:32 to say just do IVF my job's to explain what's going

1:46:35 on what the options are and help you make that decision.

1:46:40 I think a lot of older trained physicians practice

1:46:44 medicine in the day where this field specifically patients did

1:46:48 not have knowledge and access to knowledge therefore when

1:46:52 a doctor said do this they just blindly said okay

1:46:56 and they view that as a simpler way to practice

1:46:59 and therefore can be very dismissive of patient questions

1:47:02 when they are say what about CoQ10 or any any

1:47:06 merit of the other lifestyle factors that we talk about

1:47:09 the plethora of research that exists which is more

1:47:11 and more now is that these lifestyle factors matter

1:47:13 a lot that decreasing inflammation can influence your fertility

1:47:17 from a how your hormones function how your ovaries respond when

1:47:20 you're how many eggs you pull out to the what

1:47:23 you say how how many embryos you form

1:47:25 and that supplementation is one piece of the puzzle it's

1:47:29 not the end all be all I think we can probably

1:47:32 should always you know focus first on where we

1:47:35 can move the needle the biggest so those more core

1:47:38 lifestyle practices this should be tenant number one when we

1:47:42 feel like we've mastered those and we want to add

1:47:44 to the puzzle that's when we can start to say

1:47:46 what supplements help me and one thing that I

1:47:49 really encourage is allowing ourselves space in each patient

1:47:52 to be their own N-of-1 experiment meaning how can I

1:47:55 get so in tune with my body that I can say this makes me feel this way and trust

1:48:01 that sense for yourself because we are all unique

1:48:04 and our response will be different to different medications or different

1:48:07 interventions and learning to trust that and think about

1:48:11 what's working for you or oh this isn't that's really

1:48:15 important when it comes to optimizing your own health

1:48:17 regardless of what tenant of health that we're talking about.

1:48:20 If we'd been sitting here 15 years ago

1:48:22 and I said you know red light therapy can be

1:48:26 useful for skin and for offsetting age-related vision loss

1:48:31 um any reasonable physician would be like that's nonsense.

1:48:37 Um I spoke to an ophthalmologist yesterday

1:48:39 there's been a clinical trial using red

1:48:40 light and infrared light for what's called

1:48:43 dry AMD a dry macular degeneration to offset

1:48:47 age-related vision loss and it is looks

1:48:49 promising I mean it doesn't reverse age-related

1:48:51 vision loss completely but seems to help

1:48:53 the mitochondria in the photoreceptors people are holding

1:48:55 onto some vision that they would lose there was a cover of what I am

1:48:58 told is the premier dermatology journal exploring

1:49:01 the recent studies on red light and infrared

1:49:03 light so it's a common practice now so it takes time but this stuff

1:49:07 was considered super woo nation nonsense by most

1:49:12 {quote} traditional physicians 10 15 years ago.

1:49:16 In the field that you're in, how are things like red

1:49:18 light infrared light therapy looked at currently and if they are used,

1:49:25 where is it directed?

1:49:26 Mhm.

1:49:26 Is it actually on top of the ovaries?

1:49:28 Is that the idea or that it's a more of a systemic effect?

1:49:31 Great question.

1:49:33 I think again, let's just think about the fact that chronic inflammation impacts

1:49:35 your body when it comes to your hormones

1:49:37 and your fertility multiple ways, right?

1:49:39 So, if you have chronic inflammation,

1:49:41 it's going to interfere with hypothalamic receptivity.

1:49:44 So, your brain can't interpret your hormonal signals as well.

1:49:47 It's also going to send out signals differently.

1:49:49 You're also going to have distinct ovarian changes and how

1:49:52 the ovary responds and then of course for the egg quality.

1:49:55 So, the bigger answer of like what type of therapy matters maybe depends

1:49:58 on the outcome that we're looking at or how we're trying to show benefit.

1:50:01 And in short, that is inconclusive,

1:50:03 but all appears to be beneficial for the reasons you stated,

1:50:06 whether it is to improve ovulation patterns,

1:50:08 which we've seen signs showing that.

1:50:11 That's more of the systemic probably.

1:50:13 Like you're sitting in front of your red light panel,

1:50:15 that's going to decrease some whole body inflammation.

1:50:18 That's the inflammation that's most likely

1:50:19 contributing to some of the brain sensitivity.

1:50:22 So, you're improving the ovulatory pattern.

1:50:24 There have been some studies looking at ovarian directed red light therapy,

1:50:28 so through the abdomen.

1:50:29 But there is now, I mean we don't have definitive data,

1:50:31 but there's even a vaginal ultrasound wand that's got red light therapy.

1:50:35 So, we don't have data on that yet,

1:50:36 but seeing intravaginally you're much closer to the ovaries,

1:50:39 that's why we do [clears throat] vaginal ultrasound

1:50:41 monitoring for IVF to try to see if directing

1:50:45 the response closer to the ovary can have

1:50:47 more benefit or could potentially benefit egg quality more.

1:50:51 I think most people are going to say,

1:50:52 you know, we don't have definitive data yet.

1:50:55 Yet everything's pointing to likely benefit.

1:50:57 Mhm.

1:50:58 I don't know if this study could be done,

1:50:59 but um one arm of this my podcast company funds research

1:51:05 and one thing I'd love to see the experiment done is um either

1:51:10 maintaining or doing fertilization of of eggs under red light because so

1:51:15 much of the proper chromosomal arrangement

1:51:17 seem to be dependent on mitochondrial health.

1:51:19 That's a short-term exposure.

1:51:21 But um the more I learn about the different

1:51:23 wavelengths of light and how they impact mitochondria

1:51:25 and I think about the horrible lab lighting

1:51:27 that I lived under for many years of my life.

1:51:29 I think are these these such precious embryos

1:51:32 is there a way to put them under um

1:51:35 beneficial lighting as opposed to either neutral or I'm

1:51:38 not saying detrimental lighting, but I don't know.

1:51:40 It'd be a fun study to to fund if um if there's a way to do it.

1:51:43 Yeah.

1:51:43 I think it definitely could Okay.

1:51:44 I think it definitely could be done.

1:51:45 You mean we have incubators.

1:51:46 They that could definitely be done and where you fertilize, too.

1:51:50 I was going to say off topic,

1:51:51 my daughter did her science fair project on chicken eggs,

1:51:54 but they looked at blue light, green light, and natural light Ooh, cool.

1:51:59 if they, you know, they're all fertilized,

1:52:00 but to see if their hatchability was different and the group that was

1:52:04 exposed to blue light actually had the highest hatchability and you know,

1:52:07 UV light was actually the lowest.

1:52:10 But in their research,

1:52:11 what so fascinating is that red light is really detrimental to chicken eggs.

1:52:14 So, anyways, I think Yeah, well that's why science is fun.

1:52:17 Oh, congratulations to her.

1:52:18 She should write it up.

1:52:19 You know, there's a journal where kids can write up their Yeah,

1:52:22 I'll send you a link to it.

1:52:23 She'll be published and that's what's so cool about science.

1:52:26 Sometimes we think, oh the red light is going to be the beneficial one,

1:52:29 the UV light is going to or the blue light is going to be the bad one,

1:52:32 but then you know, vitamin D production is dependent on blue and UV.

1:52:36 So, you know, nature's mysterious.

1:52:38 You know, that's awesome.

1:52:40 It It keeps it interesting for us.

1:52:41 Awesome.

1:52:41 Is she going to become a scientist?

1:52:43 Or she's already a scientist, but 11, but she's a scientist right now.

1:52:46 I love it.

1:52:47 I love it.

1:52:47 I'll send you that link.

1:52:48 It'd be cool if she would write that up.

1:52:50 Um So, red light maybe.

1:52:53 Yeah.

1:52:53 And I should point out I red light and infrared comes from sunlight.

1:52:56 So, and of course there's circadian good circadian effects of getting sunlight.

1:53:01 All circadian benefits of getting sunlight are pro-fertility,

1:53:04 pro-hormonal health.

1:53:05 Yes.

1:53:06 Yeah, I don't want to give people

1:53:06 the impression that they have to purchase a panel.

1:53:09 Um there's no hidden agenda here.

1:53:11 So, those are the things that one can take that do not,

1:53:15 I think broadly as don't smoke, don't drink.

1:53:17 I was shocked, but I need to ask um to learn what I found was that 15

1:53:24 15% of women in the United States report having

1:53:28 used cannabis in some form or another while pregnant.

1:53:30 Does that concern you?

1:53:32 Cannabis use is probably the most concerning

1:53:34 thing that I see in clinical practice.

1:53:36 So, both you can just say if that many are using it in pregnancy,

1:53:40 let's extrapolate to how many are using it beforehand.

1:53:43 And ultimately something that we are just now getting robust

1:53:46 data on because it's hard to study something when it's illegal.

1:53:49 All cannabis use is hugely detrimental

1:53:51 to sperm for sure across the board, right?

1:53:53 Both production, the quantity of sperm,

1:53:56 testosterone production, also the quality of the sperm,

1:53:59 specifically the DNA fragmentation inside the head of the sperm

1:54:02 to the degree that female partners who conceive

1:54:04 from a male partner who's using cannabis have much

1:54:07 higher miscarriage rates than partners who do not utilize cannabis.

1:54:11 And I will say clinically in the IVF lab when I

1:54:13 see embryos halt at that male developmental stage on day three,

1:54:17 we say, "Oh, here's a young couple.

1:54:19 They've got no embryos and we were expecting them to have

1:54:21 some." When we go back nine out of 10 times,

1:54:24 he is using cannabis that he previously denied.

1:54:28 So, it is one of the most movable

1:54:30 factors right now in this country for improving, you know, fertility outcomes.

1:54:36 For women, cannabis use in the prior year can decrease the eggs you get at egg

1:54:40 retrieval by 25% and can decrease fertilization

1:54:44 rates by 28% and can increase miscarriage rates,

1:54:48 therefore decreasing live birth rates.

1:54:49 So, huge numbers in science, right?

1:54:52 I mean like we get excited when something's a few,

1:54:54 you know, percentage points different, but these numbers are really high.

1:54:59 To the degree that it's really easy to sit here

1:55:00 and say if you're trying to get pregnant the fastest,

1:55:03 if you want to have the best pregnancy outcomes

1:55:05 or even you want to have the best hormones you can,

1:55:09 have longevity of your ovaries or have

1:55:11 the best sperm counts or the most testosterone,

1:55:13 cannabis use should not be a part of that.

1:55:16 And THC crosses the placenta directly.

1:55:19 And THC levels in, you know, edibles are usually the highest.

1:55:22 So, I think it's really important that sometimes people are like,

1:55:24 "Oh, well I don't smoke it, so I'm okay." We want to be really careful

1:55:29 that this is not something your body is meant

1:55:33 to be exposed to when we want to think about

1:55:35 the core of how your body is meant to function.

1:55:38 Critical message.

1:55:39 Thank you so much.

1:55:39 I I've been put through the ringer around this cannabis thing cuz I've hosted

1:55:43 people that said it does increase the risk

1:55:45 of psychosis in certain typically young males, although not everyone.

1:55:49 I've been accused of all sorts of things related to that, then

1:55:53 had someone on who confirmed that, someone who refuted it and um

1:55:56 cannabis I believe is recently rescheduled from schedule one no

1:56:01 at the federal level it's assigned to no medical application to schedule three.

1:56:07 So, there's going to be a lot more cannabis use going forward.

1:56:09 It's so critical that people hear this.

1:56:11 And the argument I always hear and it's always dudes typically on X,

1:56:15 they'll say um that they smoked a lot of weed and they

1:56:19 got their or took edibles and they got their wife or girlfriend

1:56:22 pregnant X number of times and it sort of becomes this sort

1:56:25 of point of boasting and then I never want to make the comment,

1:56:27 but I'll make it now.

1:56:28 It's like, "Yeah, but you're talking about brain development

1:56:31 in your kid." And I'm not saying your kid is dumb,

1:56:34 but I'm saying they're maybe not as smart as they

1:56:35 could be or as um healthy as they could be.

1:56:39 I'll just say that cuz I'm talking to the guys

1:56:40 out there and that's how we talk to one another.

1:56:43 Yeah, you had a bunch of kids, but they could be a lot healthier.

1:56:45 And so, I think to me it just seems like anything that one

1:56:48 could do since it's a ostensibly

1:56:51 a short-term decision certainly for the man, right?

1:56:54 The woman who's going to breastfeed

1:56:56 should probably avoid cannabis during breastfeeding, too.

1:56:58 You see where I'm going with this.

1:56:59 The outcome is so important, right?

1:57:01 And when we want to think about even just male cannabis use.

1:57:04 Yes, sperm count, etc.

1:57:07 Decreases the sperm quality.

1:57:08 That sperm quality is important for programming

1:57:10 of the embryo for how the placenta develops.

1:57:12 If the placenta is not as good, you know, association with earlier birth.

1:57:16 I mean, it's just not worth the risk when the outcome is so important, right?

1:57:22 We're all weighing risk every day with different decisions.

1:57:25 To me, there's a lot harder decisions you have to make,

1:57:27 but you know, nicotine use, cannabis use, alcohol use, like the data here,

1:57:33 none of that is advantageous for your health,

1:57:35 especially if we're looking primarily through a fertility lens,

1:57:38 a hormone lens, or even or [clears throat] specifically a pregnancy lens.

1:57:42 Like there's there's no place for it.

1:57:44 You can choose to do what you want with that data, right?

1:57:46 And people will always say, "I know so-and-so who did this and they

1:57:50 got pregnant." And there will always be those people.

1:57:52 But you're the one making decisions for your journey.

1:57:55 And the recommendation even stronger if you

1:57:57 are having infertility, if you are older,

1:58:00 depending on your scenario because you want to control

1:58:03 what you can because you can't control everything.

1:58:06 So, I call those the behavioral toxins that there's

1:58:08 really no place that we need to add these to the world if we're talking about

1:58:11 how do we get my body to function optimally.

1:58:14 It's interesting that um certain substances get politicized.

1:58:19 You know, in the past experience this thing

1:58:22 that you can tell with some degree of friction.

1:58:25 Um in the past cannabis was associated with the left.

1:58:28 It was like pro-cannabis was left.

1:58:29 Now, pro-cannabis is actually very strongly correlated with the

1:58:33 with the with the um the laws anyway this rescheduling is

1:58:37 very and you watch the media just kind of pivot and it's

1:58:40 just very clear that they're not paying that the media is

1:58:43 in the traditional media isn't paying attention to the to the actual data.

1:58:47 It's sort of like, "How can we use this as a weapon?" On both sides.

1:58:50 On both sides.

1:58:51 And so, depending on where people get their news,

1:58:53 it can be very confusing to people um along those lines.

1:58:58 For whatever reason,

1:58:59 nicotine has become kind of this right-wing associated thing.

1:59:02 I know.

1:59:03 I recently spoke to about 4,000 young men and women and I would say about

1:59:08 30 to 40% of them raised their hand

1:59:10 that they're using oral nicotine every single day

1:59:14 anywhere from probably I did I did some

1:59:17 crude analysis by hand so these aren't you

1:59:20 know hard data but it was somewhere between 12 and 70 mg of nicotine a day.

1:59:28 Wild.

1:59:28 So for women in particular is oral nicotine use

1:59:33 detrimental to either egg quality or probability of successful pregnancy?

1:59:38 It's definitely correlated because of how it works

1:59:41 in the brain to you know ovulation getting pregnant hormone response.

1:59:45 So it should not be something that we're adding to you know

1:59:49 our day-to-day life in any form if we're trying to get pregnant.

1:59:53 Most the egg quality data from nicotine comes from cigarette smoking so

1:59:56 I think it's a little bit more nuanced because smoking directly we want

2:00:00 to look at that you know I would say it's one

2:00:02 of the few things that gets into the vault and decreases our egg count.

2:00:05 I used to say chronic inflammation can get

2:00:06 in there but you know nicotine cigarette smoking definitely does.

2:00:10 You go into menopause early you'll get

2:00:12 fewer eggs the egg quality is detrimental.

2:00:15 It makes sense based on what nicotine does to your body

2:00:18 and how it kind of changes your cellular response that it probably

2:00:21 is impacting your egg quality also even with these oral nicotine pouches

2:00:25 you know that we're seeing everybody utilize and it's tanking sperm counts.

2:00:29 I mean that one's really clear.

2:00:32 I mean then it of course everyone's talking about the reduction in in uh

2:00:36 in just population growth which when I was growing up we were told

2:00:40 that like the earth is going to be overcrowded now we're told that there's

2:00:43 not going to be enough people everyone's going to be alone on their phones.

2:00:45 I don't think either extreme is true um

2:00:48 but these are these are vitally important things

2:00:50 for people to think about cuz these are easy

2:00:52 decisions to make and they can be short-term decisions.

2:00:54 They are.

2:00:54 You know we make decisions every day and and you don't have to be perfect

2:00:57 and you don't have to be all or nothing and it doesn't have to be forever.

2:01:01 A lot of these things once you really start making

2:01:04 a bunch of them and decreasing inflammation you will tangibly feel better.

2:01:08 I think we are creatures of our own world and humans

2:01:11 by nature adjust to the environment we put our body into.

2:01:15 So even things like we talked about sleep

2:01:16 but you know chronic stress how it's directly associated

2:01:19 with insulin resistance how building skeletal muscle is one

2:01:23 of the top ways you can reverse insulin resistance.

2:01:25 It's the best mechanism for hormonal health

2:01:28 we have is to build more skeletal muscle.

2:01:31 These things can impact your fertility and your health long-term.

2:01:35 And so once we start to make these little

2:01:37 decisions eating more fiber anti-inflammatory

2:01:39 foods cutting down the ultra-processed

2:01:40 foods removing the toxins changing the toxic behaviors sleeping more

2:01:45 really trying to manage stress in a more productive way.

2:01:49 Together when your inflammatory burden lowers people feel

2:01:52 better and then they get it then they say oh like this running on just caffeine

2:01:57 and eating whatever food I could on the go

2:01:59 and not getting enough sleep and then using

2:02:02 100 nicotine like that was my body giving

2:02:05 me 100 red flags that it is working overtime to deal with what I'm handing it.

2:02:10 So how's it supposed to do its normal day-to-day

2:02:12 function which at its purest that's where your body should

2:02:16 try to be especially when it comes to trying

2:02:18 to get pregnant and have the best egg and sperm quality.

2:02:21 I would never ask you to assign any validity to something for which there's

2:02:24 no data but in your experience

2:02:27 your clinical and scientific experience is there something

2:02:31 that you've heard from your patients and then

2:02:32 observed in terms of outcomes that is

2:02:35 intriguing to you that if that you would like to see more science on?

2:02:39 Um and the reason I ask this is is there's this um incredible

2:02:43 intuition that comes from just being in regular contact with a certain process.

2:02:48 For instance anytime I've spoken to an embryologist who does the kind of work

2:02:52 that they do in your clinic they read

2:02:54 journals and there's a process they learn protocols

2:02:56 but they also they develop an intuition to pick that sperm to wait just a little

2:03:01 bit longer maybe even maybe even fertilizing that egg at the end of the day

2:03:05 Oh I know it's a couple of hours.

2:03:07 It's a little small it's a little this this is the this is the art not

2:03:10 je ne sais quoi Right right the art not the science

2:03:12 of it the same way you know cooking is chemistry

2:03:15 but there's an art to it too and that nothing

2:03:18 can replace those millions of hours in contact with the process.

2:03:22 So you've had so many hours in this process at every level.

2:03:26 Um is there something that intrigues you

2:03:27 and that you'd like to see more science on?

2:03:30 I love that question.

2:03:32 One thing I think I want most people to take away then I'll

2:03:35 answer the question is that you can make tangible improvement in your fertility.

2:03:41 By looking at these lifestyle factors and coming up

2:03:43 with a plan to try to decrease your inflammatory

2:03:46 burden you can have a different outcome and I

2:03:48 think that conversation's even more important if you're waiting

2:03:51 longer to get pregnant or if you're at an older

2:03:53 age or you have lower ovarian reserve because

2:03:55 knowing that you are controlling all these variables to put

2:03:57 the best egg and sperm forward is really important.

2:04:01 The most intriguing part of the conversation for me right now

2:04:03 is GLP-1s and their use

2:04:06 for potential chronic inflammatory disease like endometriosis.

2:04:10 As a field we quickly accepted that they are hugely powerful for PCOS

2:04:14 and states of obvious insulin resistance

2:04:16 for reasons that make sense to everybody.

2:04:18 They also help obviously patients lose weight.

2:04:22 Fat cells make estrogen they impact the ovulatory process.

2:04:25 Fat cells are inflammatory.

2:04:27 So all the things that we said were negative.

2:04:28 So by simply losing weight we can restore ovulation we can have improved

2:04:32 IVF outcomes and it is just a more effective mechanism for weight loss.

2:04:37 So easy to jump on and say I have a patient who needs to lose weight.

2:04:42 I have a patient with PCOS GLP-1 agonist can be a very powerful tool to that.

2:04:47 Where I see right now are patients who have known

2:04:49 endometriosis or what I call probable endo they have unexplained infertility.

2:04:54 50% of those patients will end up having endometriosis.

2:04:57 Maybe you know one of the problems with endo

2:05:00 is gold standard is a surgical diagnosis only.

2:05:03 We don't have a lab test for endometriosis.

2:05:06 But when we are getting unexplained IVF outcomes that do not match what

2:05:10 we would expect or we have these known chronic inflammatory diseases I will

2:05:14 have patients go on a GLP-1 low dose for 3 months we should

2:05:20 take stop them and then go through a cycle with different IVF outcomes.

2:05:24 We will see more embryos in the lab and we don't have

2:05:26 to study to say that but talking to colleagues across the country

2:05:31 we know that GLP-1s can be very anti-inflammatory and the way

2:05:36 to kind of target that what appears to be that inflammatory burden

2:05:40 and I think that there will be utility there within the context

2:05:44 of these chronic inflammatory disease that might be able to help

2:05:47 a patient population that we've struggled with with difficulty to get

2:05:50 to a diagnosis or limited data points on what to do with it.

2:05:55 So the data's not out yet but it is a tool I add to the box

2:05:59 especially if we're not getting outcomes we would

2:06:01 expect and we don't have another reason why.

2:06:04 So do you think there could be direct effects of the GLP-1s

2:06:06 in reducing inflammation that are independent of less adipose tissue?

2:06:11 some of these patients do not have much adipose tissue.

2:06:13 So I think obviously that person's going to get

2:06:17 even more benefit if they have adipose tissue

2:06:19 to lose that's causing inflammation but I think

2:06:21 especially if we think about autoimmune disease where people's

2:06:25 immune system their inflammatory response is mistriggering I think

2:06:30 that there's benefit for the GLP-1s in that population

2:06:32 specifically that is giving them an added benefit

2:06:36 to decrease inflammation in a really profound way.

2:06:39 It's really interesting cuz I would have

2:06:40 thought GLP-1s reducing body fat for a woman

2:06:45 who doesn't isn't carrying excess body fat

2:06:47 that might actually be detrimental to getting pregnant.

2:06:49 fair point that we have to be really careful when it comes to skinny culture.

2:06:55 I mean we are seeing just societal norms shift again to be very

2:06:59 thin after being more you know body body positive be of a healthy weight.

2:07:03 We're definitely seeing celebrities go back to being extremely thin and we

2:07:07 know at both extremes of body weight again the hypothalamus is your checkpoint.

2:07:10 If you don't have enough body fat we are worried that you

2:07:14 cannot maintain a pregnancy so it can stop how it's sending

2:07:17 off hormones and again we can see like a luteal phase

2:07:20 defect is that first warning sign before you're in true hypothalamic amenorrhea.

2:07:24 So you have to be really careful in that patient group and it has to be

2:07:27 done with the right person who's a lot

2:07:29 of experience with GLP-1s are super low doses.

2:07:31 The goal is not weight loss it's really a different goal.

2:07:35 And again I don't have a paper to like prove it

2:07:37 but we are seeing that clinical experience to say at the end

2:07:41 of the day because there's merit in trying to decrease inflammation especially

2:07:44 in people who we suspect is contributing to the circumstance they are in.

2:07:48 And you said low dose GLP.

2:07:50 Yeah.

2:07:50 Yeah.

2:07:50 Are these available in generic form now or they just

2:07:53 still are they still under patent where they have to be

2:07:55 know the answer to that one.

2:07:56 Okay.

2:07:57 I don't know I know compounding pharmacies are making them.

2:07:59 I know today today the gray market for peptides in this country was shut down

2:08:04 so no more you can no longer buy that just for research purposes but compounding

2:08:08 pharmacies seem to be protected but I just asked because of the GLPs at least

2:08:14 the non-generic forms in their full dosage

2:08:16 my understanding is that they can be rather expensive.

2:08:19 Yes.

2:08:20 But the lower dosages from in generic form perhaps are

2:08:24 more for I would I have to be more affordable.

2:08:26 One would think yeah and I think again these add-on or there's

2:08:29 a lot of kitchen sink approach we do in fertility medicine right?

2:08:32 I've used human growth hormone for years and years and years right?

2:08:35 There's no FDA approval to use HGH for egg quality.

2:08:39 Yet we see that it can improve egg quality in the right patient in the lab.

2:08:42 So if somebody has a cycle and they don't get as many mature eggs

2:08:46 or their embryos don't do as well my partner actually did a study where she put

2:08:50 them through the same protocol so the same

2:08:52 medications in a subsequent cycle and the only

2:08:54 change was adding human growth hormone and had

2:08:57 improved embryo development and maturity of eggs.

2:08:59 Amazing.

2:09:00 So it's like an IUI night or something like that.

2:09:02 Like some low dose of of HGH during during that.

2:09:05 I see.

2:09:05 Just during the stems.

2:09:06 So it's like 2 weeks of use.

2:09:07 And so then now that's starting to be extrapolated and people

2:09:09 are starting to look at it longer or before stem.

2:09:13 You know, and so we have to take that I

2:09:15 love the fact that my field's always viewed cutting edge research.

2:09:19 You know, it's a double-edged sword.

2:09:20 Like there's some good and there's some bad.

2:09:22 We really want to think about mechanistically

2:09:24 if it could potentially help having, you know,

2:09:26 a low threshold to attempt it in patients who

2:09:28 are getting at the end of their journey specifically, right?

2:09:31 When they've they've done all the basics.

2:09:32 They're controlling the lifestyle factors.

2:09:34 I will say one thing I dislike is this just do IVF mentality,

2:09:39 meaning nothing you can do can impact your egg quality.

2:09:42 Let's just do IVF and then we're compounding dollars and dollars and dollars.

2:09:47 Yet we're not eating anti-inflammatory food and we're drinking

2:09:50 wine every night and we're not getting enough sleep, right?

2:09:52 Like so I think that we've got to really look at these, you know,