Everything You Were Never Taught About Fertility ft. Dr. Lucky Sekhon | SHE MD

0:00 We spend our teenage years and early

0:03 20s [music] trying desperately not to get pregnant.

0:06 We start to see more rapid changes [music] at 35 and older.

0:09 Having said that, 35 is not a fertility cliff.

0:13 When does your fertility start to decline?

0:15 Even in our 20s, 20 to 25% [music] of embryos,

0:19 which form from our eggs once they're fertilized,

0:21 are going to be genetically [music] imbalanced.

0:23 If PCOS and endometriosis are the leading causes of infertility,

0:27 how come fertility doctors [music] don't diagnose it?

0:32 Hi everyone, it's Mary Alice Haney.

0:34 And Dr.

0:34 Taz Bhatia.

0:36 We talked to so many women in our SHMD community who are just done.

0:42 They're doing the workouts, they're eating the right things,

0:44 but they're still [music] hitting that 3:00 p.m.

0:46 wall, dealing with brain fog,

0:48 and feeling like their body is working against them.

0:51 As an OBGYN, I see this every single day.

0:54 Women are told they're just getting older or they're stressed,

0:58 but the truth is your metabolism is your body's master regulator.

1:03 You don't need another caffeine [music] fix.

1:05 You need to support the system that powers you.

1:09 That's why we created Ovia.

1:10 We weren't looking for a quick fix or a miracle pill.

1:13 We wanted a real doctor-formulated solution for complete metabolic care.

1:18 We built Ovia to the Ovia standard.

1:20 No proprietary blends, no fillers, just clinically studied ingredients.

1:25 It's designed to help your body manage blood sugar spikes

1:29 and stay in a steady high-energy state [music] all day long.

1:34 And it's the easiest part of my morning.

1:36 No more giant pill organizers, just one simple ritual.

1:40 Real metabolic support isn't a quick fix.

1:43 It's [music] a phased journey.

1:45 Give your body 90 days to start, feel, and see the sync.

1:50 It's time to get your spark back.

1:52 Head to ovia.com to start your 90-day metabolic reset today.

1:57 [music]

1:56 Use code SHMD at checkout to save 10% off your order.

2:00 That's ovii.com.

2:03 Your body will thank you.

2:10 That was one of my favorite episodes.

2:12 Anybody that is thinking about getting pregnant,

2:15 that's having a hard time getting pregnant, that's having miscarriages,

2:19 even if you're in your early 20s

2:21 and just want to understand your reproductive health,

2:23 you're going to want to watch this episode with Dr.

2:25 Lucky.

2:25 She has a book called The Lucky Egg and I just I was just kind of blown away.

2:30 Was that an amazing?

2:31 Amazing.

2:31 I love anything that has to do with fertility

2:34 and I love how we went through different

2:36 causes of infertility and how to work it

2:38 up and what to do to improve your fertility

2:41 and honestly how to become your own health

2:43 advocate and to address these things early on even

2:46 in your early 20s so you're not shocked

2:49 in your 30s uh with you know, fertility issues.

2:53 When you see so much of it in your own daily patient work,

2:56 so having another amazing expert was incredible.

3:00 So listening to you too.

3:01 So do not miss this episode.

3:04 Every single woman and man,

3:05 we talked a little bit about the men and their sperm,

3:07 too, should tune into this episode.

3:11 So in today's podcast we are so lucky to have Dr.

3:15 Lucky who has written the most amazing book called The Lucky

3:18 Egg and we're going to go really deep into fertility, IVF,

3:23 um really just get to the basics

3:25 of of why women have a hard time getting pregnant,

3:28 what they should be thinking about, what tests they should do.

3:30 So I'm just thank you so much for being here.

3:33 Thank you for having me.

3:34 So can you can we start off by you telling us a little bit about

3:37 yourself and the journey to write this book

3:39 and why you're so passionate about this topic?

3:42 Of course.

3:42 So I am a New York City-based fertility doctor.

3:46 I'm a reproductive endocrinologist and fertility expert and OBGYN.

3:50 I've been seeing patients now for many, many years.

3:53 I've helped thousands of families to be built,

3:57 to overcome various forms of infertility.

3:59 I've helped thousands of patients freeze their eggs.

4:02 And in all of those conversations over the years,

4:06 all the counseling, answering questions,

4:09 it became very clear to me early in my career

4:11 that there is a huge fertility knowledge gap.

4:14 And this knowledge void has led to a lot of the anxiety and a lot

4:20 of the fear that comes along with any

4:23 type of journey when it comes to fertility,

4:26 and a lot of people wasting time or being led astray.

4:30 And I think that knowledge and education

4:33 is really the root of solving this problem.

4:36 And as women in society,

4:39 it's kind of crazy that we're expected in our 20s and 30s to automatically

4:43 just know about our biological clock and figure it all out for ourselves,

4:48 especially it being the first generation that's truly

4:51 on equal footing in education and the workforce,

4:53 but also wanting to prioritize our personal goals as well as our professional.

4:57 So, you know, I have these conversations with patients every day,

5:01 and from that was born all of the things I do on social media.

5:06 But then even after, you know, years and years of creating content,

5:09 I grew frustrated with that because it felt too fragmented.

5:13 There's no index, right?

5:14 People are constantly DMing me asking me, "Can you send me a post if you have it

5:18 on this topic or that topic?" It's not an easy thing to search.

5:22 So, I decided I needed to write a book.

5:24 In 2024, I had really no concrete plan.

5:27 I just kind of set the intention.

5:30 And then my book agent found me as a patient

5:33 who was searching for answers and not getting answers

5:35 from her own fertility expert and had a failed

5:39 cycle and ended up becoming my patient and was like,

5:42 "I think you need to write a book." And so,

5:44 I helped her have have baby, she helped me have my book baby.

5:48 Haha, your book baby.

5:48 By the way, it is a book baby.

5:49 On the same timeline, to be honest.

5:51 I handed in my manuscript the weekend she had her baby.

5:54 So, we have this beautiful relationship where we were in parallel

5:58 with our goals and I'm so excited about this book because I really,

6:03 you know, I flip through it all the time and I think to myself,

6:06 "How did I pack this much information?" It's like a fertility Bible.

6:10 And I really think that this is going to be part

6:12 of the revolution that we so badly need in my field.

6:16 Well, I always say to Taye Diggs, "Dr.

6:18 A, we spend our teenage years and early

6:22 20s trying desperately not to get pregnant.

6:25 And then, we spend our late 20s, 30s,

6:29 and sometimes 40s desperately trying to get pregnant.

6:32 And it's it all happens at the same time.

6:34 Your career starts taking off at the exact

6:36 moment it is time for you to have babies.

6:38 And and you're right, we do aren't educated.

6:40 We don't really I didn't know one in six people globally experience infertility.

6:44 And that but I know from experience and with all my friends,

6:47 a lot of people don't know about their egg quality until

6:50 they're trying to get pregnant and then it's almost too late.

6:52 And you And Dr.

6:53 A talks about that all the time with her patients.

6:56 So, can we start at the beginning and really just talk about fertility,

7:00 ovulation, hormones, egg reserve,

7:03 like you're born with a certain amount of eggs and then

7:07 just just the basics of of of a female anatomy,

7:11 body, and her eggs and her ovaries and the whole thing.

7:14 I love that as an opener because that's literally

7:17 how I start every consult with a new patient.

7:20 No matter where I think they're coming in knowledge-wise,

7:22 there's always a gap to fill, right?

7:24 So, I always start by telling them human reproduction is inefficient.

7:29 Doesn't matter who you are, this is just what it means to be a human being.

7:33 And I think that's important.

7:34 It's not meant to start out in a negative way,

7:37 but it's to give people realistic expectations that even in our 20s,

7:41 when you're considered in your reproductive prime years,

7:44 every cycle when you ovulate, you're only releasing a single egg.

7:47 That egg lasts for 12 to 24 hours.

7:49 If it's not fertilized in that timeframe, sorry, too bad.

7:52 You have to wait till the next month or the next cycle.

7:55 Not everyone has a cycle each month, right?

7:57 Um and so it's a very narrow, fleeting window of opportunity.

8:01 And even if you time things perfectly,

8:04 there's no guarantee that that one single egg will fertilize successfully.

8:07 Even when we try to force that to happen in the high-tech IVF lab,

8:11 it's like 70 to 80% chance for an egg to fertilize, right?

8:14 So it's complex.

8:15 It's not just the simple coming together of the egg and the sperm.

8:18 And then only about half of fertilized eggs can grow into an embryo,

8:22 and that takes about a week.

8:24 And during that time, if you imagine this happening in the body,

8:27 the fertilized egg is kind of traveling

8:29 through the fallopian tube to the uterus.

8:31 And if it gets there, which is a big if,

8:35 we have to ask, is the is the embryo healthy and normal?

8:38 Not every embryo is going to have what it takes.

8:41 Even in our 20s, 20 to 25% of embryos,

8:45 which form from our eggs once they're fertilized,

8:47 are going to be genetically imbalanced.

8:49 They're going to have missing or extra DNA,

8:51 meaning that is not an embryo that can implant.

8:54 It might stop growing before it has a chance to turn into a pregnancy,

8:57 or it might implant for a little bit and then stop growing.

9:00 And that is the number one cause of first trimester miscarriages.

9:03 So it's kind of like playing the slot machine,

9:07 which is part of the reason I called my book The Lucky Egg,

9:09 because you are just kind of hoping and praying that each

9:12 ovulated egg will kind of get past all of those checkpoints.

9:16 And it is normal and natural and a part

9:18 of our expected biology for us to have to really be persistent,

9:23 and for that persistence to hopefully pay off.

9:26 And then it's all about understanding based on your age and your risk factors,

9:30 when is it time to call it and say, "You know what?

9:31 I'm done with playing the slots.

9:33 I'm going to go to see a specialist and look for barriers,

9:36 look for test results that could point to a particular

9:40 cause as to why it's not happening yet,

9:42 and then find a solution to make a really inefficient process more efficient.

9:48 So, with eggs, so you're born with a certain amount of eggs.

9:51 Can you Can you just go to the basics

9:53 for that and what happens throughout the lives until menopause?

9:56 So, you're born with all the eggs you're ever going going to have.

9:59 You're born with a stockpile deep inside both

10:01 ovaries of about 1 to 2 million eggs.

10:04 By the time we get into menopause, the average age is, you know, 50, 51.

10:09 That's where we typically are below

10:11 a critical threshold of less than 1,000 eggs.

10:13 And that's almost like your ovaries have so few eggs, bottom of the barrel,

10:17 that when your brain is sending a signal to the ovary

10:20 and trying to get one of those eggs to ovulate,

10:23 the ovaries no longer listen, right?

10:25 So, many of the patients who are coming to see me,

10:26 who are reproductive aged, they're in between those two time points.

10:30 And I always tell them, "I'm going to do an ultrasound on you today,

10:33 and whatever number I can see of these bubbles of fluid,

10:37 they're called follicles, and each one contains a single microscopic egg,

10:41 those aren't all the eggs that you have for the rest of your life.

10:44 These represent a very limited subset

10:46 of your eggs because there is a very magical

10:49 process happening in the background that most

10:51 people aren't even aware of in their bodies,

10:54 where every cycle there are waves of eggs

10:56 that get recruited to the surface from your stockpile.

10:59 And that is a process I can't control or manipulate,

11:02 and neither can you as the patient.

11:04 And those are the eggs that are available,

11:06 and they're kind of like auditioning to see who gets to ovulate.

11:09 Your brain sends a signal to the ovary,

11:11 like a lottery, again, with the luck element, right?

11:14 And one of those eggs randomly will be selected to be the dominant one,

11:18 and you ovulate that one egg.

11:20 The rest of them die off and go away,

11:22 and then a new set of recruits come up to bat from the stockpile.

11:26 So, when we think about what does it mean, you know,

11:29 what what does the number of eggs that you count on the ultrasound,

11:32 the follicles, the bubbles that each contain an egg, what does that mean?

11:36 Well, it tells me how many I have access

11:38 to if and should you need to do an egg retrieval,

11:41 whether you're trying to freeze eggs or go through

11:43 a process of IVF to overcome infertility or to freeze embryos.

11:47 Otherwise, the number I'm seeing has no bearing on your ability to get pregnant

11:52 on your own when you're just trying ovulation

11:54 after ovulation because you're only ovulating one egg.

11:57 It's not really a numbers game.

11:58 But, it is a numbers game when

12:00 we're talking about treatments like egg retrieval, IVF.

12:03 And so, that's where numbers come into play.

12:05 What really matters for your natural fertility,

12:08 your ability to get pregnant from an ovulated egg,

12:11 is what is the odds of ovulating a healthy egg.

12:14 And a healthy egg in my world means an egg that has

12:18 all of the packages of DNA that they're supposed to have, the chromosomes.

12:22 Now, I don't want to get too technical, but I think this analogy really helps.

12:27 Imagine chromosomes as packages of DNA.

12:30 Each egg should ideally be bringing 23 to the table.

12:33 Most sperm bring 23 to the table,

12:36 and then they join together and we have 46 chromosomes to be healthy, right?

12:40 As a human being.

12:41 And eggs basically have these proteins,

12:45 and the proteins are like a filing cabinet,

12:47 and they're keeping the chromosomes or the packages of DNA organized.

12:51 And these proteins have no repair mechanisms,

12:53 and they break down as we get older.

12:56 And so, imagine it being like a filing cabinet that kind of is cheap.

13:00 It It breaks down over time.

13:02 And so, there's more chromosome disorganization, and there's a higher tendency,

13:08 an increased tendency to ovulate eggs that have disorganized chromosomes and end

13:12 up contributing the wrong number to embryos as we get older.

13:15 And this happens in 20-year-olds.

13:17 It's never perfect for anyone.

13:19 The lowest possible rate of these errors that don't allow an embryo to implant

13:24 or stay implanted happen at a rate of about 20 to 25% in our 20s,

13:29 but this rises to about 50% of embryos

13:32 being genetically imbalanced or abnormal at 37 38,

13:35 and about 70% by the time we're age 40,

13:38 and almost close to 90 to 95% by the time we're 45.

13:42 So, you can imagine that relying on ovulating

13:46 like a lottery randomly a healthy egg,

13:49 if they become few and far between as we get older,

13:52 and so it can take many more ovulations

13:53 of that random egg to get to a pregnancy,

13:56 and there are higher risks of things like miscarriage as we get older.

13:59 And that's really the crux of the biological clock.

14:03 And so, when is that point?

14:04 And it's not a It's different for everyone,

14:06 I know, but when does your fertility start to decline?

14:09 We start to see more rapid changes at 35 and older.

14:13 Having said that, 35 is not a fertility cliff.

14:16 People come into my office all the time freaking out that they're 34,

14:20 they're turning 35 next month, and I will say,

14:22 "You're not Cinderella at the ball,

14:24 and the clock is striking midnight." This is really on a continuum,

14:28 and these changes are setting in throughout our life.

14:31 They tend to be relatively stable for most people in their 20s,

14:35 but then you see a little uptick, right?

14:37 If you go from 20 to 25% in your 20s to maybe 30% in your early 30s,

14:42 35% maybe up to 40% at 35 36, and then there's a bigger uptick to 50%.

14:49 So, over age 37 38, you start to flip the coin.

14:53 It's like a weighted coin in favor of it being slightly more likely

14:57 for an egg that's being ovulated to result in an abnormal embryo than not.

15:01 But, it's not all or nothing,

15:03 and I want to balance this by saying there's plenty of women

15:05 out there that get pregnant from ovulating

15:07 on their own without any intervention, and have babies at 38, 40, even at 43 44.

15:14 It's just the statistics dictate that it's typically going to be a little bit

15:18 more challenging for the average person as you enter that that zone of life.

15:25 And then my I guess I this is for both of you because you obviously see,

15:29 you know, you deliver babies all the all

15:31 day long and you you follow over their pregnancy.

15:33 Is there for a woman listening whether she's in her 20s, 30s, teenagers,

15:37 40s that wants to get pregnant and wants

15:40 to make sure that she's her keeping her egg,

15:43 the one that ovulates, is healthy as possible.

15:45 Is there anything you can do to make that happen?

15:48 Is there are there supplements?

15:50 Is there diet?

15:51 Is there I mean, or is it really just that egg comes and it is what it is?

15:57 It's a combination of both.

15:59 Like yes and no, right?

16:01 Um there is an element to our fertility, the eggs that we ovulate,

16:07 the quality of those eggs, that is determined by genetics.

16:11 Um so some of there's going to be a genetic contribution.

16:15 Um there are certain conditions that can

16:17 influence the quality of our eggs like endometriosis,

16:21 even PCOS, and these can have a strong genetic component.

16:25 So it it's not to say, "Oh, you didn't do all the right things or, you know,

16:29 have the right supplements or it was your diet." It's like, "No,

16:32 some of it's just genetically how

16:34 we're wired that we have certain predispositions.

16:37 Age is a big factor.

16:39 When I think about, you know,

16:41 the the chromosomes and the the proteins

16:45 breaking down and the chromosomes being more

16:47 likely to be haphazard in the way they segregate and end up in the embryo.

16:51 Um that's the effect of age, right?

16:54 The wear and tear.

16:55 There's no repair mechanisms.

16:56 If you picture it like a factory

16:58 with chromosomes being organized on an assembly line,

17:01 the machinery can break down over time.

17:03 That's just the wear and tear of aging.

17:05 But if you imagine things like insulin resistance where there's an environment

17:10 around the eggs where they're being matured and ready to ovulate,

17:14 that's not ideal because insulin resistance is

17:17 basically a condition often associated with PCOS.

17:20 Not every woman with PCOS will have it,

17:23 but it's something we see really prevalent in today's day and age

17:27 where and it probably has to also do with the rise in obesity,

17:30 but there can be a tendency for people to not listen to the signal of insulin,

17:35 which is a hormone that's produced by a gland called the pan- pancreas.

17:39 It's helping you to store blood sugars effectively.

17:42 And if your body's not listening to that, your fat cells,

17:45 your muscle cells, they're not storing sugars effectively.

17:48 You have higher amounts of sugar in your bloodstream and it's pro-inflammatory.

17:53 You end up producing more insulin because

17:55 your body's trying to store the sugars effectively,

17:58 but the cells aren't listening.

17:59 And insulin actually makes your ovaries overproduce testosterone.

18:03 A lot of women aren't even aware that they make testosterone.

18:06 But your ovaries can overproduce testosterone and it can lead

18:09 to a very unhealthy imbalance at the level of the ovary.

18:13 So that environment where the eggs are being recruited

18:15 and going through different stages of genetic uh reorganization,

18:19 that insulin resistance and that high testosterone

18:22 can actually throw things off even more.

18:25 So if we're going with the factory analogy,

18:27 imagine it's like turning up the temperature or turning the lights down.

18:30 It's like, "Okay, now there's going to be even

18:31 more errors that can happen on that assembly line,

18:33 right?" In addition to the wear and tear of aging

18:36 and the breakdown of the machinery in the factory.

18:38 So certainly, you know, exercising regularly, maintaining a healthy body weight,

18:45 um not smoking, not drinking in excess.

18:49 These are toxic exposures and things that we know

18:51 can make your ovaries and your eggs more error-prone.

18:56 But there's also the element of age, timing,

18:59 and just biological predispositions that come from genetics.

19:02 So it's really a combination of factors and levers that you

19:05 can control and pull and things that you can cannot.

19:09 What sort of a patient that's overweight

19:11 or has diabetes that comes to your office,

19:15 do you with that and tell me that they're interested in getting pregnant?

19:18 Do you fix that?

19:20 I mean, obviously it's one of the main

19:22 things you have to address, but it all depends.

19:25 You can't put every patient in the same bucket.

19:28 The age makes a huge difference.

19:30 So, if I get a 40-year-old who's overweight, I don't say, "Oh,

19:33 let's take a year for you to lose

19:35 your weight before you can start for pregnancy." Absolutely.

19:38 somebody younger, then that's different.

19:41 As you know, majority of my practice, Dr.

19:43 Lucky, I see a lot of endometriosis and PCOS patients.

19:46 And for me, uh for the these subgroup of patients,

19:51 leading causes of infertility,

19:52 both endo and PCOS, I address it them very aggressively early on.

19:58 Extreme aggressive.

20:00 So, PCOS, I if they're especially if they're overweight or obese,

20:04 I address their metabolic health early on, whether it's using uh supplements,

20:09 whether it's putting them on Metformin,

20:11 on GLP-1s, on different medications, getting them healthy.

20:15 So, when they try for pregnancy, I'm optimizing their ovulation,

20:18 as she was explaining the insulin resistance that affects the androgen

20:23 secretion in the ovaries that are just toxic to these little follicles.

20:27 So, addressing their metabolic health,

20:28 lowering that testosterone can optimize their ovulation and their fertility.

20:33 For endometriosis patients, addressing it early,

20:36 diagnosing them on time, getting their pain under control,

20:40 lowering the inflammation in their pelvis,

20:42 all of it will also optimize their fertility.

20:45 When you let an endometriosis patient go

20:47 for years until their tubes are scarred,

20:49 their egg count is gone, the quality is gone, the ovarian reserve is diminished,

20:54 uh then they're going to end up needing fertility help

20:56 versus if you address it early and um uh you know,

21:01 deal with the situation early, uh you can definitely uh you know,

21:07 get them I always say if every 20 year old would go through my office at age 20,

21:12 I would bankrupt the fertility clinics.

21:15 [gasps] We'll just educate them.

21:16 You know, I had a patient yesterday.

21:18 She had bicornuate uterus.

21:20 I She has duplication of her uterus, so two horns of it.

21:27 And she had stage three endometriosis and she came

21:29 for her post-op yesterday and she told me that her doctor

21:33 in San Francisco told her that she was shocked that I

21:37 was operating on this 20-some year old with stage three endometriosis.

21:42 She's like, "Usually these patients, you know,

21:44 get surgery in their 30s, not early on.

21:49 And I don't think you have endometriosis." Like it just, you know,

21:54 it's just and that's what we I was talking to Dr.

21:57 Lucky before you came in and before we went online.

21:59 It's so frustrating for me because my practice is endo and PCOS.

22:05 Yes.

22:04 And I see these patients come from fertility clinics to me

22:08 and they're they can't get pregnant or they put out 20 eggs

22:12 at age 40 and the doctor's not making embryos and they get

22:16 upset at the fertility doctor because no one diagnosed them with PCOS.

22:19 No one explained to them that the quality of these eggs at 40 with PCOS

22:23 is going to be very different than someone who's not doesn't have PCOS at 40.

22:28 So there's just so much misinformation, but what surprises me, Dr.

22:31 Lucky, is that if PCOS and endometriosis are the leading causes of infertility,

22:37 how come fertility doctors don't diagnose it?

22:41 Yeah, and I and I don't even think it's just fertility doctors.

22:43 It's like general OB/GYNs as well as fertility

22:47 doctors who should be hyper-focused on this often

22:50 do miss it and it puzzles me as well and it's a source of major frustration.

22:54 I see a lot of patients, you know, being in New York City,

22:58 a lot of people come to me for second, third opinions.

23:00 You know, there are so many people struggling and not

23:03 having answers even if they've taken the step to do treatment.

23:07 Now, why isn't the treatment working?

23:10 And a lot of people aren't aware

23:12 that uncontrolled insulin resistance can really impact egg quality.

23:16 So, yes, you might be doing IVF and going through an egg retrieval,

23:19 but now you're asking,

23:21 why are so many of my eggs not turning into healthy embryos?

23:25 Or my embryos are seemingly healthy, they were genetically tested,

23:28 but they're not implanting or I'm having miscarriages.

23:32 And I have had insulin resistance as the answer,

23:35 the core reason behind all of those problems.

23:37 And so, whenever someone comes to me now with a difficult case

23:41 and I'm reviewing and I'm the second opinion or the third opinion,

23:44 I'm my brain always goes to PCOS, insulin resistance,

23:49 undiagnosed endometriosis because those are the blind spots

23:53 that I'm seeing in my experience where I'm like, oh,

23:55 this wasn't checked and we need to rectify this and this is

23:58 the thing that's going to make your path from here on much easier.

24:03 We've had so many experts on SheMD educate us on how

24:07 the gut is connected to so many important other aspects.

24:11 Gut health is tied to skin, to stress, to metabolism.

24:14 It's one of those areas where the research keeps growing and once

24:17 you start to understand what's actually happening at that gut level,

24:21 you begin looking at your entire wellness routine completely different.

24:26 So, when I learned Ali launched a new

24:28 probiotic line built around exactly that science, I was genuinely interested.

24:33 Precise probiotics are made with clinically studied strains

24:36 that go beyond supporting your digestive and immune health.

24:40 We're talking benefits that target specific parts of your gut microbiome.

24:44 Each one is formulated differently.

24:46 Skin support is designed for healthy, hydrated skin.

24:51 Everybody likes that, especially on those days

24:53 when you're not drinking enough water.

24:55 Stress support helps manage normal cortisol levels.

24:58 It seems everyday there's a new study showing how harmful cortisol spikes are.

25:04 No matter the season, when I feel like I need a real reset,

25:08 metabolism support promotes beneficial bacteria for a healthy metabolism.

25:12 This gives you a boost to your regular diet and exercise routine.

25:17 Your probiotics just got smarter.

25:19 One daily capsule, no synthetic color or flavors, gluten-free.

25:23 Your probiotics just got smarter.

25:26 Shop OLLY Precise Probiotics at Walmart.

25:29 These statements have not been evaluated by the Food and Drug Administration.

25:33 This product is not intended to diagnose, treat, cure, or prevent any disease.

25:37 I feel like over the years I've tried everything when it comes to body care.

25:41 Lotions, oils, creams, you name it.

25:43 And I'll be honest, a lot of them either don't absorb well,

25:46 feel greasy, or just don't really do anything long-term.

25:49 That's why I keep coming back to OSEA.

25:51 I actually met the founder.

25:52 They're based in Malibu, and I went up to her and said,

25:55 "This is my favorite product." I use their oil,

25:57 I slather on their lotion, and my skin looks and feels different.

26:02 Their formulas are seaweed powered and clinically tested,

26:05 and you can really see the difference.

26:08 They have a full lineup of body care staples,

26:10 so there's truly something for everyone.

26:12 But the product I'm most obsessed with is their Undaria Algae Body Oil.

26:16 It's one of their best sellers,

26:18 and it actually won the 2025 Allure Best Beauty Award.

26:22 What makes it so good is that it's lightweight,

26:24 fast absorbing, and not greasy at all.

26:26 It's powered by hand harvested Undaria seaweed,

26:29 and it deeply hydrates while improving the look of skin elasticity.

26:33 So your skin looks smoother, firmer, and more radiant.

26:36 So for me, the first thing I noticed

26:38 was the texture and how quickly it absorbed.

26:40 My skin just feels softer and more supple.

26:43 It's also a reminder that skin care is self care.

26:46 OSEA has just launched their newest product in the Dream Collection,

26:49 the Dream Bio-Retinol Body Serum.

26:52 This is a full body restorative overnight treatment that visibly

26:55 de-stresses the skin using a holistic blend of bio-retinol,

26:59 red seaweed, magnesium, and lavender.

27:02 Give your skin a rest with clean, clinically tested skin care from OSEA.

27:06 And right now we have a special discount just for listeners.

27:10 Get 10% off your first order sitewide with code SHMD at oseamalibu.com.

27:18 Can we go back?

27:19 Um so, here you have a couple, they want to try to get pregnant.

27:22 This is what I tell them in my office, right?

27:24 Let's say I have a 30-year-old couple.

27:26 I always do the basics.

27:28 I check and I count even though I do a blood test AMH,

27:32 even though AMH does not mean, just like you said, uh if you have a low AMH,

27:36 it doesn't mean you're not going to get pregnant.

27:37 If you have a super high AMH, it doesn't mean you're super fertile,

27:41 uh but it's just a reflection of your ovarian reserve.

27:44 So, I like to do that.

27:45 I always do a pelvic ultrasound to make sure the anatomy is normal,

27:48 there's no duplication of the uterus, uh the horns, or there's no septum,

27:54 that there's no endometriosis, and there are no polyps, fibroids.

27:58 I check for everything.

27:59 Then, I always ask about the partner.

28:02 If the partner's healthy, then there's no reason to really go

28:05 and do a semen analysis if they're just starting.

28:08 And correct me if I'm doing any of this wrong.

28:11 I do a basic hormone panel on my patients,

28:13 make sure their thyroid, testosterone levels, everything is good.

28:17 I rule out endometriosis, I rule out PCOS.

28:20 If I do all of that, then I send them to get to try for pregnancy.

28:24 And I usually tell them, if they're less than 35,

28:27 I tell them have sex three to four times a week,

28:29 give yourself about, you know, uh a year, and then if you're not pregnant, back.

28:34 And if you're 35 and above, I might give them six months to try Correct.

28:38 and then come back.

28:39 But I do all my work like all the basic workups.

28:43 I get out of the way.

28:44 I don't wait for them to to for a year and then

28:45 do a pelvic ultrasound and find out they have an endometrial polyp.

28:49 Well, that brings me to one of my biggest pet peeves,

28:51 which is as a subspecialist who's hyper-focused on fertility,

28:56 I can't count the number of times that I have been

29:00 the first person to do a pelvic ultrasound on a patient.

29:03 And I'm a big Yeah, I mean,

29:05 there are people that have gone throughout their 20s and 30s

29:08 and now they're in their 40s struggling with infertility and I'm

29:11 the first one to ever do a vaginal ultrasound to really

29:14 get a good look at their ovaries and their uterus.

29:17 And I have diagnosed for the first time in patients fibroids, um you know,

29:23 ovarian cysts that were really big and were

29:25 taking up a lot of space in the ovary.

29:28 I have diagnosed really obvious cases of endometriosis.

29:32 And I think patients feel really blindsided that they've lived their whole lives

29:35 with these things happening in their pelvic cavity and they had no idea.

29:39 And I know this may be viewed as controversial because

29:42 we as doctors are supposed to follow public health guidelines,

29:46 but I really think that sometimes guidelines are just not where they need to be.

29:50 And one big one is I believe every woman in her 20s

29:54 should ideally get a baseline pelvic ultrasound and definitely preconception.

29:59 I think taking a look, you know,

30:01 because there's sometimes no symptoms associated with having

30:04 a uterine anomaly where your uterus is just shaped differently.

30:07 And if a woman knew about this before getting pregnant,

30:10 it could save her a lot of anxiety and it could also

30:13 change her decision-making of how she wants to proceed as she moves forward.

30:17 I think it's really sad if someone has a miscarriage or they're dealing

30:21 with being pregnant now and they find out they have a huge septum

30:24 or they have a fibroid that's taking up space in their uterine cavity

30:28 and it could cause complications even if they do get pregnant with it in place.

30:32 You know, you talk about standard of care and I always say people ask me,

30:35 well, is do you practice standard of care?

30:37 And I go, no, I don't.

30:38 Doing a pelvic ultrasound takes 1 minute.

30:41 the minimum and it could give you so much information.

30:43 And you know, the counter argument is, well,

30:45 how many do you have to do to find an abnormality?

30:48 But like you said, it's not

30:49 like someone's being exposed to radiation unnecessarily.

30:52 It's such a minor intervention.

30:54 And I think for those people who you do pick up something,

30:58 it could make a huge difference in the trajectory of their fertility,

31:02 their quality of life.

31:04 And I feel really strongly about that.

31:06 And and and also, it's not fair because

31:08 there are some people that every annual GYN visit,

31:12 they are getting a pelvic ultrasound because their OBGYN

31:14 believes that that's the right thing to do.

31:16 And then there are some people that, like I said, who've never had one.

31:19 And I'm the first one doing it at age 40.

31:22 But you know, they do the bimanual exam.

31:24 They put, you know, where the doctor puts their finger in the vagina,

31:28 which is I think that's so like impersonal and it's uncomfortable.

31:34 I'd much rather take that time and put it do a pelvic ultrasound.

31:40 100% It literally takes me 1 to 2 minutes.

31:42 Yeah.

31:42 And you can see more.

31:43 I mean, you're able I I can I I get way

31:47 more information from an ultrasound than doing a bimanual pelvic exam.

31:51 Bimanual means nothing.

31:52 I agree.

31:53 You can miss ovarian cancer with a bimanual exam.

31:56 So that needs to be replaced.

31:58 A lot of things need to be replaced.

32:00 So when you talk about this standard of care,

32:03 it's so bad that we can never practice at that level.

32:07 Because that's why women get dismissed all the time.

32:10 And that's why unfortunately these fertility clinics are packed.

32:14 So can you go through a workup of a patient who comes

32:17 to your office who's tried for a year and can't get pregnant?

32:22 Yeah.

32:22 I mean, the simplest way to think about it is what

32:24 are the four components of what it takes to get pregnant, right?

32:27 You have sperm, the fallopian tubes where

32:29 the sperm and the egg meet, the uterine cavity,

32:31 which you want good real estate where it's nice and smooth ideally

32:35 and you have a lot of surface area for an embryo to implant.

32:38 And then the ovaries and the eggs they contain,

32:40 are they able to release eggs in a timely fashion?

32:43 Do you have a lot of eggs?

32:45 Do you have a low number of eggs for your age?

32:47 That's just good information to kind of have in the in the back

32:49 of your mind in case someone needs to think about a treatment option like IVF.

32:54 And then the quality of the eggs,

32:56 unfortunately that's the biggest blind spot in our field because

32:59 there is no direct way to assess that and we're

33:01 making a lot of assumptions based on all of the embryos

33:05 that have undergone genetic testing for women of varying ages.

33:09 We see a very distinct pattern and we know age-related increases

33:12 in those chromosomal imbalances and problems

33:15 with embryo quality is a very real thing,

33:17 but it's an imperfect marker because it's a guess based

33:20 on a number and we know our patients aren't numbers, they're individuals.

33:23 So, in terms of the tests, to look at the tubes in the uterus,

33:27 a really good test is either doing an HSG which is an x-ray,

33:32 a hysterosalpingogram where you can do

33:35 this with a a fertility doctor or radiologist.

33:38 You're lying on the table, a speculum exam,

33:41 dye is kind of put through the cervix and it spills and fills

33:45 the uterine cavity which looks like a triangle in most cases and then

33:48 it kind of fills the the fallopian tubes and by doing the x-ray

33:52 the dye lights up and you can kind of highlight the inner reproductive tract.

33:56 So, you're going to be able to this is a two-for-one test,

33:59 you're going to be able to see blockages in the fallopian tubes.

34:02 Something subtle that I pick up a lot especially when

34:05 patients went straight to IVF and maybe their doctor said,

34:08 "Oh, we don't need to look at the tubes,

34:09 we're bypassing them." And now they've had maybe two failed embryo transfers.

34:14 I'm like, "Did you ever have an HSG?

34:16 Like let's look at your tubes

34:17 because sometimes there's inflammation and often endometriosis

34:20 can be a cause of that, having a prior STI or pelvic infection,

34:24 even like a ruptured appendix." Like there's so many things

34:26 that can cause that and you just didn't even know about it.

34:29 Your body tried to heal itself and it kind of walled off,

34:31 and became this old chronic infection.

34:34 And And people are like, "Well, why does that matter?

34:37 You're not even using my fallopian tubes." Well,

34:39 it's communicating with your uterine cavity in a way that can lower

34:42 the chance of an embryo implanting

34:44 cuz it's creating an inflammatory environment.

34:47 And it can also increase your risk of miscarriage.

34:49 So, recurrent losses, infertility, you really have to rule out tubal issues.

34:54 You don't always have to do an x-ray.

34:55 There's a way to do it with fluid that contains bubbles or foam,

34:59 and that lights up on an ultrasound.

35:00 So, there's different ways to go about it,

35:02 but must look at the tubes if you're

35:04 trying to get pregnant and it's not happening.

35:07 That is a major miss.

35:08 Even if you're going straight to IVF, look at the tubes.

35:10 That's my PSA.

35:12 And then, um you know, there's more detailed ways of looking at the uterus.

35:15 If you don't do the tube test, or maybe you did the tube test a year ago,

35:18 and now you don't feel like you need to repeat it,

35:20 but you want to look at the uterine cavity.

35:22 There's a saline sonogram.

35:24 Um sperm testing.

35:26 It's like this is the silliest thing to be missing.

35:28 It's a cheap test.

35:29 It's an easy test.

35:30 And 50% of couples that I am working up

35:33 for infertility will have some form of male factor infertility.

35:37 Maybe it's a combination of factors.

35:39 And a third will have just male factor.

35:42 And so, we're looking at the number of sperm under the microscope.

35:46 We're looking at how they're swimming, how they're shaped.

35:49 And you know, men are always making new sperm.

35:51 Every 74 days a new sperm cell is generated.

35:53 So, there's definitely room for improvement.

35:56 Lifestyle matters.

35:58 You know, habits matter.

36:00 Um there could be a role for taking

36:02 uh supplements that are rich in antioxidants.

36:05 But you also don't want to overdo it because you

36:07 do need a healthy level of inflammation for your normal biology.

36:10 And there's some studies that show overdoing it

36:13 can actually have a negative impact on sperm quality.

36:16 So, it's all about just leading a balanced lifestyle

36:18 and trying to do the best that you can.

36:20 But getting all these tests done, you know,

36:22 up to 15 to 30% of people will have all normal testing.

36:27 And and I didn't really even mention like testing AMH to look

36:31 at the egg count cuz that's not really a fertility test per se,

36:34 but we also will look at things like thyroid.

36:36 We'll look at things like prolactin.

36:37 These are hormones that are coming

36:39 from your pituitary gland and they are, you know,

36:43 responsible sometimes for really subtle

36:45 imbalances that can cause irregular ovulation

36:49 or not producing enough progesterone in the second half of the menstrual cycle.

36:54 Um so, you're really looking at all of these different elements, the hormones,

36:58 the structure of the pelvic the the pelvic organs, and the sperm.

37:03 And if everything comes back normal, I always tell patients, I'm like,

37:06 "Listen." And I ask them very detailed questions about

37:09 their their menstrual history because often times they will say,

37:13 "Yeah, I have terrible periods." And and it's obvious too,

37:16 sometimes they'll say, "I was on the pill from age 13 till till now.

37:21 And now I went off of it because I'm trying." And it's like, "Well,

37:24 why did you go on the pill that early?" "Well,

37:26 I had really awful painful pain painful heavy periods.

37:29 Okay, well, I think you might have endometriosis.

37:32 So, this isn't exactly unexplained.

37:35 I think there is an explanation.

37:37 And in any case, as long as your tubes look healthy and everything,

37:41 you know, looks normal, we have options.

37:43 We can do subtle things, laid-back things to try to, as a first step,

37:48 overcome the inefficiency of human reproduction,

37:51 including the added inefficiency because

37:54 of the inflammatory environment that might

37:56 be there if if we think that you have endometriosis.

38:00 There may be a role for surgery, right?

38:02 Not everyone needs surgery.

38:04 Um and and I think a lot of the treatments

38:06 that we offer sometimes can help overcome the effects,

38:09 but there's many patients that I will send

38:11 for surgery because if you can't be on the pill,

38:14 which traditionally stops the process that's feeding the endometriosis,

38:17 it prevents you from ovulating,

38:19 and you will need to be ovulating month after month

38:22 and all the while it's feeding this process and you're suffering,

38:26 I mean it makes sense to get assessed surgically and remove what we can,

38:32 create a healthier environment.

38:34 It may not it's not guaranteed to improve your pain,

38:37 but it may and it often does help people's pain.

38:40 And it can allow them to have a longer window of being able to try,

38:44 you know, without having to go maybe straight to IVF.

38:47 Um you know, and I think if if it if

38:49 your endometriosis is very obviously affecting

38:51 the structure of the reproductive tract,

38:53 it's damaged the fallopian tubes, you're going to need surgery anyway.

38:56 If there's a very large cyst, um you know,

38:59 even sometimes in severe cases of adenomyosis,

39:02 which is like it's related to endometriosis, it's not the exact same thing,

39:06 but it's kind of like they're they're evil twins, right?

39:09 They kind of um happen concurrently in a lot of patients.

39:12 And this is where there's infiltration of the inner lining

39:16 of the uterus cells that act like the inner lining of the uterus,

39:19 the endometrium, in the muscle wall of the uterus.

39:21 And that can deform the uterus and make it harder to have implantation

39:25 of a of an embryo or have that embryo continue to be able to grow.

39:29 People have a lot of losses or, you know, implantation issues.

39:33 And sometimes there can be a role for surgery in that.

39:36 That can be complicated and so that's not always what we propose.

39:39 We might say, "Let's use a medication like Lupron to suppress

39:42 the endometriosis." And that's something we do a lot of, you know,

39:45 in the lead-up to an embryo transfer.

39:47 So there's a lot of different ways to address it.

39:50 I don't think every patient with a suspected

39:52 endometriosis case necessarily needs surgery to say, "Okay,

39:56 now we've proven it." I think a lot

39:58 of times we can kind of clinically make the diagnosis,

40:01 especially if someone has all the symptoms and then the symptoms

40:04 went away when they stopped ovulating cuz they went on the pill.

40:07 That to me is, you know, the most obvious sign.

40:10 And I don't know, to your point, um you know,

40:13 why there is this resistance to give in to a diagnosis.

40:16 Like why can't we have a lower threshold to say yeah,

40:20 you you may have a subtle case, but I'm I'm going to call it and say I'm going

40:24 to err on the side of saying yes, you have PCOS.

40:26 I'm going to err on the side of yes, you have endometriosis.

40:29 I think all too often we're seeing the opposite and that's why we have

40:33 such chronic under diagnosis and what feels

40:36 like gaslighting to a lot of patients.

40:39 Well, can I ask a question about that?

40:40 So we've done a several podcasts on both endo and PCOS.

40:45 So and we've talked about how they're leading causes of infertility.

40:48 So let's say that you have a patient you if if they have either one of them,

40:51 you've dealt with it, that's you know,

40:53 when do you move on to the different phases?

40:56 So and you know, when you can start with the basics,

40:59 which is tracking your ovulation,

41:01 but that that's what somebody who's just

41:02 first starting out that has no issues whatsoever.

41:04 We're saying hey, track your ovulation.

41:05 That's what that's what I did.

41:07 And then you can go to egg freezing and then you

41:08 go to IUI and IVF and then you go to genetic embryo.

41:12 So can you kind of walk through the levels

41:15 and and what you would go through someone trying to get pregnant?

41:18 Yeah, I think you know,

41:19 ovulation tracking everyone should be doing that if they're

41:21 trying because if you don't know when you're ovulating,

41:24 you might not be in the game.

41:26 So ideally, if you're trying,

41:28 it shouldn't be like I don't know when I'm ovulating and now

41:31 it's 6 months of that and now I'm going to start tracking.

41:33 I think everyone should track to make

41:35 every attempt as efficient as possible, right?

41:37 And if you're finding that that's difficult from the get-go,

41:40 then go see a specialist to understand what's going

41:43 on because if there's even slight irregularities in the cycle,

41:46 these are things that we could do subtle interventions to try to improve it,

41:49 especially if we're addressing things like insulin resistance, for example.

41:53 Now, if you're I really quickly have one question about that?

41:56 How do you track your ovulation?

41:58 So there's many different ways.

41:59 If you're someone who kind of sees a regular pattern, just start simply, right?

42:04 And if you're if you're coming off of the pill,

42:06 I would say you need at least 3 to 4 months or 3

42:09 to 4 cycles worth of data to really establish a true pattern.

42:13 So, the simplest form of tracking is marked down on a calendar

42:16 or in an app that will do the math for you.

42:20 Um the first full day of of flow of menstrual flow.

42:25 Uh not when you're spotting, but when you have like a full flow, that's day one.

42:28 Then track your next day one.

42:30 Then track your next day one.

42:32 And if you see a fixed interval between each of those day ones,

42:35 then you know you have a regular ovulation and you can kind of start using

42:40 that data to prospectively model out when

42:43 your next ovulation is typically going to occur.

42:46 Because if you look at that interval of time,

42:49 it's typical and and and this dogma has been challenged,

42:52 but most people have a fixed interval

42:54 between ovulation and the subsequent period, right?

42:57 When you ovulate an egg from that dominant follicle,

43:00 it goes from producing high levels of estrogen to now

43:03 producing estrogen and high levels of progesterone and they soar.

43:08 And if that egg that turns into an embryo or it doesn't turn

43:11 into an embryo or it turns into an embryo or the embryo doesn't implant,

43:15 then your progesterone levels kind of just drop, right?

43:17 If the embryo implants, it starts secreting hCG.

43:20 That's the pregnancy hormone when you pee on a stick and it

43:23 will send a signal to your ovary to say keep making progesterone.

43:27 So, if your progesterone drops and you get

43:29 your period because that allows your lining to break down,

43:32 that tells you, okay, roughly 2 weeks prior is when I ovulated.

43:37 And so, now if you're establishing a pattern

43:40 and I think apps do a great job of this.

43:42 Obviously, you have to feel comfortable putting your information into an app,

43:45 which is a whole other topic.

43:46 But, I think, you know, if you're using a calendar or an app,

43:50 it may help you to just kind of say,

43:52 okay, here's where the 14-day mark is prior to when you got your period.

43:56 So, this is when you were ovulating and your fertile

43:58 window is kind of the days leading up to that.

44:02 It's a, you know, I would say the 2 to 3 days are probably the most high yield,

44:06 but even 5 to 6 days starting prior to ovulation,

44:10 that's ideally when you want to start getting sperm

44:12 in the reproductive tract because sperm will last for 3-5 days,

44:15 the egg will only last for about 12-24 hours.

44:18 So, to get maximum overlap,

44:20 it's all about really trying to have sex before you ovulate.

44:25 And doing it in a way where the sperm

44:26 isn't going to die off before the egg arrives.

44:28 That's one method.

44:29 On top of that, you can layer tracking by peeing on a stick,

44:33 an ovulation predictor kit.

44:35 When you're detecting the signal that lights up on the ovulation predictor kit,

44:39 whether it's just two lines or a blinking or solid smiley face,

44:43 what that's showing you is that it's

44:46 detecting the second signal your brain sends

44:48 to your ovary when it detects that you have an egg that's ready to ovulate.

44:51 It's called LH or luteinizing hormone.

44:54 And it shows up pretty quickly, it gets filtered into your urine.

44:56 So, the minute you see that positive

44:58 on an ovulation predictor kit detecting LH in your urine,

45:02 that gives you about a 24-36 hour heads-up that it's time

45:06 to have sex now because that's when you're probably going to be ovulating.

45:10 And so, I like to use both methods.

45:12 I think that improves accuracy, um, to answer your question.

45:16 And then obviously, you can look at your body's signs.

45:18 You know that your temperature rises by half

45:20 a degree after you ovulate because you start making progesterone.

45:24 Using the temperature method, I think it's less helpful,

45:27 but it's more like a sanity check to be like,

45:29 "Oh yeah, my body's doing all the things

45:30 it's supposed to be doing." Cervical mucus changes,

45:33 your breasts get more tender, um, you know,

45:35 when you start when you're when you're

45:37 done with ovulation because you start producing progesterone.

45:40 So, really just trying to track all of your symptoms,

45:43 but really it's about tracking day one

45:45 of your period and then using ovulation predictor kits,

45:48 I think can be a helpful add-on.

45:50 There are more sophisticated trackers.

45:52 I think for a lot of patients, it tends to burn them out and make them

45:56 feel really confused because it's giving them data overload.

45:59 I think what really matters is that LH surge,

46:02 picking that up, and and establishing a pattern.

46:05 Now, if you don't have a fixed pattern,

46:07 calendar method is not going to work well for you.

46:10 And even ovulation predictor kits, you're often going to get a bunch of false

46:13 positives cuz a lot of women with PCOS,

46:16 which can be associated with irregularity in the cycle,

46:19 it's probably the number one cause of why

46:21 patients come to me with an irregular cycle,

46:23 they tend to have very high LH levels cuz

46:25 it's almost like the ovaries are resistant to the signals.

46:28 And so, your brain tends to send out stronger

46:30 signals to try to get through to the ovary.

46:33 So, it's almost like your ovaries is always being yelled at.

46:36 And so, you're going to see signals all over the place.

46:40 And so, I always say that DIY tracking might not

46:43 be an ideal plan for a patient with really irregular cycles.

46:46 That's why I never say, "You know,

46:47 just keep trying on your own." The definitions of, you know,

46:51 "Try for 6 months or try for a year." do not apply if you have irregular cycles.

46:55 I would go straight to a specialist.

46:58 Okay, so tracking ovulation, that's the basic.

47:01 Right.

47:01 Then, what's the next?

47:02 So, let's say you're tracking, you have regular cycles,

47:05 you feel like you've had a reasonable shot at it.

47:08 Like Like uh Dr.

47:09 A said, if you're over 35 and it's been 6 months, if you're 40,

47:13 it's been 3 months, you want to have a low threshold to seek expert help.

47:17 If you're under 35, it could make sense to try up to a year.

47:20 But again, this is one of those standard of care arguments, right?

47:23 Like I think there's a difference between being 28 and trying

47:26 for a year versus being 34 and trying for a year.

47:29 I think if you're 33, 34, you know you want to have two to three children,

47:33 I'm never going to turn you away if you come to me at the 6-month mark

47:36 because I want to help you get

47:37 on the path to pregnancy quicker given where you're at.

47:41 And like I said, 35 is not some magical cliff that we're all falling off of.

47:44 It makes sense and it's practical to be

47:46 a little bit more cautious as you're approaching 35 even.

47:50 So, um at that point, I'll say, "We've done all the testing.

47:54 Now, the testing may push us in one direction or the other,

47:57 but let's assume all tests come back normal.

48:00 Then I really present both options.

48:02 I say there's two buckets of treatment.

48:04 There's a more laid-back approach,

48:05 which I call speed dating for the reproductive tract.

48:08 Right, if you think about um ovulating one egg and hoping that one

48:12 egg is met with sperm and all the things go off without a hitch,

48:16 it's kind of like meeting the one when you're out there dating, right?

48:19 Um now, if you're going to a speed dating event,

48:22 there might you might be improving your probability

48:24 month after month of a connection actually happening.

48:26 And so, what what that looks like in the fertility

48:29 world is something called medicated IUI or intrauterine insemination.

48:34 And so, you're doing two things to try to boost

48:37 the odds on both the egg and the sperm side,

48:39 because you don't really know what you're targeting.

48:41 On the egg side, if you can give someone medications,

48:44 usually oral medications like Clomid or letrozole,

48:48 these can make the signal from your brain a little bit stronger,

48:52 so that it gives you the opportunity or chance to release more than one egg.

48:55 And if one egg feels like a long shot for anyone, no matter what your age is,

48:59 cuz that's just human reproduction being inefficient,

49:01 then having two or three in play might improve your odds slightly.

49:05 And then on top of it,

49:06 we can take a sample of sperm right before those eggs are about to be released,

49:10 and we can wash it and concentrate it and inject a really

49:13 healthy fraction of that sperm sample at the top of the uterus.

49:16 So, more eggs, more sperm, you're hoping for a connection to take place,

49:19 but anyone who's gone to a speed dating event knows that you're

49:22 not destined to get there the first time you go, right?

49:25 Um and so, it's one of those things that's a subtle push in the right direction,

49:28 and if you're doing it, it makes sense logically to say,

49:31 "Okay, I'm signing up to do this, you know,

49:33 maybe at least three or four times and then see

49:35 what happens." Studies have shown for couples with unexplained infertility,

49:39 where we don't really have any clear indication of why it's not happening,

49:43 who do this process, and they're not successful on that sixth one,

49:47 there's tends to be diminishing returns.

49:49 You tend to kind of like peak with your cumulative probability of success.

49:53 So, thereafter I would say it's been

49:54 half a year of trying this laid-back approach, let's move on, right?

49:58 But, IVF is never wrong to go to right away,

50:01 especially if someone comes to me at say let's say 38 and they're like,

50:05 I want to have two to three children.

50:08 It's probably smarter to go straight to IVF, right?

50:10 Because IVF is a completely different ball game.

50:14 It involves taking shots.

50:15 So, unlike the oral medications I just

50:17 talked about with the speed dating option, this is more intense.

50:20 You're taking injections.

50:22 These are injections that are in the lower abdomen subcutaneous,

50:25 so superficial right under the skin.

50:27 You are injecting that same hormone signal your brain normally

50:30 sends to the ovary to get one egg to randomly ovulate,

50:33 but at a higher level because we want

50:35 to try to capture all those other recruited eggs.

50:38 And we try to get all of them to grow.

50:40 And the goal is to get all of them to grow

50:42 over the course of the 8 to 10 days of shots.

50:44 You're usually coming into the clinic much more

50:46 than with the first treatment option I described.

50:49 Maybe five or six visits for ultrasound, blood work.

50:52 So, it's a lot of poking and prodding.

50:54 And this is kind of like the more

50:55 rigorous treatment experience that people will go through.

51:00 But, it is much more efficient because then you have an egg retrieval.

51:04 It takes 10 minutes.

51:05 It's done under anesthesia.

51:06 You don't feel anything.

51:06 You don't remember anything and it's all done vaginally where

51:09 a needle goes through the vaginal wall into the adjacent ovary.

51:12 We drain as many of the bubbles of fluid as we can.

51:14 We get those eggs out.

51:16 You wake up in the recovery room.

51:18 You're supposed to get picked up to go home that day.

51:20 You're going to feel groggy and out of it.

51:21 That's the one day you take off of work.

51:23 And then we take those eggs and we

51:25 can put the sperm and the eggs directly together.

51:27 And there's different ways of doing this depending on the level

51:29 of severity of male factor issues if there are male factor issues.

51:33 But, you can put the eggs and sperm together,

51:36 cultivate them for a week into embryos.

51:39 And typically there's a lot of drop-off because, you know,

51:42 just because you're doing this high-tech process that can be very expensive

51:46 and involved doesn't mean that that inefficiency

51:48 of human reproduction magically went away.

51:50 We're still working within the confines of that.

51:52 But, the difference is if we're not working with just one, two, or three eggs,

51:55 we're hopefully working with 10, 15, 20, depending on how many are available.

51:59 And that's why egg count matters.

52:01 And the numbers matter because it's survival of the fittest.

52:04 So, whatever you start with, there's an IVF funnel, right?

52:07 And and only a certain number will make it to the embryo stage.

52:10 At that point, you can put an embryo in someone's uterus.

52:14 You could say, "I'm going to freeze these embryos

52:16 and then defer putting that into the uterus

52:18 later on if they're not ready to get pregnant."

52:21 And most of the cycles that we're doing nowadays,

52:23 we're actually taking the opportunity to remove some of the outer cells

52:26 of the embryo that would one day become the placenta without harming it at all.

52:30 And then we freeze them and send those biopsies off for testing,

52:33 and we get results back within a week or two.

52:35 And we can actually identify which embryos have

52:37 the right amount of chromosomes and which ones don't.

52:40 This is probably the thing that has revolutionized our field.

52:43 This is the reason why every week when I call

52:46 my patients who had their embryo transferred the week prior,

52:49 I'm calling at least 70% of my patients every week and saying, "Hey, guess what?

52:53 You're pregnant." Um, you know,

52:55 a lot of people will get pregnant the first transfer,

52:57 and sometimes it takes more than one to get

52:59 there because a third of embryos will not implant, even the highest quality.

53:03 That's the best success rate we can offer, right?

53:05 Cuz we're just putting it at the top of the embryo

53:07 at at the top of the uterus and hoping for everything else to go well,

53:10 but we can't control it all.

53:12 And within three successive embryo transfer attempts, if we even get that far,

53:17 92% of patients will have a live birth.

53:20 There's a cumulative 92% live birth rate.

53:23 So, it works really well,

53:24 but it's a lot more work and, you know, it doesn't always work.

53:28 You can't say it's a guarantee because some people have a really low egg count,

53:31 so they don't have that many eggs to access.

53:33 Or their egg quality issues are so great that even if they have eggs to access,

53:37 none of them are turning into healthy embryos.

53:39 And And on the other end of things,

53:41 which is the less common cause of IVF failures is, you know,

53:44 if someone has fibroids and had many surgeries on their uterus,

53:47 it just might not be an ideal environment.

53:49 It could be much harder for an embryo to implant.

53:52 And sometimes there's cases where no

53:54 one understands why the embryo's not implanting.

53:56 But in my experience, endometriosis and insulin resistance are two

53:59 of the most common hidden causes of that.

54:03 What about autoimmune conditions?

54:05 Usually when I have a patient with endometriosis,

54:08 endometriosis in a way is an autoimmune condition.

54:11 You're when your own tissue body is attacking your own tissue.

54:15 So whenever I, you know, they say when you have one autoimmune condition,

54:19 you probably have a likelihood of, you know,

54:21 there's a 33% chance of having another autoimmune.

54:24 So one thing I do routinely in my office,

54:27 if I have a patient with endometriosis, I run a full autoimmune panel on them.

54:32 And you'd be surprised how many issues I

54:35 catch just doing a simple blood test on them.

54:39 Again, I feel like a lot of patients,

54:41 especially with recurrent miscarriages, they still don't get the workup.

54:46 Can you talk to us about this autoimmune component?

54:49 Yeah, and I think it's difficult because a lot of the markers are non-specific.

54:54 Um and so people will come to me sometimes and say,

54:56 "I have an elevated anti-nuclear antibody." Or I have

54:59 an elevated C-reactive protein or erythrocyte sedimentation rate, ESR, CRP.

55:05 These are common things that people might see on routine

55:09 blood work that is ran by their primary care doctor.

55:12 Um and I think yes, sometimes it can be relevant,

55:15 sometimes it's not relevant in my experience.

55:18 Um and the key is being able to discern the difference.

55:22 But I do think we have to use our brains and our logic.

55:25 And I think when someone is suffering with a major autoimmune condition,

55:30 like I've had patients with lupus, I've had patients with rheumatoid arthritis,

55:34 it's not necessarily the case that they're

55:37 going to have a harder time getting pregnant,

55:39 but I think that it's about getting them to a place where they're

55:43 at in a in a good state of balance and you're controlling their flares.

55:47 Like I always make sure I talk to their specialist,

55:50 multi-disciplinary care is everything,

55:53 and getting them if they need to switch from one type

55:55 of medication to another because the medication they're on isn't pregnancy safe,

55:59 I want to wait for a period of stability where

56:01 their disease is well controlled because I think you know,

56:05 we we know that when the immune system is attacking your body,

56:09 that can have a negative impact on fertility directly or indirectly.

56:13 In reality, a lot of these autoimmune

56:16 underlying conditions either present when you're trying

56:19 to get pregnant and cause miscarriages

56:21 or they present during pregnancy in your 30s.

56:24 So, it's so common that of them emerge in your 20s and 30s as well, right?

56:29 Like the natural course of a lot of things.

56:32 Like most people don't know they have lupus until they're in their 20s.

56:35 Like it's not something that emerges until you're kind

56:38 of in that reproductive zone where you're also maybe going to be trying.

56:42 So, I mean, I see a lot of autoimmunity

56:45 in the thyroid and and these are things that I even

56:48 look for in cases where I have patients who come

56:51 in with really low AMH at a younger than expected age.

56:56 Um, you know, it's not part of the guidelines.

56:58 It's like more of the guidelines

56:59 for someone with primary ovarian failure insufficiency.

57:04 But I'm like, okay, well,

57:05 I have a 26-year-old in front of me and her AMH is very, very low.

57:10 I don't need to wait for her to go into ovarian failure to then say,

57:14 "Now let's look for genetic causes.

57:15 Now let's look for autoimmune markers." I can try to get

57:19 ahead of it now because if I find any of those things,

57:22 that is going to make light a fire under us even more to be like,

57:25 "Okay, we really do need to actually think about

57:27 egg freezing now." Like because you have an organic

57:30 cause that leads me to believe you could be

57:33 on a trajectory where you're entering menopause earlier, right?

57:37 So, I think I think that so much of medicine

57:40 is reactive and a lot I think of what differentiates good

57:44 fertility doctors from those that are kind of just following guidelines

57:49 and maybe just thinking that they're doing the standard of care,

57:52 but you know, not necessarily really reaching and looking for answers,

57:57 I think it's about thinking ahead,

57:58 thinking 10 steps ahead and not waiting for someone

58:01 to meet a certain criteria before you look into something.

58:03 And I think the thing that's really guided me,

58:06 I mean, I grew up with two sisters.

58:08 I always think, what would I want someone to do

58:11 for my sister if she was coming to them with this problem?

58:14 You know, like that's when the guidelines kind

58:16 of go out the window cuz you're like, I just want to know.

58:18 I want to be extra cautious and leave no stone stone unturned.

58:21 And I think that's really how I've approached patient care and and in my book,

58:26 that's really kind of the way I guide my patient.

58:29 I want them to feel like they have someone

58:30 in there in the know that's in their ear saying, "Hey, look into this.

58:34 Look into that." And I'm very transparent in the book

58:37 about when I am kind of just giving

58:39 you my professional opinion from my experience versus what

58:41 is according to the American Society of Reproductive Medicine.

58:45 But I think it's okay and it's it's actually more

58:47 sophisticated and nuanced to go above and beyond and say, "Okay,

58:52 let's use our logic and our brain and our life experience with treating

58:56 patients and sitting across from thousands

58:58 and thousands of patients and and seeing how

59:01 things unfold and just trying to really

59:03 get ahead of it because ultimately fertility

59:06 is so time sensitive that that is how you do right by your patient.

59:10 Connect with Cass one question about what you

59:12 just both of you guys just talked about.

59:13 Actually, two questions.

59:15 Egg freezing, there's two things that I hear all the time.

59:18 That it's better to freeze an embryo than an egg.

59:22 Is that true?

59:23 I actually hate hearing that because the strategy that you take for fertility

59:29 preservation is only as good as your ability to come back and use it.

59:33 And I think this idea that it's better to only freeze embryos versus eggs has

59:38 led to people making a lot of bad decisions that they weren't ready to make.

59:42 Like they're in a relationship and they're like, well, yeah,

59:45 I think we're probably going to get engaged in like a year or two.

59:47 So, like, just because I've been told embryos are better,

59:51 I'm going to rush to do something with a partner who

59:53 we may or may not be together in the future, right?

59:56 Unfertilize that embryo and go back in time.

59:59 And so, you know, egg freezing gets a bad rap.

1:00:02 It's not perfect like any test or any treatment.

1:00:05 There are always going to be blind spots and things that you cannot control.

1:00:10 The difference between eggs and embryos is this.

1:00:12 When you're freezing eggs, you're freezing potential.

1:00:15 And we already talked about the IVF

1:00:16 funnel and the inefficiency of reproduction, right?

1:00:18 I keep saying that over and over

1:00:20 because it's it's such an important concept even

1:00:22 when we talk about egg freezing because not

1:00:24 every egg is going to survive the thaw.

1:00:26 The thaw survival is the the thing that worries me the least.

1:00:30 I mean, we do pretty well.

1:00:31 It's like 85 90% of eggs will survive the thaw.

1:00:35 But if you were turning those eggs into embryos,

1:00:36 you wouldn't be freezing them and you wouldn't be thawing them.

1:00:38 So, theoretically, you're losing maybe 10 to 15%

1:00:43 of the numbers and numbers are so important.

1:00:45 So, that's one disadvantage, right?

1:00:47 Eggs are more fragile.

1:00:49 But that's not a reason to not freeze eggs.

1:00:52 I think as long as you freeze enough and you bake

1:00:54 into the equation this is how many may survive the thaw.

1:00:57 70 to 80% of eggs will typically fertilize

1:01:00 on average whether they're frozen or fresh eggs.

1:01:02 And only about 60%, maybe 50% or 60% of fertilized eggs will grow into embryos.

1:01:08 Once they get to that stage, I mean,

1:01:10 if you're going straight through and freezing embryos,

1:01:12 you're going to know in real time.

1:01:14 It's not to say that that drop off isn't going to happen,

1:01:16 but you're going to know in real time

1:01:17 the next day after the egg retrieval how many fertilized.

1:01:20 A week later, how many turned into embryos.

1:01:22 And up front, you're going to know a few

1:01:23 weeks after that which embryos came back normal.

1:01:26 So, there is advantages because you kind of have a much

1:01:29 better handle on where you stand when you freeze embryos.

1:01:32 So, you have much more knowledge and it does increase your confidence.

1:01:36 But, when you freeze eggs though,

1:01:38 it's not to say that they're not likely to be successful.

1:01:42 It's just you don't know what you have.

1:01:44 That's the biggest drawback.

1:01:46 But, the younger you are, the less eggs you need to feel confident

1:01:49 and the more people tend to follow the statistics.

1:01:52 I think it becomes more of a wild card and harder

1:01:55 to know where you stand when you're freezing eggs in your late 30s

1:01:58 and beyond because then you see a lot of variation in quality

1:02:02 and it's like you can't really have as much of a handle on it.

1:02:05 Even if someone freezes a high number,

1:02:07 even if they do multiple cycles to get that number, I always tell them, "Listen,

1:02:10 disclaimer, we just don't know." And I always tell patients over 38,

1:02:14 "Listen, what's more important to you in this fertility preservation journey?

1:02:18 Knowing that you can do this with a future partner and hopefully

1:02:22 then we focus on eggs and make sure you have enough whether

1:02:25 it takes one cycle or multiple and we do the math and bake

1:02:29 into the equation what your goals are and hope for the best.

1:02:31 And if you come back with a partner and we don't get as many as we want,

1:02:34 well, we could always try a fresh round of IVF.

1:02:37 And if that turns out to be difficult, plan C might be donor eggs, right?

1:02:42 Like that's how my brain thinks and then I'm like,

1:02:44 "But, if it's more important for you to know

1:02:46 you did everything in your power to preserve your fertility,

1:02:49 your ability to have children with your own eggs,

1:02:52 more so than doing it with a future partner, do you want to think about at 38

1:02:57 and older maybe turning some or all eggs into embryos?

1:03:01 You could do a round of embryos, you could do a round of eggs,

1:03:03 but at least with embryos, you know what you have.

1:03:06 Now, I don't really give that same speech to my younger patients

1:03:09 as much because as long as they have a good enough number of eggs,

1:03:12 their conversion rate is assumed to be lower or sorry, higher.

1:03:16 And so, you should be able to feel a bit more confident,

1:03:20 but you're always accepting some level of unknown with egg freezing,

1:03:23 and that's the the downside, but the flexibility is there.

1:03:26 And so, for someone who comes to me in their 20s or early 30s,

1:03:29 I think they're a great candidate based on their presumed egg quality.

1:03:33 I'm not going to push them into doing embryos with a partner

1:03:35 if they're not ready because they have their whole life ahead of them,

1:03:38 and I want them to be able to come back

1:03:39 and use those eggs however they please in the future.

1:03:42 So, it's really about priorities, their personal situation, their egg count,

1:03:47 their goals, all of that goes into that decision.

1:03:51 Um, so, the I want to say this, and I the reason

1:03:53 I brought that up was because even I at in my 30s,

1:03:58 I had two children and I got divorced

1:04:00 from my first husband when they were very little, and I wanted more children.

1:04:04 Mhm.

1:04:03 It was right after we got divorced.

1:04:05 And so, I I went to him, I said, "We make beautiful babies.

1:04:07 Let's just Let's just create some embryos

1:04:10 and so that we can have some more babies.

1:04:12 We don't want to be married to each other,

1:04:13 but we make beautiful babies and we're going to co-parent wonderfully." We went

1:04:16 to the fertility doctor and when they sat us down and started talking about,

1:04:21 "Okay, well, who's going to Who's going to have custody of the embryo?

1:04:27 Are you going to have it If you don't got it, who's it?

1:04:30 Yeah, if you don't use it, do you Are you going to give it to science?

1:04:33 Are you going to destroy it?" And all

1:04:35 of these things that when you're young and thinking about fertility,

1:04:38 like you aren't thinking about that.

1:04:41 That this embryo is Could be a human.

1:04:43 want to give it for adoption?

1:04:45 Do you want to give it You know, all of these.

1:04:47 The other question that comes up all the time

1:04:49 I hear all the time is that IVF causes cancer.

1:04:53 Mhm.

1:04:53 Not true.

1:04:54 Not true.

1:04:55 Unequivocally not true.

1:04:57 Uh, that is a really harmful, dangerous one.

1:05:01 Um, and there is actually a ton of data

1:05:04 on women who've gone through IVF and, you know, there's one great paper.

1:05:09 There's actually multiple, especially in countries like Denmark,

1:05:12 where they're really good about tracking long-term outcomes of, you know,

1:05:15 being in a socialized health care system.

1:05:17 They have like registries where people are tracked.

1:05:20 And there was this great study with a a large

1:05:23 number of patients who had gone through multiple egg retrievals,

1:05:27 and they followed them up until age 50,

1:05:29 and they found no link between doing multiple

1:05:31 egg retrieval cycles and incidence of breast cancer.

1:05:34 I think the reason this gets conflated is it's

1:05:36 a very obvious association that people will make because,

1:05:40 you know, many types of breast cancers are uh hormone sensitive.

1:05:44 And if you're normally ovulating one egg,

1:05:47 and now you're getting multiple to grow,

1:05:49 and each of them are producing estrogen, it's a natural thought that, okay,

1:05:52 these higher estrogen levels are an exposure

1:05:54 that can increase your risk of breast cancer.

1:05:56 The difference between that type of exposure and long-term,

1:06:00 like years and years of chronic exposure, is that this is transient.

1:06:05 Your estrogen levels are higher than they normally

1:06:07 are from ovulating one egg for a very, very limited window of time.

1:06:11 Like, I'm talking a week and a half, 2 weeks max.

1:06:15 And so, it makes sense to me, you know, as a fertility expert,

1:06:18 when I'm looking at these levels and I'm seeing, okay,

1:06:20 this is just such a short window of time, that that's not the type of exposures

1:06:24 that over the long term cause tumors to grow.

1:06:27 And, you know, we're so not worried about this that I work

1:06:30 with oncologists who send me patients with active breast cancer all the time,

1:06:34 and they allow us to stimulate their ovaries.

1:06:36 Sometimes they allow us to do multiple cycles to freeze

1:06:39 eggs or freeze embryos before their patient does chemotherapy.

1:06:42 So, it's just it's not a thing.

1:06:44 One of the reasons I think it's

1:06:45 conflated is because the number of ovulations you

1:06:48 have in your lifetime is known as an independent

1:06:50 risk factor that's associated with breast cancer.

1:06:53 So, that's called nulliparity, right?

1:06:56 And so, a lot of women who are going through fertility treatments,

1:06:59 they were nulliparous, they didn't have children, and and weren't pregnant,

1:07:04 and had many more months of ovulation under their belt

1:07:08 than than patients at lower risk of breast cancer.

1:07:11 And so many patients, you know, who are coming to me with infertility,

1:07:15 it's like they tend to be that nulliparous population.

1:07:18 They also tend to be older.

1:07:20 Those are independent risk factors for breast cancer.

1:07:22 And so I think there's a lot of confusion around it,

1:07:25 but I'm here to set the record straight that IVF does not cause breast cancer.

1:07:29 What about ovarian cancer?

1:07:30 Let's say you have someone who does 10 cycles of IVF.

1:07:35 Same thing.

1:07:35 There was one paper that found an association between six or more

1:07:39 retrievals and something called tumors

1:07:42 of borderline malignant potential in the ovaries.

1:07:45 But it by and large the data is very reassuring.

1:07:48 And again, I think it comes down to the fact

1:07:51 that it's a very limited window of exposure or stimulus.

1:07:55 It's not something that, you know,

1:07:57 when you think about hormones and cancer risk,

1:08:00 it's like we're talking about hormone exposure for years and years and years.

1:08:05 Like it's just very, very different.

1:08:09 Right.

1:08:08 So I want you've given us so much of your time.

1:08:10 Thank you so much.

1:08:11 But I wanted to end this with some myth busting.

1:08:13 That we get a lot of these questions that come

1:08:15 in and we have this incredible fertility expert on our podcast.

1:08:19 So I'm going to go through these really quickly.

1:08:21 Let's do it.

1:08:22 Number one, IVF guarantees pregnancy.

1:08:26 False.

1:08:27 False.

1:08:28 It can help and it's a wonderful technology.

1:08:30 But like I said earlier, if you have a very low egg count,

1:08:33 doesn't mean you're going to definitely We have failed cycles,

1:08:35 but it can make it a little bit more challenging and it may take

1:08:38 more rounds to get the number of eggs needed to get those healthy embryos.

1:08:43 Similarly, egg quality issues can make IVF difficult,

1:08:47 um you know, in terms of success.

1:08:48 And that's where sometimes conversations around things like

1:08:51 donor egg come into play when we've exhausted every

1:08:54 option and someone just is really grappling with some

1:08:57 of these issues that there is no other workaround.

1:09:00 This is when people might make that pivot.

1:09:02 And then with, you know, the uterus, if there's issues with implantation that we

1:09:07 just can't get around no matter what,

1:09:09 and we're down to a limited number of embryos,

1:09:11 there's a lot of people in this situation where it can be very difficult,

1:09:14 but there are many success stories,

1:09:17 and I think you have every reason to be hopeful,

1:09:19 but know that sometimes it can take more than one round to get there.

1:09:22 It's not a slam dunk the first time every time, even though we wish it was.

1:09:27 Okay.

1:09:28 IVF causes early menopause or uses up your eggs.

1:09:32 False.

1:09:33 And this is why I always start by talking about how our biology works.

1:09:36 That's why it's relevant to know that you

1:09:38 recruit a limited subset of eggs, and those eggs,

1:09:41 whether you took them out or not, they were going to get thrown out anyway.

1:09:45 So, think of an egg retrieval for egg freezing or IVF

1:09:47 as a form of salvaging what was never going to be yours anyway.

1:09:52 So, it's it's really not going to put you into menopause earlier.

1:09:54 Those were eggs that never were going to be recycled.

1:09:58 Bed rest after embryo transfer improves success.

1:10:02 No, actually.

1:10:03 Studies have shown either no difference,

1:10:05 and there's one study, it was a small sample size,

1:10:08 that actually showed lower outcomes when a patient

1:10:10 was sedentary and did bed rest after embryo transfer.

1:10:13 So, we do not recommend bed rest.

1:10:15 After I do an embryo transfer, the patient is there lying down,

1:10:19 the embryologist checks that the catheter is empty,

1:10:21 the embryo's actually in their uterus,

1:10:23 and we allow them to get up and walk away.

1:10:26 I I actually went through IVF.

1:10:28 I did my transfer after doing 11 embryo transfers on my own patients,

1:10:32 including one of the most difficult, challenging ones of my career.

1:10:35 So, I was like sweating bullets,

1:10:37 and then I got up on the table, and it was my turn,

1:10:39 and then I went upstairs and sat in my office

1:10:41 and continued with my work day, you know?

1:10:43 So, You sound like Tidy.

1:10:45 That [laughter] is exactly what she's 9 months pregnant,

1:10:48 the baby's head's coming out, she's still in there delivering a baby.

1:10:51 Oh my god.

1:10:51 And then the I want to lead the last question.

1:10:54 I I love this question.

1:10:58 about the grandpas.

1:10:59 So how is it that you see an 80-year-old

1:11:04 Because we we we're starting to learn that the sperm also ages,

1:11:07 but how is it that an 80-year-old grandpa can be having a baby and you know,

1:11:13 with a not not with an 80-year-old grandma,

1:11:16 but how is it that these men are able

1:11:18 to continue to have babies if their sperm is declining?

1:11:22 Well, because they're able to make new sperm.

1:11:25 So those proteins, the filing cabinets that keep the chromosomes in check,

1:11:29 that's being regenerated with each new sperm cell.

1:11:32 So the machinery is fresh, right?

1:11:34 So the factory is kind of working at at its most optimal level,

1:11:38 except there's other things happening, right?

1:11:41 As a man ages, he is accumulating mutations in the DNA in the head

1:11:46 of the sperm and those mutations can be passed on to their children.

1:11:50 And so we know it's not benign.

1:11:51 Men have a biological clock.

1:11:53 It just ticks differently than that of a female, right?

1:11:56 We have a limited supply of eggs and we don't have repair mechanisms.

1:11:59 So the quantity and the quality of our eggs is always

1:12:01 kind of declining more rapidly as we approach 40 and and beyond.

1:12:06 For men, there is no really universally

1:12:10 agreed upon definition of advanced paternal age,

1:12:14 a term which we don't hear enough about I think in society, right?

1:12:17 We hear a lot about advanced maternal

1:12:18 age and people talk about geriatric pregnancy, which I've never used that term,

1:12:22 but we don't hear about advanced paternal age,

1:12:23 but some studies say over 45 for men, others say maybe 50,

1:12:28 but we certainly know that as we enter our 50s and 60s for men,

1:12:32 they have a higher rate of certain medical

1:12:34 problems that can show up in their children.

1:12:37 It's not a guarantee if you're a man listening

1:12:39 to this or you have a partner who's in their 50s or 60s,

1:12:41 don't freak out and say oh my gosh,

1:12:43 I'm going to definitely have a child with a problem,

1:12:45 but it's just a known association that we have to talk about, right?

1:12:48 There are higher rates of neurodevelopmental disorders, autism.

1:12:53 There's even some studies that have linked um higher rates of childhood cancers.

1:12:57 And so, it's not a benign thing.

1:12:59 And I often wonder to myself, if a man is in his 40s,

1:13:03 it's so cheap compared to egg freezing to freeze sperm.

1:13:06 If you're in your 40s and you're at the prime of your career and you're like,

1:13:09 I don't plan on settling down anytime soon,

1:13:11 but you're open to the idea that one day you might want to have children,

1:13:14 I don't know why people aren't freezing sperm, you know?

1:13:17 Because there is something to be said and and it and even like miscarriage risk,

1:13:22 there are subtle uh effects on fertility.

1:13:24 Even though it is possible for an 80-year-old

1:13:26 to father children, it can be harder.

1:13:28 And we do see couples with uh you know,

1:13:31 lower quality embryos developing from older sperm.

1:13:34 So, there's subtle effects, even though it's possible, you know,

1:13:38 there can be risks to it that people need to be aware of.

1:13:42 Um birth control causes long-term infertility.

1:13:45 No, I've treated thousands of patients as a fertility doctor.

1:13:49 I've seen so many complex cases.

1:13:52 I have yet to find a case where I'm like, this was caused by birth control.

1:13:56 Um birth control works in various ways.

1:13:59 The main form that we often are thinking about

1:14:01 when we talk about birth control is the pill.

1:14:03 The pill, the patch, the ring,

1:14:06 um these are all forms that prevent you from ovulating.

1:14:10 And when you take them away, that ovulation will return.

1:14:13 The Depo-Provera injection may cause a delayed return to ovulation.

1:14:17 So, for someone who's like, I need contraception now,

1:14:19 I want to start trying next year,

1:14:21 maybe that's not the best form compared to some

1:14:23 of these other ones that we're talking about.

1:14:25 The IUD is different.

1:14:26 The IUD doesn't reliably suppress ovulation.

1:14:30 It acts more like a bouncer that's preventing the sperm from getting

1:14:33 to where it wants to go, to get to the egg.

1:14:35 And so, it's preventing sperm transport.

1:14:37 It also has effects on your lining.

1:14:39 Um but once you remove it, that local effect goes away and it's reversible.

1:14:45 For patients who've been on birth control, let's for 10-15 years,

1:14:49 do you see sometimes a small percentage of them

1:14:51 uh having chronic suppression of their ovarian reserve?

1:14:55 I see chronic suppression of ovarian reserve,

1:14:57 but if it's truly low reserve because of chronic suppression,

1:15:02 it's it's temporary.

1:15:03 It goes away.

1:15:04 Um so, you know, what I do is I do a qualitative assessment.

1:15:08 So, if someone comes to me, a lot of times it's like egg freezing, right?

1:15:10 Cuz they're on long-term birth control cuz

1:15:12 they're not actively trying to get pregnant.

1:15:14 And so, I have this conversation multiple times

1:15:16 a day every day with patients where they're like,

1:15:18 "I've been on birth control for the last 10 years." And I'm like, "Okay, well,

1:15:22 let's go do your scan and I'll tell you if

1:15:24 I think you should consider coming off of it." It's not

1:15:26 a decision I take lightly because people have unplanned pregnancies

1:15:29 and I don't want to put anyone at risk of that.

1:15:32 But sometimes I tell patients, "Listen,

1:15:34 I want you to use protection, have a backup method,

1:15:38 cuz I'm looking right now at your ovaries and they look

1:15:40 tired and sleepy and I can't really see the follicles clearly.

1:15:44 I'm not convinced that you actually have low ovarian reserve.

1:15:46 I think you've just been on the pill for a really long time.

1:15:49 So, let's have you stop it and let's

1:15:51 re- re-evaluate maybe like in 2 months from now.

1:15:54 And in my experience, you need more than a month.

1:15:57 Like, usually it's like 2 months and then they come back and we rescan them.

1:16:00 And I would say, I wish I had a real figure for you and I

1:16:03 should probably do a study on this cuz I've had so much experience with this.

1:16:06 I'd say like maybe a third of the time to like 30 to 50% of the time,

1:16:11 it's like, "Whoa, your ovaries look completely

1:16:14 different." And I do think, you know,

1:16:16 we have some data, some clinical data that shows maybe

1:16:19 it requires less medication to get the response we want,

1:16:21 less days of medication, and potentially a few more eggs at retrieval.

1:16:25 So, I do think it can be worthwhile for some people,

1:16:28 but it's certainly not something everyone has to do

1:16:30 before they freeze their eggs and go through this process.

1:16:32 And it's certainly not something that's dangerous to your fertility.

1:16:35 It's just that your ovaries have not had as much activity for many, many years.

1:16:39 And you're not going to get that type of profound suppression

1:16:41 of the ovaries after being on the pill just for a few months.

1:16:45 Well, oh my god.

1:16:46 Yeah, that was a You were amazing.

1:16:48 We're going to have to have you back on because I have so many more questions.

1:16:51 I would love that.

1:16:52 Honestly, you you're almost just like Dr.

1:16:55 A's twin where you're able to really take this very complicated

1:16:59 information and make it very bite-size and very attainable to women,

1:17:03 which is what we're trying to do in the podcast.

1:17:04 So, tell everybody how they can find you.

1:17:06 First of all, you have the most amazing book called The Lucky Egg,

1:17:08 which is a great great great title and And it's everywhere.

1:17:13 It's everywhere.

1:17:14 Wherever you find books, there's an audio book that's narrated by me as well.

1:17:18 Um, and it's really for a guide for everyone.

1:17:20 It's not just for people doing IVF.

1:17:23 This is something that I hope people read as they enter

1:17:26 their 20s so that they're not feeling freaked out about their biological clock.

1:17:30 They actually know what it means and they're not worried

1:17:32 that their birth control is going to cause fertility issues.

1:17:35 Like, I just want everyone to have the same information and be

1:17:38 on a level playing field so they can make good decisions.

1:17:41 It's like driving down a freeway and not using GPS, right?

1:17:44 The way people have been kind of operating and they're just like,

1:17:47 "Let me hope to see the sign and then I'm

1:17:49 swerving lanes." And it just feels like you're making chaotic,

1:17:52 rushed decisions that aren't always the best decision.

1:17:55 And so, this is really like your fertility GPS,

1:17:58 a fertility Bible to answer all your questions whether they're simple or complex

1:18:02 and to lead women through sometimes their darkest hours where they're like up,

1:18:07 you know, till 2:00 a.m.

1:18:08 on Google or Reddit trying to understand why their third transfer failed.

1:18:12 It's really to be able to guide them through

1:18:15 the simple and the complex and everything in between.

1:18:18 I'm on Instagram.

1:18:19 I make a lot of content at lucky.sekhon.

1:18:23 I have a blog called the luckyegg.com,

1:18:26 which I think is a good supplement to my book because

1:18:29 it has a lot of interactive tools like an egg freezing calculator,

1:18:32 an AMH calculator that kind of tells you where you stand,

1:18:37 you know, in the sea of women from varying ages.

1:18:40 Like what's normal?

1:18:41 What's not normal?

1:18:42 And so, you know, that's those are all the places you can find me

1:18:45 and the tools that you can use and I I hope you found this helpful.

1:18:48 Oh my god, thank you so much.

1:18:50 I mean that.

1:18:50 We're lucky to have you, Dr.

1:18:52 Lucky.

1:18:52 Thank you [laughter] for coming on our podcast.

1:18:54 Thank you so much.

1:18:56 Okay, guys, I hope you learned as much as I did about fertility,

1:19:00 about the reasons for infertility, about male sperm,

1:19:04 about 8-year-old men having babies, about Dr.

1:19:07 A's fertility workup.

1:19:09 It was just the most amazing episode.

1:19:11 So, thank you so much for joining SheMD.

1:19:13 Thank you so much for being a SheMD warrior and hopefully this podcast

1:19:17 going to help so many women out there who really struggle with this.

1:19:27 Thanks so much for joining us today on SheMD.

1:19:30 If you want to own your own health,

1:19:32 a good place to start is by following us on social media at SheMD

1:19:36 podcast and by subscribing to our show

1:19:39 on YouTube or wherever you get your podcasts.

1:19:42 For takeaways from today's episode, visit our website shemdpodcast.com.

1:19:48 We'll see you next time on SheMD.

1:19:51 This podcast is for educational and entertainment purposes only.

1:19:54 It is not intended as a substitute for a physician's medical advice.

1:19:58 You should regularly consult your medical provider

1:20:00 in matters relating to your own health.

1:20:03 Even though we share our honest beliefs on SheMD,

1:20:06 some of the products and services we

1:20:07 discuss may involve sponsorships or paid advertising.