The Manosphere Report

0:00Everybody should get an AMH test.

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

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

0:07for this test. It is not a test of egg quality.

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

0:12Genetics and egg competency. But it is a test of how many eggs you have.

0:17And that knowledge can be really impactful for how you view your future and your

0:21plan. Welcome to the Huberman Lab podcast, where we discuss science and science -based tools

0:26for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at

0:35Stanford School of Medicine. My guest today is Dr.

0:38Natalie Crawford. Dr. Natalie Crawford is a double board certified physician specializing in obstetrics and

0:44gynecology, fertility, and reproductive health.

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

0:51and hormone health, both to enhance probability of successful pregnancy, but also because fertility and

0:57hormone health are strong correlates of general health and longevity.

1:01Dr. Crawford shares what all women, regardless of age or reproductive goals, can do to

1:06enhance their health using lifestyle, nutrition, supplementation, and prescription medical tools that she indeed uses

1:13in her practice. We also have a very honest discussion about biological versus chronological age

1:18and fertility, why age is not just a number, but also why it is that

1:23many women do successfully conceive in their 40s.

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

1:31Today, thanks to Dr. Crawford, you'll learn what is known and documented and what she

1:36has herself consistently observed clinically in her practice about women's health and fertility.

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

1:43Crawford's training, clinical acumen, understanding of the new research, and incredible ability to communicate the

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

1:53Dr. Crawford also has a new book out entitled The Fertility Formula, Take Control of

1:58Your Reproductive Future, which again, focuses on reproductive health, but also hormone health and how

2:03both of those things impact female health in the short and long term.

2:07Before we begin, I'd like to emphasize that this podcast is separate from my teaching

2:10and research roles at Stanford.

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

2:15information about science and science -related tools to the general public.

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

2:23And now for my discussion with Dr.

2:25Natalie Crawford. Dr. Natalie Crawford, welcome back.

2:28Thank you so much for having me.

2:29I'm thrilled to be here.

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

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

2:38complete a book that offers people so much advice, not just people who want to

2:43get pregnant, but also looking at things through the lens of fertility as an important

2:48health metric. Yes. Thank you so much.

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

2:55of mine. And after educating and talking about fertility with patients and people online, it's

3:01been something I've wanted to do.

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

3:06work with editors, to try to refine.

3:09Within your word count, you know, it's 20 ,000 words over and try to bring

3:13it back in. So thank you for having me and for holding it up and

3:16reading it early and sharing your endorsement for it to you.

3:19That means so much. Yeah.

3:20I am insisting, as much as one can insist, that various people in my life

3:25read this book, including family members and other people.

3:28Because again, it's not just about people who want to have children or who already

3:33have children, but fertility as a way of kind of knowing where one is and

3:38their health arc and their life arc.

3:40So if you don't mind, how should people think about fertility purely as a readout

3:47of health? I mean, just how do you frame this for, like, if somebody comes

3:51to you and says, listen, they have kids or they don't want kids or they're

3:54not sure if they want kids, but why use fertility as a lens on general

4:01health? Yeah. Fertility is a health marker.

4:04And I love that you bring that up at the top of the episode here

4:07because so often patients, women specifically, think fertility is only the ability to get pregnant.

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

4:16But if we want to zoom out, your fertility is a sign that you have

4:19good hormonal health, good cellular, good metabolic health, because it takes so many different moving

4:25parts to ovulate, for an egg to allow a sperm to fertilize, to implant, to

4:30get pregnant. But also your hormonal health and the ovarian function is really going to

4:35impact your entire life, how you feel on a day -to -day as a woman.

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

4:44rates of metabolic syndrome, cancer, heart attack, stroke, and dying early.

4:50Those are extremely scary statistics.

4:52And you know, I had my own infertility journey.

4:55So I fall into this category.

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

5:01It's that for most people, it's one of the first warning signs that something is

5:06not right in their body and that there's higher levels of chronic inflammation or insulin

5:11resistance that we know can impact long -term health outcomes.

5:15For women who are still of reproductive age, and I realize there's no strict cutoff,

5:22we can and certainly will.

5:24Talk about what are the measures, direct and indirect, of fertility that can give them

5:29a window into their kind of health span risk factors, lifespan risk factors.

5:34For women that have already reached menopause or in perimenopause, how should they think about

5:39fertility as a health marker?

5:42Meaning, if somebody has passed the point where they can safely get pregnant, does that

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

5:52I imagine their periods, features about their menstrual cycle are still very informative about their

5:57general health. As long as you're having a menstrual cycle, it is a sign that

6:01you're ovulating and you theoretically could get pregnant.

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

6:07transitional time between having regular, appropriate hormonal function, that reliable characteristic of the ovary responding

6:15to the brain, this is the transition time as you're starting to get to a

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

6:22But you also have a lot of hormone dysfunction, but you can still get pregnant.

6:26And in fact, I see a fair amount of patients who said, I thought I

6:30was past that stage of my life based on my age.

6:33But if you're still having periods, it's a really important window into your hormonal health.

6:39It can tell you a lot about your body, especially if you know when you

6:42ovulate, and we can look at the distinct phases of the cycle, the follicular phase

6:47and the luteal phase. When we're a little bit past this, menopause by definition, which

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

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

6:56Really, it means you've been in ovarian failure for 12 months before you'll magically get

7:00this diagnosis. But menopause at its purest is ovarian failure.

7:04The ovaries no longer have the capability to respond to the brain signals.

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

7:11At that time, a woman's metabolic health completely changes.

7:15But the age of which you went through menopause really can impact your reproductive health

7:20outcomes long term. And some of the characteristics you might have had in your cycle

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

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

7:31And then on a bigger scale, we're seeing the tide turn on hormone replacement therapy.

7:37And I know that's not what this entire episode is about.

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

7:42I love hormones. And I think it's really important for women to know that you

7:46can start hormone replacement therapy at any time.

7:48So even though a long time ago we felt really comfortable starting it right at

7:53the time of menopause, we're starting to see benefits starting in the perimenopausal period.

7:58We see a benefit starting it once you have menopause.

8:01But I think it's a disservice to women to make them have no period, ovarian

8:07failure for 12 months, no estrogen, feel terrible, before we'll allow them to have hormone

8:13replacement therapy. This is such an important theme.

8:16And if I may, I realize I have to be very careful to not draw

8:22parallels to men's hormonal health when talking about women's hormonal health because it's not a

8:27one -for -one. They're very distinct processes.

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

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

8:38now, for reasons that are unfair, hormone replacement therapy was sort of became widely available

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

8:52There are reasons for this.

8:53We don't have to go into it, but they're the kind of obvious ones, that

8:58things were pushed to market more quickly and so forth.

9:01But there's been this idea, you know, should – there it's usually testosterone replacement therapy,

9:06right? And there was this idea that unless somebody fell below 300 nanograms per deciliter

9:13for a male, that they weren't – that they shouldn't get testosterone replacement therapy.

9:20Now it's kind of understood that if somebody chooses, they can usually find a doctor

9:24that if they're at the low end of normal, they can push to the high

9:27end of normal or to the middle of the range so that they can get

9:30their symptoms away and just feel – right, to optimize within the normal range.

9:34That sort of – and so I'm relieved to hear that you're saying the same

9:38is true for women. And I'm relieved to hear it because I think that having

9:42these strict cutoffs of like no periods for a year, well, I mean, it could

9:46take a long time to reach that.

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

9:50Does that mean that that person doesn't deserve the therapy, which is what – essentially

9:53what I think you're saying.

9:54So the R in hormone replacement is the dangerous letter in my opinion because there

9:59is this notion of augmenting hormones.

10:02Exactly. Okay. So forgive me for going long, but I think the two situations, it

10:06would be great if both women and men could augment their hormones to be at

10:10the high end of normal or wherever puts them in a place where they're not

10:13experiencing symptoms. Absolutely. We know that as humans, we now have longer lifespans.

10:19We outlive our reproductive hormones, yet they are essential for our day -to -day function

10:22and to feel our best.

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

10:30be offered hormone therapy if we want it, and to not have to have these

10:33harsh cutoffs, especially for something that can be so protective long -term.

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

10:41It can help lower the risk of Alzheimer's disease.

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

10:45So I love this greater discussion, and it really stems from learning about your body.

10:51knowing what's normal so you can advocate for what's not normal and really feeling like

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

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13:34I wish that the medical profession could agree on nomenclature that included hormone replacement, the

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

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

13:48Hormone augmentation therapy for people that want to push within the normal range.

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

13:56And that's kind of how all of this got here was there were a bunch

13:59of mainly guys taking tons of anabolic steroids.

14:02And then, estrogen's a steroid, you know, testosterone's a steroid.

14:06And then it just became a long road to get to this point where people

14:11like you are able to even talk about this, right?

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

14:16to the idea that a 40 -year -old woman, for instance, who had not yet

14:20undergone menopause by the strict definition, would take estrogen.

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

14:26Isn't it interesting? And, you know, by professional organizations, they would even call it menopausal

14:32hormone therapy, MHT, not even just hormone replacement therapy.

14:35And I talk about this a lot with my patients, the difference in replacing a

14:38hormone we'll use in an embryo transfer cycle.

14:42If I'm going to give you estrogen, you haven't ovulated, I now have to replace

14:46your progesterone, or I have to give it in a certain format that it can

14:49get to high enough levels, versus supplementing.

14:52Your body's making some, and we're supplementing that or augmenting it, like you said, to

14:56get it to the appropriate level or to make sure we have enough.

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

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

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

15:08So going into ovarian failure before age 40, well accepted that these women need hormone

15:14replacement, even when they still have the low end of hormonal function.

15:19So in this population, we've been doing it for a really long time.

15:22But for menopause, it's been so frowned upon because of the WHI and fear -based

15:28tactics about what would happen with hormone replacement.

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

15:34And we're really allowing people to stand up for themselves, to also know what's normal

15:42within their body, which sounds so common.

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

15:49long. And if you go to your doctor and you talk about your painful periods

15:53or your irregular cycles or your bloating that you have with your period and some

15:57of these red flag warning signs, the spotting, the this, and it gets pushed to

16:01the side, when you start to go through actual hormonal change later, it's really hard

16:07to then believe yourself. And so I think it's really important.

16:11You know, I have a whole chapter in the book about how to learn to

16:14track your cycle and your ovulation and really learn to see the red flags your

16:17body gives you not just the red flag.

16:19if you want to get pregnant now, but to know that your hormones are really

16:22functioning as they should. And that's going to help you stand up for yourself later

16:26when you're in this transitional period.

16:28Because perimenopause or diminished ovarian reserve, like we call it in the fertility world, I

16:33mean, that can last five to 10 years.

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

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

16:41Are all, now I want to call it hormone augmentation, hormone, let's just call it

16:46hormone replacement for sake of simplicity.

16:49Hormone therapies for women, do they always start with estrogen when it comes to trying

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

17:02That's an interesting question. I think when it comes to hormone replacement therapy in general,

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

17:09Most women, when they start not reliably making estrogen, that's when they really start to

17:14feel bad. And so typically some type of estrogen replacement, and there's many different ways,

17:19right? There's patches, there's pills, there's vaginal inserts, there's vaginal cream, often helps some of

17:24the symptoms they're having. But progesterone alone or in combination can be a big player.

17:30Progesterone also is not made if you're not ovulating well.

17:33So there's this tandem where often you need both of them.

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

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

17:45depend on clinical scenario. There's nuance.

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

17:50So for most women, if they are adequately being replaced on estrogen and they still

17:55have functioning ovaries, so in this transitional period, they tend to not need testosterone.

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

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

18:07extend the ovarian lifespan is a really good one.

18:10We know that women who go into ovarian failure early, so when we look at

18:13that, we call it POI, the premature ovarian insufficiency group.

18:17Their ovaries have more inflammatory markers.

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

18:23There's a higher prevalence with autoimmune disease or chronic inflammatory disorders.

18:28So I think there's also something to be said, despite not having the perfect paper

18:31to sit here and say, that we know a variety of different things that increase

18:37chronic inflammation, cause you to have a lower egg count, and are associated with earlier

18:42menopause or earlier ovarian failure, that paying attention to these factors earlier in your life,

18:47whether it's controlling an autoimmune disease, earlier diagnosis of Hashimoto's, whether it's treating your endometriosis,

18:54or cultivating a lifestyle that's decreasing inflammation, right?

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

19:03with those lifestyle tenants, that that likely has the capability to extend our ovarian lifespan

19:09to the degree that it can.

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

19:15Yeah. And you mentioned toxins, so I was going to get to this later, but

19:18I'll just ask now, how concerned are you about plastic water bottles?

19:23And I mean, we can't avoid exposure to plastics.

19:26And I think one thing that Dr.

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

19:33microplastics are really the ones that we worry about the most because they can get

19:36into so many tissues, but we're constantly ingesting plastic.

19:39Some of them are just excreted because they're big, but some of them get into

19:43our cells. Are there any data that have you, or observational data, that have you

19:50genuinely concerned that plastics are becoming more of an issue vis -a -vis fertility?

19:57There definitely is concern. I always want to frame this, and you did a nice

20:01job of it, so I'll double down.

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

20:07You cannot avoid every toxin in this world, nor should we try to have this

20:10all or nothing mentality, which is what so many people do.

20:13Oh, if I can't avoid it, I just will totally ignore it then in general.

20:19When we want to think about toxins, there's many different mechanisms why plastics can be

20:23harmful. When it comes to microplastics, as you mentioned, we know they can accumulate in

20:26the ovary. So if we want to be really transparent and simple, your ovaries must

20:31function in order for you to make estrogen and progesterone, in order for you to

20:36ovulate, in order for you to get pregnant.

20:38So if microplastics can accumulate inside the ovary, that's obviously detrimental towards fertility or ovarian

20:45function. On a greater scale, we know that some of the endocrine disrupting chemicals that

20:51are in plastics have been associated with worse IVF outcomes, lower live birth rates, longer

20:57time to pregnancy. And these are population -based cohort studies, so there's no randomized controlled

21:01trial. So we have to limit it.

21:04And there's some truth to the fact that people who might be more exposed to

21:08plastics may have other lifestyle factors, such as we know plastics can also be in

21:14food wrappers, right? So maybe they have more of an ultra -processed food diet.

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

21:21But I look at all of these lifestyle factors, and I include toxins as one

21:25of them. These are all either contributing to your inflammatory burden or they're helping you.

21:30And when we start thinking about optimal hormonal health and fertility, it is your decision

21:36every single day, am I drinking water out of this cup or out of a

21:39plastic bottle? Am I going to lift weights, do nothing?

21:42Am I going to run?

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

21:45What foods am I going to eat?

21:47How do I deal with stress?

21:49And these choices, even though one single one is not going to make it or

21:52break it, together, they can add up to that inflammatory burden or they can help

21:56decrease it. And that chronic inflammation does, in fact, matter to your fertility and does

22:01worry me. I realize I'm jumping around here a bit, but in just thinking about

22:05what seems to be on a lot of people's minds, I took an informal poll

22:10of some people heading into this because obviously I only know my own experience as

22:14a male. Also, to a number of women, I asked the question, you know, what

22:20are you wondering about? And a common question was, it seems that for some women,

22:27if they've been pregnant once before, they have it in mind that it's going to

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

22:35And of course, they understand the logic that they were younger before by definition, even

22:39if it's a year, right?

22:42And that fertility drops off with time.

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

22:51that it's going to be possible to get pregnant again within the normal windows of

22:55biological windows for getting pregnant.

22:57Is there any evidence that having been pregnant before makes it easier to get pregnant

23:04again that's separate from the fact that obviously they were pregnant before?

23:07I realize that it's a convoluted question, but it's not a perfect experiment, right?

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

23:14If they haven't, the control group is not a very, it's not a good control

23:19group for an experiment. But for within the person, if they've been pregnant before, can

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

23:26I did fellowship research with the primary investigator on a large cohort study, one of

23:32the biggest ones we have on natural fertility, and this study was called Time to

23:35Conceive. And it was looking at women who did not have a history of infertility,

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

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

23:44And one of the most startling pieces of data is that there's a huge age

23:48-related impact of fertility, right?

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

23:54Meaning if I will sit here and say, if you're trying to get pregnant with

23:56your first child and you're 30, you'll have a 20 % chance per month, right?

24:01The finest point we look at in natural fertility studies is called fecundability, the probability

24:07of pregnancy per month. But as you age, when you're 35 to 36, that number

24:11will be 11 to 12 % per month.

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

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

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

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

24:25But in the group who had a child before and were trying to conceive with

24:29the same partner, that number stayed between 18 to 20 % up till age 37.

24:34And then it dropped. So we do see that there is this protective benefit for

24:40a multitude of reasons, right?

24:41You conceived with that person.

24:42So they had sperm, right?

24:44Sometimes I find out some patients, the male partner has no sperm and we didn't

24:48know all that time they were trying.

24:49Oh my goodness. Right? Oh, I've had patients try for years, be dismissed by their

24:53doctor. Because men and women mistakenly think that because there's semen, there's sperm.

24:58Exactly. There's ejaculate. So there must be sperm inside of it.

25:01And then when we find out there's none, it's heartbreaking.

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

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

25:15a failure. And we don't even recommend testing or screening or talk about a preventive

25:21approach at all until you have failed.

25:23Yet if we look at the population and say, okay, the definition of infertility is

25:27trying to get pregnant for 12 months.

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

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

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

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

25:39So we're making you go through this period of time where you're trying and yes,

25:45maybe the majority of people will get pregnant, but most people who do will get

25:50pregnant the first six months.

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

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

25:59That's why if you're 35 and older, we will shorten that testing interval down to

26:03six months. But sitting across from so many people who've tried and tried, went to

26:08their doctor, their doctor said, oh, you're fine, you're young, you're this, you're that, forced

26:14them to try longer and fail.

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

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

26:20He had no sperm. She had low ovarian reserve.

26:23And they would have intervened differently back at time period A had they had that

26:27data. Really makes me feel like we have to switch how we approach infertility in

26:32the world where infertility rates are rising.

26:35Women are waiting later to get pregnant.

26:37It doesn't really make sense to make people fail first before we'll even do an

26:42investigation. We should test things.

26:44And if it's all normal, maybe you do just go try your six or 12

26:47months. We would capture people who don't get pregnant and be able to help them

26:53at a sooner time period, which is so valuable.

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

27:02statistically at a higher chance of getting pregnant again.

27:06But secondary infertility is real.

27:08This is where you've gotten pregnant before and now you're having a hard time conceiving

27:12your second child. I want to acknowledge that it's.

27:14Really hard for people who walk it because they weren't expecting it.

27:18They're a little underprepared for it because they said, oh, I got pregnant so fast

27:23before. They come into it just assuming it will be as easy.

27:27They watch their children have a longer age gap, a bigger age gap than they

27:31wanted. But also they don't really fit into the community, meaning there's a really robust

27:35infertility community and they support each other.

27:37And so many patients who have secondary infertility say they feel caught in between feeling

27:42guilty that their child's not enough for wanting more.

27:46Of course, they're thankful for their child, but not really fitting into that category, yet

27:51also simultaneously feeling left behind their friend group or their family group or watching their

27:57family start to look differently.

27:59And so even in women who've had a prior child, age does become impactful.

28:04It's not the only variable.

28:05We also see that, you know, sperm counts change with age.

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

28:11We see egg quality starts to change with age, largely because metabolic health changes with

28:15age as well. And then we see things like endometriosis and adenomyosis, which are tincture

28:21of time diseases. It's simply you've had more time.

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

28:28So I think it's important to say, yes, you can probably take a sigh of

28:32relief that most likely you won't have trouble again.

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

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

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

28:45later, it's never too early to get an evaluation for anybody at any time because

28:49you can't make decisions on data you don't know.

28:51I'm a big fan of knowing the data and then making the choice that's right

28:55for you and your circumstance versus taking population -based data and just applying it to

29:00every single person. Yeah, all excellent points.

29:03And with respect to the sperm testing, since clearly there are men who think they're

29:08making sperm and they're not, there are at -home tests of that as well.

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

29:16They can do it at home, although I don't know how high quality the at

29:18-home tests are. There are some that are just telling you almost like a pregnancy

29:22test, plus minus, are sperm present, are sperm not.

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

29:27There are, though, some mail -in tests that go to a true lab that we

29:30would even take as valid.

29:31So, it's called a CLIA -certified lab, C -L -I -A, for somebody listening, and

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

29:40They send you the whole kit.

29:40You mail it off. It's very valid.

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

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

29:50doctor tell you no or go to a fertility clinic.

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

29:55Well, it's usually earlier that patients are getting roadblocked, whether it's their PCP or their

30:01regular OBGYN. They're getting dismissed and just, oh, just try first.

30:05It's probably fine. You mentioned that if a woman has had a successful pregnancy, that

30:10the probability of getting pregnant again is significantly higher, although with the caveats you mentioned.

30:15Is there any data about if someone has been pregnant and either terminated or lost

30:20the pregnancy, whether or not that's related to ability to get pregnant again later?

30:24That's a good question. Most of the data that exists is looking at prior live

30:27birth. So, I think there's a couple of things.

30:29If you've gotten pregnant, regardless of the outcome of that pregnancy, if it's with the

30:34same partner, we can feel confident that they had sperm present.

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

30:40If it was an intrauterine pregnancy, we know at least one fallopian tube was functioning.

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

30:50the things that we think about.

30:51Well, and we know your body could accept an embryo implanting at least to some

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

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

31:04to truly implant. So, I think that should give you some sigh of relief that

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

31:14I think it's also really important to say, I mean, I had four pregnancy losses

31:18myself. I don't know if you know this.

31:19So, I had four pregnancy losses.

31:20I mean, and by the way, I really appreciated the personal story sharing in the

31:27book because it really clearly was in service to your patients and to the reader.

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

31:39it was not only very moving, but it was really a testament to just how

31:45that sort of thing lands and then the process of trying to sort out what's

31:50real. And it just made me even more grateful for the other information because otherwise,

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

31:58Which I've talked about on podcast.

32:00Which we're talking about. Yeah, with all the caveats, you know, that how – but

32:04of course, how could I possibly know?

32:05So, your personal experience, while the reader and I feel and felt for you in

32:11reading it, it is super impactful because people – there's a level of trust that

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

32:18Thank you. I'll try not to cry on this show about it, which is funny

32:22because it's so long ago, right?

32:23I have two children now, had them after this journey, and it was terrible for

32:30so many different reasons. Of course, going through pregnancy loss is an emotional roller coaster.

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

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

32:39Something was wrong. And professional – what I was unprepared for is I was, this

32:46was the end of OBGYN and then the beginning of my reproductive endocrinology fellowship.

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

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

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

33:02so unprepared for, right? We, especially in an era where you separate your personal and

33:07professional life, which is, you know, what was 100 % accepted back then.

33:11You know, my last pregnancy loss was an ectopic pregnancy.

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

33:17I mean, everybody knew about it and I felt like a really big failure.

33:22And when I sought help to say, it'll happen, just relax, there's nothing you can

33:28do, or even just do IVF, felt so dismissive of what I felt like was

33:34true as the patient experience.

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

33:39Or what about this question?

33:40And just really, really pushed aside.

33:42And I'll be honest, it made my whole careers different because of it, which isn't

33:46that interesting how sometimes things happen to us that are not ideal and that can

33:51be really terrible. I have the two kids I'm meant to have, but also I

33:55have forever viewed fertility differently.

33:58In fact, all my fellowship research was on natural fertility because of it.

34:02Because I said at the core, I want to know why some people get pregnant

34:06naturally and why other people don't.

34:08Like, I really want to know that.

34:09I want to do epidemiologic research.

34:11I got a master's in clinical research because that research is very complicated to understand.

34:16And most fellows do an IVF lab project, which is great, but it's a lot

34:20more of a controlled environment.

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

34:25And so I think to walk back, what I wanted to say though, is if

34:29you've gone through pregnancy loss, I don't want to ever dismiss how terrible that experience

34:33is. And sometimes it can feel that way by me sitting here as a professional

34:37and saying, oh, you had a pregnancy loss, so that could be a good sign

34:41for the future. And I don't want anybody to ever feel that hearing it, but

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

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

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

34:58uterine and tubal evaluation. That can be moved up to one if you had heavy

35:05blood loss, you know, needed a DNC procedure, if your periods have changed afterward, if

35:10anything was really off, you can always get tested.

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

35:16go through three pregnancy losses before they would get an evaluation.

35:19And I fell into that camp.

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

35:23I'm starting to fall off the curve here.

35:25Isn't something wrong? And I was told, you need to have another pregnancy loss before

35:29we'll do those tests. And that's the worst thing, the worst feeling that I had

35:34to fail again to a certain degree and lose a pregnancy before they would even

35:38investigate why. Yeah, this theme, it seems, of like, it's only menopause when you haven't

35:45had a period for a year.

35:46You have to have two pregnancy losses, and then we can put you into this

35:48category of, like, amenable for treatment.

35:52I mean, it's something really backwards about all of that, I imagine, with your book

35:57and you being public -facing with health information and hopefully others with you in your

36:02field that eventually this will change.

36:04I mean, if I were to draw the parallel to psychiatry, which isn't a fair

36:08one, I mean, should someone really have to be waking up at three in the

36:12morning for an entire year and have no hope for the future and be near

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

36:19Right, before we'll treat them for depression or whatever's going on.

36:21It doesn't make sense. I don't think it serves us.

36:25And I will say this, too.

36:26We're starting to see a change.

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

36:33fertility. Like, I understand why OB -GYN used to take care of this.

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

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

36:45And I did three years of training in that after OB -GYN.

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

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

36:55And I might tell you, hey, the greatest likelihood is all the tests will come

36:59back normal, but we should do them because sometimes it doesn't, right?

37:04If I look across somebody who has recurrent pregnancy loss and I say, 80 %

37:07of the time, every test will come back normal.

37:09But 20 % is a big number.

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

37:16Maybe it's a procedure. Something can markedly change what they're going through.

37:20And in the same breath, the 80 % really needs specialized care because what's really

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

37:28So I agree with you.

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

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

37:35we approach reproductive health and hormones and fertility and really in a more proactive patient

37:41-centric approach. And women and men are driving this really by talking about it.

37:4610 years ago, when I started on social media, nobody talked about fertility.

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

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

38:01for genetic reasons or whatever happened.

38:03And those stories are so powerful to drop the stigma, but also highlight how So

38:10I think that ourhta är alltid på och med руks Sawyer.

38:10And then since Katherine Angst Mandel på Guilherme antarала mail, Thank you.

38:10wrong it is that we force women to fail before we'll even evaluate what's going

38:14on, let alone treat. As many of you know, I've been taking AG1 for nearly

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39:41One theme that I heard over and over again was women would say, okay, they

39:49thought that they might have been pregnant before, or they knew they had been pregnant

39:52once before. Circumstances varied, but they sort of had it in mind that they could

39:56get pregnant at one point.

39:58And that their mom had either them or a sibling, let's say at like age

40:0542 or 43, and they're in good health themselves.

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

40:14I think this is not uncommon.

40:16And given that life is very expensive, most people in the world seem to be

40:21underpaid nowadays. And people are waiting longer to get married and have children.

40:29And the other common narrative that I was hearing was that there are people that

40:34want kids, but it's under the, well, if I found the right person, I would

40:37do it, but otherwise I wouldn't do it on my own.

40:40That's not always the case, but it's a common theme, right?

40:45So for those women, which I think is quite a few, whether or not they're

40:49in their 20s or their 30s or their 40s, what sorts of things do you

40:53recommend they would add to that rather just kind of real life analysis?

40:58Those are not meaningless metrics, like how one's mother had a child, for instance, but

41:03things have changed. Microplastics, maybe certain things have gotten better, right?

41:07We're no longer eating margarine.

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

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

41:12People are living longer, yet they're more environmental toxins, perhaps.

41:16I mean, people are smoking less.

41:18Are they, though? Are they?

41:19We'll talk about nicotine for sure.

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

41:30level of urgency that they get certain things checked out?

41:32And what should they get checked out?

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

41:37I'd love to answer it, and I'm going to, but for the person who's maybe

41:41coming to this discussion, let's explain egg quality really quickly, because it really is going

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

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

41:52have. The eggs are kept, I like to think about it as in a vault

41:55inside your ovary, and so they're stored there.

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

42:00You have six to seven million eggs.

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

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

42:07So you lose eggs over time.

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

42:14and some from your mom's health while she's pregnant with you, things she's exposed to,

42:18her current disease state. What I want people to think about is every single month,

42:22you are losing eggs. So I like to imagine and describe to my patients a

42:25group of eggs that's coming out of the vault.

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

42:30The brain sends out follicle -stimulating hormone, or FSH, well -named, gets a follicle to

42:35grow. As the follicle grows, it makes estrogen.

42:38This is called the follicular phase.

42:40Estrogen levels talk back to the brain.

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

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

42:49That's what hormones are. They're communication signals.

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

42:54When estrogen is high enough for long enough, 200 picograms for 50 hours, and that's

42:59the level it'll tell the brain it's time to ovulate.

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

43:05A follicle will rupture. Egg will be released.

43:08It only has 24 hours to be fertilized, but that follicle will actually reform and

43:12become the corpus luteum. Now we're entering to the back half of the cycle called

43:16the luteal phase. The corpus luteum makes progesterone stimulated from LH pulses from the brain.

43:22So then it makes progesterone pulses throughout the luteal phase, can only live for about

43:27two weeks unless a pregnancy occurs.

43:30When you have an embryo come in an implant, it makes HCG, the pregnancy hormone.

43:34We check in a pregnancy test.

43:36Fun nerdy fact, HCG in LA.

43:38share a receptor. So HG comes into the corpus luteum and now stimulates a constant

43:42production of progesterone. But if that doesn't happen, corpus luteum will die, progesterone will drop,

43:48and you'll get a period.

43:50Okay. Also back to the vault, you have a different number of eggs that come

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

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

44:01the vault every month. As you get older and you have fewer eggs, fewer come

44:05out every month. That explains why you go from six to seven million to one

44:09to two million and why you go from one to two million to half a

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

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

44:18We're going to call that ovarian failure and not menopause for the sake of our

44:21discussion. But so everybody will go into ovarian failure.

44:24Now, the timeline, once you have, your clock is now up because at that point,

44:30there's no more eggs, you cannot get pregnant with your own genetic child.

44:34You still have a functioning uterus.

44:36It's just not being stimulated.

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

44:42They can still carry a pregnancy.

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

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

44:50Now, two things are happening with time that are really important because your eggs are

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

44:59your life. And your egg has many different functions.

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

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

45:13gets exclusively passed on to the embryo.

45:15It completely controls embryo growth and development.

45:18In fact, the male genome doesn't even kick in until day three after fertilization.

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

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

45:30So an interesting fact is that inside the egg, it is frozen in metaphase of

45:35meiosis II for whatever reason.

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

45:40meiotic spindles and they do not separate until you ovulate.

45:43And so then you get your egg that has what we think about as your

45:4623X. The other part goes into a polar body.

45:50Okay, this means that when you're 25, your eggs have only been held in metaphase

45:54for 25 years. Your chromosomes are, for the most part, still in the right position.

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

46:01Most people have better generalized metabolic health.

46:04Their mitochondria are stronger. When you are 40, 40 years have passed.

46:09We've asked those chromosomes to hold there longer.

46:12I always say if I have a line of kindergartners and I ask them to

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

46:17So tincture of time adds up.

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

46:22get more metabolically unhealthy. So we see more chronic inflammation, more insulin resistance, more obesity.

46:28And all of those factors influence oxidative stress, mitochondrial health, DNA damage.

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

46:39So we also see more genetic abnormalities as we age, but that is worsening as

46:45metabolic health worsens too. Okay.

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

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

46:52Genetic normalcy and egg competency.

46:54How good are the mitochondria?

46:56Can it do its job?

46:58We approximate it to age, which has some faults because not all 40 -year -olds

47:02are created equal. When we think about ovarian reserve, this is how many eggs you

47:07have remaining. So this is how many eggs are inside the vault.

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

47:14AMH stands for anti -mullerian hormone.

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

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

47:24Fewer eggs in the vault, fewer come out, lower AMH.

47:28Not a perfect test. The vault also is not perfect.

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

47:35And in prolonged periods of not ovulating, AMH can be suppressed, whether it's from birth

47:40control pills, pregnancy, postpartum, whatever the reason is.

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

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

47:52us how many eggs do we have outside the vault.

47:55And the way I like to frame this is that every woman who wants to

48:00have children or understand her own reproductive timeline should get an AMH checked.

48:06That is against medical advice, meaning the American College of OBGYN says that women should

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

48:14This is wild to me, right?

48:16I mean, to me as well, I mean, it just seems like this failure criteria,

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

48:25Unless there's some hidden agenda to try and prevent people from maintaining fertility or having

48:31children because – and that doesn't square with at least my assumptions.

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

48:38This is what they say in their document, American College of OBGYN.

48:41It can be very stressful for a woman to find out she has a low

48:44AMH and that it doesn't predict fertility.

48:47And there's some truth to that.

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

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

48:56one has five eggs outside the vault.

48:58Well, if every single other factor is the same and they each are ovulating one

49:03egg, they have the same chance of getting pregnant.

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

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

49:11family. She will not get as many eggs if we're doing advanced treatment like egg

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

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

49:24But more so than that, Andrew, so many of the causes of a low AMH

49:28directly contribute to infertility. Things like autoimmune disease, insulin resistance, endometriosis, smoking cigarettes.

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

49:41can treat, if I have a woman who has a low AMH, I'm not going

49:46to sit here and say, okay, well, you can still get pregnant, no worries.

49:48I'm going to say, I don't know that you'll have infertility.

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

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

49:58You will go not wait, right?

50:02To your point, the woman who's 20, 30, 40 thinking about this, she might make

50:07a very different decision when she knows she's really faced with a timeline that is

50:13less than ideal. And why should we allow time to be making that decision for

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

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

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

50:25out why. Probably 50 % of the time we find an autoimmune disease.

50:29I can't reverse the clock, but I can slow down the rate of inflammation, right?

50:34Say, if it's Hashimoto's, suddenly we can do thyroid replacement.

50:38We can work on decreasing inflammation.

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

50:44At least she's being treated and probably feeling better and we'll have improved fertility outcomes

50:49because our Hashimoto's is treated.

50:50So we should look at why.

50:51Why is it low? And treating that why very well may impact fertility.

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

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

51:02for the right time to get pregnant.

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

51:09I'm going to law school.

51:10I'm doing X, Y, Z.

51:11It's not a good time.

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

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

51:20We might choose to try to get pregnant now.

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

51:25pregnant. Maybe we freeze eggs.

51:28Maybe we freeze embryos. Maybe we do none of those things.

51:31But we made the active choice, right?

51:33Sitting here saying, I chose not to pursue treatment knowing my AMH was low and

51:39that I might be an ovarian failure at the point when I was planning to

51:42have a family. And I know that makes the journey so much easier to walk

51:46because you made that active choice from a place of knowledge that was your autonomous

51:51decision versus saying, I asked my doctor for an AMH test five years ago.

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

51:59And had I known that information, then I might've done something different.

52:03That was the longest discussion to say everybody should get an AMH.

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

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

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

52:13It's not a perfect test.

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

52:18And I like to think about it as categories.

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

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

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

52:33for this test. If they say no, you can order it yourself at a LabCorp

52:37request, many of the online platforms like Function Health.

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

52:43You can ask your doctor for it and say, well, if it's low, I know

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

52:50Or call a fertility clinic and just say you want fertility testing.

52:53The end. Okay. I think it's such an important marker.

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

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

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

53:05And that knowledge can be really impactful for how you view your future and your

53:09plan. So I think everybody should get an AMH.

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

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

53:20Having a regular period is really good.

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

53:24But knowing when you ovulate and tracking ovulation is a much more sensitive health marker

53:31than simply when you bleed or when you have a period.

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

53:38phase and how long is your follicular phase.

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

53:45And we know this well.

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

53:52of your luteal phase. So you're ovulating, but the brain and ovary have a miscommunication.

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

54:02Less than 11 days is a short luteal phase.

54:05But you'll still have regular cycles.

54:07So if I sit across from somebody and I just say, are your cycles regular?

54:11And they say yes. And we carry on.

54:13I've missed the fact that they actually have a shortened luteal phase.

54:16And that warrants further investigation.

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

54:25The second stage of ovulation disorder is a long luteal phase.

54:28It takes the ovary longer to actually respond.

54:33to the FSH stimulus from the brain.

54:35And then from there, we'll progress into irregularity and true amenorrhea or absence of periods.

54:41But those first stages, you might miss the little red flag warning sign that something's

54:47wrong inside your body because you are just tracking when your bleed is and it's

54:51every 34 days. So you think it's normal.

54:54But if we were looking at when you actually ovulated, we have more data.

54:58So learning to track ovulation as opposed to just cycle tracking, I think is one

55:04of the most important skills a woman can have for learning to listen to her

55:09own hormonal cues. Amazing. Just, I don't say that lightly.

55:14You just explained egg quality, the biology of the ovulation cycle and how it links

55:20to the actionables. And I'm just struck.

55:22It's awesome. And it has me asking a couple of practical questions.

55:29Some people will have insurance, some won't.

55:31What's the cost of an AMH test?

55:33Let's assume insurance doesn't cover it and they just have to go completely out of

55:37pocket. And before you answer, I will say whatever it is, I think it should

55:42probably be compared against what it would be to try and, I don't want to

55:46say rescue, but not take the test.

55:50And then, you know, three years later, you're trying to harvest eggs.

55:52It could be multiple cycles because you realize it was only five eggs per, you

55:57know, per month as opposed to age match, right?

56:0015, right? Exactly. So are we talking hundreds of dollars, thousands?

56:04$79. Yeah, we're withholding a $79 test.

56:09And I feel really strongly about this.

56:13I do not view myself as the gatekeeper of information about your body.

56:16Do you want hormone levels checked?

56:18Do you want an AMH?

56:19I do not think that is the role of a physician.

56:21And now I can say your insurance doesn't cover it.

56:24You can make the decision if $79 is worth it to you.

56:27But in the age of information, where that's an easy test to do, every lab

56:31runs it. And it's relatively inexpensive compared to freezing your eggs or IVF.

56:37I mean, right? Multitudes. $79.

56:39We're throwing a fit over a $79 test.

56:43Wow. I'm going to make sure that message goes far and wide.

56:49Because, you know, I thought you were going to say maybe in the high hundreds

56:51or thousands, which for some people is going to be, you know, prohibitively expensive.

56:55Yes. So get AMH checked.

56:57I think I'll avoid going into too much editorializing here because I'm really just interested

57:01in how you view this.

57:02But how you describe the sort of the way your field has originated and where

57:09it's headed reminds me a little bit of I remember in the 80s, there was

57:12a genetic testing was starting to become possible.

57:15And a lot of it was happening at Stanford.

57:17I happened to grow up near campus.

57:18And I remember hearing you could get tested for like Huntington's disease, which can be

57:23a devastating disease. And the idea was people don't want to know.

57:27People don't want to know.

57:28I think everything I've observed, I can't speak for everyone, but everything I've observed about

57:33people's interest in their own health and genetics and what genetics does and doesn't mean

57:39tells me that people are actually much more interested and they're much smarter than, let's

57:45just call it, the traditional medical field, certainly medical genetic testing, gave them credit for.

57:50A hundred percent. It's like people aren't idiots.

57:52You can sit someone down and say, hey, listen, you have this gene.

57:55There's an X probability. Here are the things you can do to protect yourself.

57:58But there was this assumption like people don't want to know because now they're going

58:01to live in dread and their life is going to be destroyed if they know

58:04they're going to get full -blown Huntington's or something like that.

58:06It's so paternalistic. It's actually, I mean, water's unethical.

58:12People are smart. People can take in information and they can make decisions that don't

58:17necessarily crater them on the basis of just knowledge.

58:20I mean, it feels like we sort of treat people like children, like little children.

58:24And even little children would probably want to know certain things, although you don't want

58:27to give them genetic information.

58:29But certain things like, hey, you have a challenge with X, Y, and Z and

58:33you can overcome it in the following ways.

58:35Look, technology's advanced. It has.

58:37How we counsel and how we approach health care needs to advance also, meaning we

58:43don't live in a universal health care system.

58:45We don't have only X dollars to spend on every single patient.

58:48And in certain circumstances, when that's the case or a patient has limited money, we

58:52do have to make very judicious decisions about the best use of those dollars.

58:56But for the majority of people who will be listening to this, they are willing

59:00to spend money on their health.

59:03And it shouldn't be a society or a physician or somebody standing in the way

59:07of getting data that can dramatically impact your life.

59:10And because you mentioned Huntington's, I should say, right, autosomal dominant disorder, people have very

59:15strong feelings on if they want to know they have it or not.

59:17And I've had patients because we can test for this with IVF.

59:20So we do genetic testing of embryos.

59:23And we often do screening to see if the chromosomes are in the right position,

59:27which we talked about for age.

59:28That can be really beneficial.

59:30But we can do single gene testing as well.

59:32PGT -M for monogenetic diseases.

59:34And Huntington's is one of them.

59:36And I've had some patients say, my mom had Huntington's.

59:41It was the worst experience to watch her go through that.

59:43I would love to test my embryos.

59:45But I've committed to myself that I don't want to know if I have it

59:48or not. OK. And I think it's really important just to mention that disease to

59:52say, we can blind test you.

59:55You know, you can make a probe to see if you carry it or not.

59:59You don't have to know.

1:00:00And we can. still test the embryos.

1:00:02And I've had a few patients who them themselves did not want to know, but

1:00:05we went through the steps to make a probe in case they did.

1:00:08In both cases, the patient did carry it, didn't find out that they did, but

1:00:12they could assuredly transfer an embryo that did not have it because often these people

1:00:17have felt so strongly watching a family member die from a terrible progressive disease.

1:00:22They've said, children are not in the cards for me, or I'm not going to

1:00:27have genetic kids. Or sometimes they'll come to me saying, we have to use an

1:00:30egg donor or sperm donor because I might carry this and don't want to know.

1:00:34So again, it's the idea that that should be your own individual choice, whether you

1:00:39want to know or not, but it shouldn't be the society or somebody else putting

1:00:42this roadblock up. And it's such an antiquated approach in the era of technology and

1:00:48access where you really can get so many data points.

1:00:53Why should somebody be making the decision on if that information is valuable to you?

1:00:57And I think with blood testing, the price coming down, it seems to me maybe

1:01:02it's just the circles I run in that people want more information as opposed to

1:01:05less. But I'm glad that you raised this, these cases where people don't want to

1:01:09know certain amounts of information.

1:01:13One thing that, well, I'll just pose this as a question.

1:01:16How many women out there do you think know if, I have to be careful

1:01:25how I word this, if doing a egg harvest cycle decreases their ovarian reserve or

1:01:33not? The majority of patients that I sit across from will tell me I'm afraid

1:01:39to freeze my eggs or do IVF because I don't want to go into menopause

1:01:42earlier. So the myth that doing that is going to tap into the vault and

1:01:47pull out eggs is inaccurate and a fear that really does need to be busted

1:01:52because it doesn't. It's a limitation of the science that I can only get the

1:01:56eggs outside the vault to grow.

1:01:58If I could tap into the vault, that would change the game.

1:02:01But right now I am limited by the eggs you give me, the number of

1:02:05them controlled by whatever's outside the vault.

1:02:08We in IVF, we just give FSH, the same hormone your brain makes, trying to

1:02:12stimulate more than one egg to grow.

1:02:14Your body doesn't want to have five kids or 12 kids or 20 kids, so

1:02:18it has checks and balances to prevent that from happening.

1:02:21I, however, would like every egg outside the vault to grow because in nature you

1:02:25will ovulate one and everything else will die.

1:02:28You are constantly losing eggs no matter what.

1:02:31When you're pregnant, when you're breastfeeding, when you're on birth control, before you start your

1:02:35first period, constantly losing them, I cannot change that right now.

1:02:40So doing IVF or egg freezing is not going to decrease your ovarian reserve.

1:02:44It is simply going to influence one month in time trying to not have all

1:02:48those eggs die. And I think the myth is that by doing a cycle of

1:02:53egg freezing that you're taking more eggs from your reserve.

1:02:57But as you pointed out, women are losing the same number of eggs each month

1:03:02or follicles each month. Regardless, you're maximizing on that process by just maturing more and

1:03:09taking them as opposed to letting them die.

1:03:11Exactly. We are not running out of eggs early.

1:03:14I think it's just based on, again, nobody understands basic biology.

1:03:17So we think in our brain, I'm just losing that one egg since I'm ovulating.

1:03:21We're not thinking about all the ones that were sent out of the vault who

1:03:24weren't chosen. Yeah. And I think people also assume, because they haven't been told that

1:03:30if you do an egg, you know, if you stimulate for more to mature, that

1:03:34you're somehow taking away from eggs that you would have had, you know, stuck around

1:03:39somehow. So we're hitting, we're saying the same thing three different ways.

1:03:43Yeah. So you're giving, I mean, it's fascinating to me if you think about it,

1:03:46because we are allowing the possibility for you to have children in your family that

1:03:51likely you would not, right?

1:03:53Because if you were to get pregnant naturally that month, the greatest probabilities, it would

1:03:56just be one that you would ovulate.

1:03:58Yeah. For IVF, we can sometimes take one month's group of eggs in time and

1:04:02have a couple different embryos.

1:04:04And those become a couple of children for you that you have from this one

1:04:07exact cohort. I think it's so fascinating.

1:04:10You know, early IVF days, I mean, IVF is not that old.

1:04:14It's only been around like 46 years.

1:04:16I think the oldest IVF babies, we didn't have gonadotropins.

1:04:20We didn't have FSH that was, you know, synthetic or purified.

1:04:24And so we couldn't get multiple eggs to grow.

1:04:26So original IVF patients had to go live at their IVF clinic and they had

1:04:32urinary -based hormone measurements done every day.

1:04:35So they could try to gauge when, as estradiol was rising, when they were getting

1:04:40closer to ovulation. And in those days, this is just science, they went and they

1:04:44did abdominal surgery to aspirate the egg.

1:04:46Now we do a vaginal egg retrieval where we take a needle attached to a

1:04:49vaginal ultrasound. It's a minimally invasive procedure.

1:04:52But back in the origin IVF studies, they had to go and do an abdominal

1:04:55incision to put a needle in the one single follicle to get the follicular fluid

1:04:59and the egg out. So it was very low odds of working.

1:05:03It was crazy to even think of.

1:05:06But the advent of gonadotropins, the ability to, first started by purifying FSH and LH

1:05:12and be able to give that to people to stimulate more than one egg, understanding

1:05:16this concept that there's so many more eggs that you have outside the vault every

1:05:19month, that has changed the game.

1:05:21And it's such an amazing advancement in science that we can leverage that physiology for

1:05:27egg freezing or IVF. Very practical question.

1:05:31It's clear that the younger that a woman is, the more eggs that could be

1:05:37frozen in a given cycle.

1:05:39But I think it's fair to say that many people, either because of finances or

1:05:44life circumstances, that could be not having a partner and wanting a partner before having

1:05:49kids, this sort of thing, are waiting.

1:05:52Right. They're just waiting. What stands between us now in the United States and egg

1:06:00freezing being covered by insurance 100 percent?

1:06:03I don't hold any superpowers, but there are pretty powerful ways to lobby all the

1:06:10administrations, regardless of who happens to be in office, when that actually happens.

1:06:14I mean, it is possible, right?

1:06:15The phone is a powerful tool.

1:06:17Advocacy is a powerful tool.

1:06:18So I do think that things can happen if there's a lot of advocacy.

1:06:24So first question is, you know, what would that require?

1:06:29And is that a good idea?

1:06:31I am a fan of knowledge and options, and egg freezing is not a guarantee.

1:06:35So, you know, how I pose it to patients is we are going to keep

1:06:38the door of opportunity open longer for you, and that is our goal.

1:06:42If we want to compartmentalize it, as some people will falsely sit across from me

1:06:47and say, oh, egg freezing is an insurance policy for my fertility, and it's not

1:06:51because an insurance policy always pays off, but it's an investment in my fertility, like

1:06:56investing in the stock market, like probably will pay off, but depends on external factors

1:07:01that we don't have yet, right?

1:07:02So the ROI is yet to be determined, but in general considered to be a

1:07:06good thing. I think it would be absolutely incredible to be in a place where

1:07:11egg freezing could be covered.

1:07:12And, you know, there's definitely countries where it is that they have said, well, the

1:07:16birth rate is dropping. We want to keep the reproductive lifespan open for some patients.

1:07:21We want to offer this.

1:07:22I think, to be honest and transparent, the number one restriction against that that we

1:07:28see as a field right now is the camp of people who are ethically or

1:07:32morally opposed to IVF for reasons of embryo disposition.

1:07:37Embryo disposition. Yeah, like the personhood of an embryo.

1:07:41Is an embryo a person?

1:07:42I see, because embryos that are not used are going to be either kept frozen

1:07:46or discarded, and to those people that's seen as essentially killing a baby.

1:07:51Right, that's their view. Yeah, and we should acknowledge that.

1:07:55I have many patients right now who are donating embryos, you know, when they are

1:07:57done with their family, which is an amazing way to kind of pass forward the

1:08:02opportunity for other couples to have a family.

1:08:06And I also just want to say at the top of this is that IVF

1:08:09is incredible. 17 million babies have been born in this world because of IVF.

1:08:14So I think this technology is great because, I mean, everybody has to do IVF.

1:08:17No, you are allowed to have your own feelings and decisions about anything that you

1:08:23do, IVF included. And there's often things we can do within the procedure for patients

1:08:29who might have religious or ethical concerns to limit the number of embryos that we

1:08:34make or only transfer embryos that are created.

1:08:36And that's important to know to bring that up if that's your line in the

1:08:40sand is that we can often do things differently based on your beliefs.

1:08:45It might be less efficient.

1:08:46It might cost more money.

1:08:48It might have a lower rate of success.

1:08:49But I've had patients walk that road, and that's the way it felt comfortable to

1:08:53them. In this country, there's a camp, not to get too political, and they're really

1:08:57pushing something called restorative reproductive medicine.

1:09:00And they're opposing a lot of the American Society for Reproductive Medicine's attempt to get

1:09:06fertility treatment and fertility preservation covered.

1:09:08And their rationale, even though a lot of RRM, I'm a huge fan of.

1:09:13It's about teaching women cycle tracking and getting to the root cause and really supporting

1:09:18understanding your fertility. Like bullet point 10 on their list is that IVF is unethical.

1:09:22But these people are ostensibly pro -child.

1:09:26I agree with you. My political stance, people often speculate.

1:09:29Like, I'll be really honest.

1:09:31I don't like politics. And I'm very disappointed in the current state of politics on

1:09:36both sides. And I try and go issue by issue.

1:09:38And I realize that itself is a controversial statement you're supposed to take a hard

1:09:42stance for or against. But I think that as a biologist, I look at certain

1:09:46things and I go, all right.

1:09:48And I look at other things and I go, oh, my goodness.

1:09:50Like, what Stone Age are we living in?

1:09:52And so I think that to argue whatever it is that one believes about, it

1:10:00seems to me that IVF, at least to me, maybe I just am too through

1:10:05my own lens. But the whole notion of freezing eggs and creating embryos seems very

1:10:09pro -child to me. So it doesn't square with number 10 on this list.

1:10:14I agree with you. So I agree with you.

1:10:16And I think a lot of the people who are a fan of RRM might

1:10:19actually agree with you and I.

1:10:21But there are definitely people who are very adamantly opposed to IVF who put number

1:10:2510 in there because they have a different agenda.

1:10:28I'm a fertility doctor, right?

1:10:29I want as many people to have a family as they desire.

1:10:33I want you to fulfill your life's dreams.

1:10:36If having a child is a part of it, I want to do everything I

1:10:38can to help you have that.

1:10:40I am not here to sell IVF or force IVF.

1:10:44If I – at the end of the day, it impacts me zero what you

1:10:46individually choose to do. But I believe that across the board, people deserve the tools

1:10:52in the toolbox. They deserve to be presented with all the choices.

1:10:55We could – try Clomid.

1:10:57We could try IUI. We could try surgery.

1:10:59We could try IVF. Oh, you're getting older.

1:11:01We could freeze your eggs.

1:11:02They're just more tools. There's more opportunities.

1:11:04And then based on your circumstance, your financial, your beliefs, you should be allowed to

1:11:09choose. I feel very adamantly that one's own beliefs that cause you to want to

1:11:15put it at number 10 on the list should not be the beliefs that we

1:11:18enforce on everybody, especially when we know that IVF can be so powerful to help

1:11:25so many people have a family.

1:11:26It should be something that is offered to you, if indicated, and you get the

1:11:30choice. And so back to the origin, it would be incredible to live in a

1:11:36world or country where egg freezing was offered to women as we do see people

1:11:42are waiting longer to start their families.

1:11:43It would allow more people to feel less pressure, less pressure with a partnership and

1:11:48on their relationship, not to feel like, oh, this better work out because my clock

1:11:52is ticking, and be able to really feel like they could chase one dream and

1:11:57not at the expense of another.

1:11:58I think we're further in this country than we want to admit from that.

1:12:02We can't even get fertility treatments covered for patients with cancer when we know that

1:12:07chemotherapy is going to deplete their ovarian reserve.

1:12:10We have some states that we can't even get egg freezing covered for them.

1:12:14So this is state by state.

1:12:15This is state by state right now.

1:12:17We would love federal protection for everybody.

1:12:20We would love to be able to see, I don't know, to me, that's my

1:12:24litmus, what your state or your country would do for patients who have cancer, you

1:12:28know, or are in this position.

1:12:30And if we're not even willing to move to help them, the idea that we

1:12:34could cover it for everybody, we're still ages away from that, I think.

1:12:39Yeah, because it's not, none of what we're talking about is forcing anyone to do

1:12:44anything. Nor is it necessarily the destruction of an embryo.

1:12:49I mean, it's, there is a world where the embryos are created and kept frozen,

1:12:52right? There is, there is no, uh...

1:12:54Yeah, we call that embryo banking.

1:12:56I mean, to specify maybe for somebody who doesn't understand, right?

1:12:58Egg freezing, getting those eggs outside the vault to grow, taking them out of your

1:13:02body, and we freeze them right there at the egg state.

1:13:05Making an embryo is going to be thawing that egg, fertilizing it with sperm, letting

1:13:11it grow out to the implantation stage, which is day five or six.

1:13:14Not every egg will survive, fertilize, grow.

1:13:17There's a ton of attrition in culture.

1:13:19So 90 % of eggs survive the freeze thaw.

1:13:2375 % will fertilize. 50 % will make it to the implantation stage.

1:13:27And then not everyone will be genetically normal based on your age and other factors.

1:13:31And then even a genetically normal embryo only has a 65 % chance of live

1:13:36birth. Like the science has come far, but we're not there all the way.

1:13:40With that being said, they do morally really feel like an embryo could be a

1:13:45potential life. And they do struggle with what to do if they have leftover embryos.

1:13:50And I have some patients who've told me, every embryo we make, we're going to

1:13:53transfer. Okay, well, we want to be really mindful what we do in that circumstance.

1:13:57And even though it's unlikely, I have a patient right now with four children and

1:14:01one embryo in the freezer because we froze five, five, knowing that everyone shouldn't implant

1:14:06based on that 65 % number, but we've gone four for four.

1:14:09Okay. So like we have to know that if that's what we're doing, we're prepared

1:14:13for how the data may fall because data just helps us guide decisions, right?

1:14:17Especially when it comes to live birth, it's zero or a hundred.

1:14:19It happens or doesn't. Now, if I freeze them as eggs for some patients who

1:14:24have really strong beliefs and they are afraid of that number five, we might take

1:14:29more time or take more money, but we might say, let's thaw them and only

1:14:31fertilize two. Let's leave everything else frozen.

1:14:34And then whatever makes its embryo, we can transfer.

1:14:36And yes, that's not a cost -effective way to go through the process because we

1:14:40might be having to pay for thawing and the fertilization and the transfer more times

1:14:44because there may be nothing to transfer based on that attrition.

1:14:48It can let some patients say, okay, I feel better with that process.

1:14:52So just freezing eggs, to your point, is not making embryos, right?

1:14:57And there's different things we can choose along the way to make an individual person

1:15:01feel comfortable, but we shouldn't be dictating how the field has to function.

1:15:06I think it would be incredible if we could encourage egg freezing earlier.

1:15:09I think it would open the door of opportunity and not everybody who freezes eggs

1:15:13will need them, but the peace of mind knowing that there's a chance is really

1:15:18impactful on the human mind.

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1:16:38So insurance, I would think, would want to do this because covering all the other

1:16:47stuff is expensive too. Most insurance doesn't cover IVF.

1:16:51You're not wrong, right? In principle, if I freeze a 25 -year -old's eggs, I

1:16:55will have three times as many eggs to work with, you know, than I would

1:17:00if she's going through IVF when she's 37.

1:17:03So if I'm going to pay for her to do IVF at 37, it'll take

1:17:06so many more cycles. I'll spend so much more money.

1:17:08That one cycle of egg freezing is much more cost effective if I'm covering them

1:17:13both. But we don't even cover the latter.

1:17:16So many times patients, this is such a hard stretch for everybody.

1:17:21And look, the technology is incredible.

1:17:24As somebody who has an IVF lab, as somebody who keeps embryos on site, it's,

1:17:30I mean, it's outrageously expensive.

1:17:32I mean, our generator alone is a million dollars, right?

1:17:35Because if the power goes out, like, what do we have to keep going?

1:17:39We always say if there's zombies coming, like, come to the clinic.

1:17:41The technology to keep up with all the advancements, to have trained embryologists, I mean,

1:17:48their micromanipulation skills, it's impressive.

1:17:50So it costs money to run a lab like that that will provide results.

1:17:54So the process and the technology is really, really expensive.

1:17:57That being said, like, I shouldn't be the one sitting here making assumptions again on

1:18:01what you're going to do with your money.

1:18:03And if somebody is in a position where they know their egg counts low and

1:18:07they should freeze their eggs because they're not partnered or they're not ready to get

1:18:11pregnant and they don't have the financial resources, we can sometimes find more money.

1:18:17We make decisions every day when it comes to money.

1:18:20We can't find more time.

1:18:21We can't find more eggs or more ovary.

1:18:23So, again, this idea that, well, what are they going to do about it if

1:18:26they find out they have a low AMH or, oh, they can't afford to freeze

1:18:29their eggs anyway or, oh, it's too expensive.

1:18:31We all make individual choices on how we leverage our different resources, which I consider

1:18:36to be your time, your money, your physical energy, and your emotional energy.

1:18:41And every day you're leveraging them.

1:18:43But when it comes to reproductive health, having a family, like, I feel strongly, you

1:18:48feel strongly, which I love, that we should be giving more access and more options

1:18:52to people so that they can pursue this.

1:18:54And so the arguments across the board, too, like, why not check an AMH in

1:18:57somebody who's younger? Well, they can't afford egg freezing anyway, so what are they going

1:19:00to do about it? Again, like, we shouldn't be making the assumptions of what somebody

1:19:05will or will not do with their resources or with their data.

1:19:08We should be ones helping them get the data and interpret the data, understand what

1:19:12resources or options exist, and then the individual has what they need to make the

1:19:18decision. In the Bay Area, where there are a lot of tech companies, there's a

1:19:24– my understanding is there's an opportunity at many of these companies for female employees

1:19:29to freeze their eggs. That landed much more controversial than I thought it would.

1:19:34Isn't it crazy? Because the assumption, the sort of – to some people, the tacit

1:19:41message there is don't have kids now.

1:19:44Yeah, don't have kids now.

1:19:45Work for us. Work like crazy and then have them later, right?

1:19:48Yeah. But having known some people that worked there and froze their eggs in their

1:19:52late 20s or early 30s, I think they would say, the ones I know would

1:19:57say, yeah, I'm really grateful that I did that and that the company I worked

1:20:01for paid for it. And they got to keep their eggs even though they don't

1:20:03work for the company anymore.

1:20:04So there's that. But it was kind of interesting.

1:20:06So anyway, we're getting kind of sociological here, but I think it's important.

1:20:11Yeah, what data supports is that when companies do leverage a fertility package and their

1:20:17benefits, they retain employees longer, employees are happier, and more people utilize the service than

1:20:24would without it, meaning people freeze their eggs when it's offered to them through their

1:20:27company. And that gives them that peace of mind, understanding it's not everything, but they

1:20:33feel more comfortable exploring bigger opportunities.

1:20:36And they are grateful to the company.

1:20:38They stay with the company longer because that is an investment in your employees.

1:20:42I think it's incredible. In Austin, right, a lot of these tech companies have second

1:20:45homes. So we see a lot of these patients also.

1:20:47And I do think that has changed the game for so many people to be

1:20:52able to have access. Because for many, it's not ethical or moral.

1:20:57It's financial. Often the time when you would freeze your eggs, when it would give

1:21:00you the highest rate of return, you don't have the resources to do so.

1:21:04So having a company that's able to come in and do that is really, I

1:21:09think, impactful. I wish more companies would do that.

1:21:11Maybe we can change their minds.

1:21:12I tend to get pretty loud and pretty consistently loud about the things that I

1:21:17believe in once I understand the landscape.

1:21:18So I plan to be vocal about it for what it's worth.

1:21:22You mentioned that birth control can reduce AMH levels on a month -to -month basis.

1:21:28Is there – and we should define birth control because it's such a broad category.

1:21:33But is there any evidence that taking hormonal birth control can lower chances of pregnancy

1:21:41when somebody comes off birth control?

1:21:43In my friendships and knowledge space, my – and this isn't I have a friend.

1:21:50I just – I know a number of people.

1:21:51We have kids now who were on birth control, came off birth control, and got

1:21:55pregnant right away. So I think a lot of people assume that's how it works,

1:21:59but are there any good examples of how certain forms of birth control can actually

1:22:03suppress fertility in women long after women come off birth control?

1:22:07Excellent question. Okay, let's break the data down from big to little.

1:22:11Number one, big studies looking at all different types of contraception, no higher rate of

1:22:16infertility, again, defined as failure to get pregnant at 12 months.

1:22:19So you come off your contraception at 12 months later when we look, there's no

1:22:23higher rate of infertility than we would have on the population -based level.

1:22:26So that data leads us to comfortably say birth control is not causing infertility.

1:22:31Now if we go and we look more nuanced at different types of contraception, if

1:22:36you look at the birth control pill, what most people are talking about, the birth

1:22:39control pill is a combination of synthetic estrogen, ethanol estradiol, and a type of progesterone

1:22:44or a progestin. These work by telling the brain, essentially tricking it, so the brain

1:22:49doesn't send out FSH or LH.

1:22:51And as we described earlier, those are important in getting you to ovulate.

1:22:54So you don't ovulate when you have taking the birth control pill, and that's why

1:22:58it's a very effective contraceptive choice.

1:23:00However, the half -life of the birth control pill is only 28 hours, so it's

1:23:03actually quite short. So you can miss even just one pill and you could ovulate.

1:23:08So when you stop the birth control pill, your period should come back that next

1:23:13month. So immediately you should have resumption of ovulation.

1:23:16A couple of problems with this one is that the birth control pill has some

1:23:22valid medical uses, has some non -valid ones, but very often, especially in the generation

1:23:28of women that we see right now, they were given the pill potentially for a

1:23:33valid medical reason without any investigation of what it was.

1:23:35So maybe a woman had irregular cycles or some acne, and her doctor said, well,

1:23:40here, take the birth control pill.

1:23:41It will help. And it did help.

1:23:43But just based on that history, I would sit here and say, I bet she

1:23:46has PCOS. And the woman, though, never was told, I think you have PCOS.

1:23:52Here's what it is. You probably will not ovulate when you stop the birth control,

1:23:55and your acne will come back, and you should talk to a fertility doctor, and

1:23:58here's lifestyle things we can do to decrease insulin resistance.

1:24:01Never had that discussion. So in her mind, had some symptoms, started the pill, those

1:24:06symptoms resolved. Now we stop the pill, and we're not getting pregnant, and we have

1:24:09irregular cycles. And we start to blame the pill as the reason why, instead of

1:24:14understanding that the pill was maybe masking it or treating certain aspects of it.

1:24:18So we do see failure to get to a diagnosis in women who were prescribed

1:24:23the birth control pill young.

1:24:24And then with the idea, I'm going to stop the pill and get pregnant right

1:24:27away. What I like to say is, you're not ovulating on the pill.

1:24:31If ovulation and knowing when you ovulate is one of your most sensitive health markers,

1:24:35and really essential information in trying to get pregnant.

1:24:38If you are trying to get pregnant, the egg only lives for 24 hours.

1:24:42The fertile window is the five days before and the day of ovulation, meaning sperm

1:24:47can live in the reproductive tract for up to five days.

1:24:49Most will stay around for two days.

1:24:52That's why the two days before and the day of ovulation have a 20 %

1:24:55to 30 % chance of getting pregnant compared to a zero day, the day after

1:24:58ovulation, 0%. So very defined fertile window.

1:25:02So if you know when you're ovulating and you target intercourse, you're going to have

1:25:05a higher odds and get pregnant faster.

1:25:07Data supports that very much so.

1:25:10But you don't know how to track your ovulation because you've been on the pill.

1:25:13So you don't know how to do that.

1:25:14So I recommend that you stop the pill three to six months before you're really

1:25:18wanting to start your family.

1:25:19So you can track your cycle, learn to detect ovulation.

1:25:22And if you do have an abnormality, you're not now six months of trying or

1:25:27one year of trying before it's evaluated.

1:25:29You can say, oh, I can't detect ovulation or my cycles are irregular.

1:25:33Let me go get that investigated now.

1:25:35So we're not kind of behind in our own timeline.

1:25:39The progesterone IUD is another one that we talk about a lot.

1:25:42The progesterone IUD is local progesterone that is placed inside the uterus.

1:25:46There's different types that can release progesterone in different amounts.

1:25:50It typically suppresses ovulation in the first two years, but then progesterone levels drop and

1:25:55it tends not to suppress ovulation.

1:25:57But that chronic progesterone exposure thins the endometrial lining to the degree that many women

1:26:02do not have periods anymore.

1:26:04That can be great if you don't like having a period that can decrease the

1:26:09chance of anemia or menstrual cramping.

1:26:11So it can be very lifestyle positive during those years.

1:26:14But when you stop the IUD, we do see a change in endometrial receptivity, at

1:26:20least for six months after it's been removed.

1:26:22And it can take time to build that lining back up.

1:26:25So I always recommend that a progesterone IUD is removed at least six months before

1:26:28you want to get pregnant.

1:26:30Give the endometrium time to rebuild and regrow.

1:26:33And then you'll have better odds of conceiving.

1:26:36We do see a little bit of lower pregnancy rates in those first six months

1:26:40of conceiving in women coming off of the IUD.

1:26:43More of them are getting pregnant in the back six months.

1:26:46So kind of shift your own timeline.

1:26:48And the birth control, I think, is always important to mention in this conversation is

1:26:51one that's not as common, but it's the Depo -Provera shot.

1:26:53So this is a high -dose intramuscular progesterone shot that can prevent ovulation for three

1:26:58months. On population -based levels, to use it as an effective contraceptive, must get every

1:27:04three months. But one single dose can prevent ovulation for 18 months.

1:27:09So this is that one exception where if you want to get pregnant potentially in

1:27:13the next two years, please don't get Depo -Provera.

1:27:17Great. Incredibly thorough and... clear.

1:27:19Is there any evidence one way or the other that intentional termination of a pregnancy

1:27:24can disrupt chances of getting pregnant again later?

1:27:28No study supports that having a termination is going to negatively impact your fertility later.

1:27:33One caveat I just want to mention is that any intrauterine procedure has the potential

1:27:38to damage the endometrium and result in scar tissue.

1:27:41So that could be having an IUD, could be having a fibroid removed, it could

1:27:45be a prior C -section, it can be a prior DNC because you had a

1:27:48pregnancy loss, it could be from a termination.

1:27:51Where we see the greatest risk in all of these circumstances is from heavy bleeding

1:27:56or from an infection associated with it.

1:27:59So in general, most terminations are done early, very routine.

1:28:03Where we are fearful is when they are accessed in non -safe environments, we're seeing

1:28:08more infection or heavy bleeding, or even when women are having to travel statewide to

1:28:13access care and they're getting the procedure done later with a higher risk of complication.

1:28:18In Texas, where I practice, there's obviously an abortion ban.

1:28:21And so women who need an elective termination for a medical reason, I had one

1:28:26patient who's been very open about her story.

1:28:29Her baby had anencephaly. So she went through IVF and had a baby that had

1:28:33no brain develop. And they made the decision that they wanted to terminate that pregnancy

1:28:37since that's not compatible with life.

1:28:39They don't want to have to carry the entire pregnancy.

1:28:41They had to travel out of state to access care.

1:28:44Their first appointment was canceled.

1:28:46So they had to make another one in a different state.

1:28:49Took them much longer than they wanted.

1:28:51Had the procedure much later.

1:28:53And then she had residual scar tissue inside her uterus.

1:28:55That was because it was done at a later term that we then had to

1:28:58fix before she could get pregnant again.

1:29:00So I think it's just important to say that across the board, any intrauterine procedure

1:29:06poses a little bit of a risk.

1:29:07No matter what it is, if your periods are different afterward, the hallmark sign is

1:29:11going to be a lighter cycle.

1:29:12So no matter what thing on that list you had done, if your cycle is

1:29:15now lighter afterward, I am worried there could be scarring inside the uterus.

1:29:20And we'd rather evaluate that in the clinic.

1:29:22We can do a saline sonogram to just check and make sure there's no scar

1:29:25tissue because that will impact your fertility.

1:29:28Thank you. Some practical questions about metabolic health, mitochondrial health, and egg quality.

1:29:36Please do it. In your book, you go into this in some degree of detail.

1:29:40But when you think about the things that can really help support egg quality, aside

1:29:47from age, in fact, I should say at any age, what are the, you know,

1:29:54top contour of those? You mentioned inflammation is the enemy, but inflammation happens all the

1:30:00time and we can't avoid it.

1:30:02But we can certainly avoid exacerbating it.

1:30:04So what are the things that people can do, not do, and take?

1:30:08We can do that. Okay, I love it.

1:30:10Do, not do, and take.

1:30:11Okay. So yes, inflammation is prevalent in our world and the goal is not to

1:30:17avoid all of it. In fact, acute inflammation is required for conception, right?

1:30:23We need acute inflammation with ovulation.

1:30:25If we just think real physiology, a follicle is rupturing, allowing the egg to be

1:30:31released and then reforming. Like we need our acute inflammatory response to allow that to

1:30:35happen to the degree that if women take NSAIDs around the time of ovulation, Advil,

1:30:40ibuprofen, Aleve, they'll prevent the follicle from rupturing.

1:30:43Really? Yes. So they will go through the hormonal changes of ovulation, but the egg

1:30:47will not be released. So that's why we recommend, and a fun fact, or important

1:30:52to know, if you're trying to get pregnant, you can take those medications only when

1:30:56you're on your period. So period cramping is fine, but we don't want you taking

1:30:59them for the rest of the cycle because you can prevent ovulation from occurring.

1:31:03How many people in your experience do you think know that?

1:31:06I don't think very many, honestly, right?

1:31:09Which is wild. I feel like it's sort of like banner across the sky.

1:31:12Like you said, you're not going to lose eggs by doing a free cycle, a

1:31:15collecting free cycle. I mean - Basic facts about our biology that we never taught.

1:31:21So if somebody's trying to get pregnant, NSAIDs can be problematic.

1:31:24They can be problematic. They can prevent the egg from being released with ovulation.

1:31:28So I think that this is important because I will sometimes have patients say, well,

1:31:32if inflammation's bad, can't I just take medicine for it?

1:31:35Right? Like that, you know, our brain might make sense.

1:31:38And I always want to say your immune system is essential for ovulation and also

1:31:42for implantation. So like, you know, I don't want to turn off your immune system.

1:31:46What I want to do though is not have it be so burdened with what

1:31:49we call chronic inflammation, that constant activation where it can't even do the job that

1:31:54we need it to do.

1:31:55So I like to think about this as that inflammatory burden.

1:31:58And so we're all exposed to some, but how do we, to your degree, make

1:32:02it better? How do we add to it and make it worse?

1:32:06And really framing ourselves so that we can cultivate, and I like to think about

1:32:09it as resilience within your body.

1:32:12I mean, you're going to be exposed to inflammation.

1:32:14Life is going to throw things at you, but you want to cultivate these best

1:32:18practices of your life so that you are reducing inflammation to the degree that you

1:32:22had. And this goes hand in hand with insulin resistance, which we'll get into.

1:32:26And I usually divide it into like what I call my five non -negotiables of

1:32:29sleep, stress, muscle, food, and toxins.

1:32:33And thinking about how we leverage these to our benefit by giving people the knowledge

1:32:39that they can, if they understand their bodies, they can then be empowered to make

1:32:45choices that are in line.

1:32:47with their goals. And so I really also just want to say really importantly, I

1:32:51hate the narrative that there's nothing you can do for your fertility or that it's

1:32:54all luck. Because the truth is, even if we can't control everything, we have a

1:32:59huge control over our metabolic and cellular health, which, as we just said, plays a

1:33:03huge role in our ability to get pregnant for both men and women.

1:33:07So taking control of what we can, I think, is really important information.

1:33:12And one person can take with that and make the choices they want to make.

1:33:15But the worst thing that I hear every single day is people sitting across from

1:33:19me saying, gosh, I wish I'd known that information.

1:33:21I would have made a different decision.

1:33:23Why do we make people go through a failed IVF cycle?

1:33:26They have no embryos form.

1:33:28And only then do they make lifestyle changes when we know the lifespan of a

1:33:31sperm is 90 days and sperm are so sensitive.

1:33:34And then we know that even though eggs are in your body your whole life,

1:33:37the 60 days before you get pregnant is when the egg is most susceptible to

1:33:41the world around you. So this is this time period that I like to call

1:33:45trimester zero, the time before you're getting pregnant, where the choices you make can influence

1:33:50your egg and sperm quality the most.

1:33:52And what you said earlier, if we're making them even earlier in life, can we

1:33:56influence ovarian function longer? I think there is a good thought to that.

1:33:59But how do we leverage these choices and diving into them?

1:34:03Number one for me is sleep.

1:34:04And I think that this is an important one because it can leverage that inflammatory

1:34:07burden in both ways. And I know you're a big fan of sleep.

1:34:10So this isn't going to take much to convince you.

1:34:12When you sleep, this is when your body is going to get rid of some

1:34:15excess chronic inflammation. Lowers are inflammatory markers.

1:34:19We know that when we get less sleep, it's going to cause us to have

1:34:23more cellular stress, more oxidative stress.

1:34:26Your gonadotropins, so FSH and LH are released from the brain in the early morning

1:34:30hours. So when you don't sleep long enough, you're not going to have the same

1:34:34hormonal response. And we know really directly, men who get less sleep, they have lower

1:34:39testosterone levels and lower sperm counts.

1:34:41Women who get less sleep get fewer eggs at IVF cycle.

1:34:45And we see that if you say you have poor sleep, you have double the

1:34:48rate of infertility. If you just subjectively say, yeah, I have poor sleep, you have

1:34:52double the rate. And that people who are not sleeping well, either partner, it will

1:34:57take them longer to get pregnant.

1:34:58They have lower fecundability, that month -to -month pregnancy rate.

1:35:01So it's not just me sitting over saying, oh, yeah, you need to sleep better.

1:35:05Your physiology is meant to sleep.

1:35:07It is a sign to your brain if we go back and we view that

1:35:10hypothalamic response as central command station, looking for clues that your life is stable enough,

1:35:18you're healthy enough to carry a pregnancy for a woman, which is a huge metabolic

1:35:22spend. It's looking to make sure you're taking care of yourself primarily.

1:35:26And sleep is one of the most powerful markers that we can move.

1:35:30Seven to nine hours. Most women need closer to seven and a half, especially in

1:35:34the luteal phase. Making progesterone is a big body spend.

1:35:37We really have to cultivate better sleep.

1:35:41You know, all the things you talk about, dark room, sound machine, a sleep mask,

1:35:44a cooler temperature. It takes two to tango.

1:35:47So if you sleep in the bed with somebody, they need to be on board.

1:35:50You need to go to bed at the same time.

1:35:51You need to have similar sleep practices.

1:35:53And we know that day -to -day consistency is also impactful in fertility.

1:35:57So not just the length of time, but really having that good circadian rhythm is

1:36:01so important for your hormones.

1:36:04Melatonin is obviously released before you go to bed.

1:36:07Low doses of melatonin supplementation can impact fertility.

1:36:10So doses of one to three milligrams, 30 minutes before you go to bed, can

1:36:15improve your odds of getting pregnant as well, can influence egg quality.

1:36:18And we know that naturally you make more melatonin when you ovulate to kind of

1:36:22counter some of the oxidative stress to the ovary.

1:36:25Really have to be careful though.

1:36:26A lot of over -the -counter products have like 10 times the amount of melatonin.

1:36:29So I always want to tread lightly with that one and recommending it to patients.

1:36:33Often a pediatric dose is like one milligram and that's the perfect amount just to

1:36:37augment. Again, we're not trying to replace your body's melatonin.

1:36:40We want to augment it and kind of help your body.

1:36:43I always like to think about like a toddler, really get good consistency with your

1:36:46wind down routine so that you can get enough sleep.

1:36:48I don't want to disrupt your flow, but if a woman is already sleeping well,

1:36:52should she take melatonin? I would say for the average person, probably don't need to.

1:36:57I would say the exception to the rule would be that if we know we

1:37:00have increased chronic inflammation, maybe we have endometriosis or an inflammatory autoimmune disease, or we're

1:37:05going through IVF with unexplained infertility or ever been kind of told you of quote,

1:37:11bad egg quality, then the anti -inflammatory properties of it might be advantageous.

1:37:16Since NSAIDs can disrupt the inflammation requirement for ovulation, I'm curious about other things that

1:37:24are known to potently reduce inflammation.

1:37:27I think enough terrible things have been said about cold plunges that we don't need

1:37:32to add any more, but we're seeking reality here.

1:37:35And I don't have, despite common belief, I don't have anything inherently attached to cold

1:37:39plunges. I do them sometimes, but we know that one shouldn't do them after resistance

1:37:43training or any kind of exercise where you want the inflammation to get the adaptation

1:37:48to the exercise. We know that.

1:37:50And it's a pretty potent inhibitor of inflammation.

1:37:53So is there any reason to think that in the time where somebody is trying

1:37:56to conceive that perhaps they should avoid the cold plunge?

1:37:59I usually recommend against them for reasons stated here.

1:38:02I think there's very few things we have that are going to really turn off

1:38:05that acute inflammatory response to the degree that NSAIDs do, but we should proceed with

1:38:11caution in doing those things.

1:38:13Most everything else is trying to just...

1:38:14Thank you. Get rid of the excess inflammation we have, but if something's dampering down

1:38:18into that acute inflammatory response, then I think we have to be a lot more

1:38:22judicious in saying, yeah, go for this.

1:38:24So I'm not a fan of cold plunges when trying to get pregnant.

1:38:27A lot of people will be very happy to hear that because I don't –

1:38:30unlike the sauna, nobody likes the cold plunge.

1:38:32I mean, I hate a cold plunge.

1:38:33I've tried it one time, and that was one time too many.

1:38:36I always say if you like it, great.

1:38:38If you think you benefit, great, but otherwise, don't worry about it.

1:38:41One thing that's commonly used is curcumin.

1:38:44Yeah. And it's a pretty potent anti -inflammatory.

1:38:47Do you recommend people stay away from – not cooking with curcumin, but the high

1:38:52-dose curcumin that comes in a lot of supplements?

1:38:54Yeah, I don't usually recommend it in a supplement form.

1:38:56Like I never recommend it.

1:38:58I think if you have a doctor who's giving it for a very specific purpose,

1:39:01you might be a unique person who has excess inflammation they're trying to target.

1:39:06But that's not something that I recommend.

1:39:07But cooking with it is fine.

1:39:09NAD and NR are – I get asked about them thousands of times per week.

1:39:14I don't know. But it does seem to, at least in my experience, increase energy,

1:39:26these kinds of things. But it's NR in particular.

1:39:30There are data that it can be very anti -inflammatory.

1:39:32So if a woman is trying to conceive, should she stay away from NMN, NAD,

1:39:36and NR? Because I often see it listed in fertility protocols.

1:39:40Animal data looks like NAD and NNM can be advantageous, especially for unexplained infertility, which,

1:39:49to be clear, is different than I just want to get pregnant, right?

1:39:52In unexplained infertility, you're not conceiving.

1:39:54We do the basic test, anatomy, ovulation, ovarian reserve, semen analysis.

1:39:59They're all fine. So I view that as chronic inflammation unless proven otherwise.

1:40:03And so that's a unique situation that patients may have potential benefit.

1:40:09But unlike certain things across the population that we can feel really comfortable recommending, I

1:40:15don't recommend that to everybody.

1:40:16So I think that there might be utility in certain subgroups who are kind of

1:40:21really falling off the curve.

1:40:23And we think there's excess inflammation that it could make sense for.

1:40:25So I don't ever say no, and I sometimes use it.

1:40:28But on, like, the flip hand, we could say, like, CoQ10, which has robust human

1:40:32data that is advantageous without a negative benefit.

1:40:35That's an easier place to leverage your supplement dollars if you're going to spend because

1:40:40most of us don't want to spend endless amounts on all the things that we

1:40:43can craft for our supplement list.

1:40:44But the human data is yet to be out, although animal data looks promising for

1:40:49the right patients. I'm glad you mentioned coenzyme Q10.

1:40:51CoQ10 and L -carnitine are the two, at least I'm aware of, there's some decent

1:40:57data on supporting sperm and egg quality.

1:41:00So do you encourage patients to start taking that, what, 60 days before trying to

1:41:06conceive and then continuing that through pregnancy?

1:41:08We usually stop CoQ10 in pregnancy just because of lack of data.

1:41:12We're very cautious in pregnancy of not exposing you to anything additional you may not

1:41:18need. So we just want to be really mindful of that.

1:41:21But I think it's in my, like, everybody should take before you get pregnant.

1:41:24Yep, you're trimester zero. You're, hey, we want to get pregnant soon.

1:41:27We should take a prenatal vitamin that has folic acid.

1:41:30We should take CoQ10. We should take omega -3 fatty acids.

1:41:33We should take vitamin D.

1:41:35These are all going to optimize, giving you the nutrients you need for a pregnancy,

1:41:39helping support good mitochondrial health, which is important for egg quality, without risk of harm

1:41:45to any of these specific supplements.

1:41:47So those are the universal we're trying.

1:41:49And then for sperm health, L -carnitine, we like a lot.

1:41:52And then zinc and selenium can have benefits as well.

1:41:55I know you cover specifics in the book, so we'll leave it to people to

1:41:59find it there. I have supplement charts for everybody who's, like, very curious, based on

1:42:02disease state and more info.

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1:43:15I'm sure there are sort of standards and a lot of communication in your field

1:43:20about, you know, how many follicles to try and mature if one does IVF or

1:43:26is pulling eggs. I don't know if that's the right term.

1:43:30Forgive me. There it is again.

1:43:32You know, pulling eggs. Taking eggs out carefully and for sake of freezing or fertilization.

1:43:40But how much conversation is there?

1:43:42at the various meetings and in the journals about things like coenzyme q10 l -carnitine

1:43:47i'm not trying to punch holes in these i'm obviously a big fan of supplements

1:43:50my friends joke when people ask me which supplements do you take they just shout

1:43:54all of them he takes all of them which is not true i don't take

1:43:56all of them but i've been experimenting with them since i was in my teens

1:43:59and um they're not the be -all end -all but some work so how much

1:44:03conversation is there about things like coenzyme q10 l -carnitine um is there a consensus

1:44:09or is there sort of a distribution of old school new school um and i

1:44:12am very curious um not trying to be political or politically correct whether or not

1:44:17this divides on male female um fertility docs or um like the culture within a

1:44:23field often tells us a lot so i'm not asking to throw any of your

1:44:27colleagues under the bus but if you have to no i will say this over

1:44:32the past 10 years we've seen a huge change in how we talk about fertility

1:44:37even at meetings you know the first asrm which is the american society for reproductive

1:44:42meeting that i went to was probably 15 16 years ago and it was so

1:44:47ivf heavy now to be fair like the science was rapidly involving like genetic testing

1:44:52was just introduced for embryos but as we also see more patients and the general

1:44:58public really curious about well what can i do and i think it's such a

1:45:01good question because i look at people and say ivf's incredible but i can only

1:45:05work with the eggs and sperm you give me so come to the table with

1:45:09the best eggs and sperm you can right control all of these variables that public

1:45:13curiosity drives research to a degree because if you're hearing it from your patients that's

1:45:20the formation of research questions right that we're looking at now granted all data that

1:45:24exists is is limited in its own form right in general we look at cohort

1:45:28studies of course people who tend to take coq10 have other advantageous lifestyle factors than

1:45:33people who do not when we do randomized controlled trials though which we often do

1:45:38in the ivf subset because we can look at more distinct criteria i can say

1:45:42well how many how many eggs were mature or how many embryos formed or how

1:45:47many were genetically normal or the pregnancy rate per embryo transfer which is a little

1:45:51bit of a finer point than just how many people got pregnant per month we

1:45:55definitely see robust data that certain supplementation coq10 vitamin d omega -3 fatty acids those

1:46:01are clearly associated with improved reproductive outcomes and i we're starting to see more i

1:46:06don't want to say fringe but of the specifics right inositol for pcos decreases insulin

1:46:11resistance huge benefit and acetyl cysteine for endometriosis or chronic inflammatory disease so we're seeing

1:46:18more interest in the nuance it's a hard question on the field i think there's

1:46:21definitely an old school versus a new school approach i've always been slightly controversial because

1:46:28i've always been educating i think at the end of the day my job's not

1:46:32to say just do ivf my job's to explain what's going on what the options

1:46:36are and help you make that decision i think a lot of older trained physicians

1:46:43practiced medicine in the day where this field specifically patients did not have knowledge and

1:46:49access to knowledge therefore when a doctor said do this they just blindly said okay

1:46:55and they view that as a simpler way to practice and therefore can be very

1:47:00dismissive of patient questions when they are say what about coq10 or any merit of

1:47:07the other lifestyle factors that we talk about you know the plethora of research that

1:47:11exists which is more and more now is that these lifestyle factors matter a lot

1:47:14that decreasing inflammation can influence your fertility from a how your hormones function how your

1:47:19ovaries respond when your how many eggs you pull out to the way you say

1:47:23how how many embryos you form and that supplementation is one piece of the puzzle

1:47:29it's not the end -all be -all i think we can probably should always you

1:47:33know focus first on where we can move the needle the biggest so those more

1:47:38core lifestyle practices this should be tenet number one when we feel like we've mastered

1:47:42those and we want to add to the puzzle that's when we can start to

1:47:45say what supplements help me and one thing that i really encourage is allowing our

1:47:50self -space in each patient to be their own in a one experiment meaning how

1:47:55can i get so in tune with my body that i can say this makes

1:47:58me feel this way and trust that sense for yourself because we are all unique

1:48:03and our response will be different to different medications or different interventions and learning to

1:48:10trust that instinct about what's working for you or oh this isn't that's really important

1:48:16when it comes to optimizing your own health regardless of what tenant of health that

1:48:20we're talking about if we'd been sitting here 15 years ago and i said uh

1:48:24you know red light therapy can be useful for skin and for um offsetting age

1:48:29-related vision loss um any reasonable physician would be like that's nonsense i spoke to

1:48:37an ophthalmologist yesterday there's been a clinical trial using red light and infrared light for

1:48:42what's called dry amd dry macular degeneration um to offset age -related vision loss and

1:48:48it looks promising i mean it doesn't reverse age -related vision loss completely but seems

1:48:53to help the mitochondria and the photoreceptors people are holding on to some vision that

1:48:56they would lose there was a cover of what i am told um is the

1:48:59premier dermatology journal exploring the recent studies on red light and infrared light so it's

1:49:04a common practice now so it takes time but this stuff was considered super woo

1:49:10niche and nonsense by most quote -unquote traditional physicians 10, 15 years ago.

1:49:15In the field that you're in, how are things like red light, infrared light therapy

1:49:20looked at currently? And if they are used, where is it directed?

1:49:26Is it actually on top of the ovaries?

1:49:28Is that the idea or that it's more of a systemic effect?

1:49:31Great question. I think, again, let's just think about the fact that chronic inflammation impacts

1:49:35your body when it comes to your hormones and your fertility multiple ways, right?

1:49:39So if you have chronic inflammation, it's going to interfere with hypothalamic receptivity.

1:49:44So your brain can interpret your hormonal signals as well.

1:49:47It's also going to send out signals differently.

1:49:49You're also going to have distinct ovarian changes in how the ovary responds.

1:49:53And then, of course, for the egg quality.

1:49:54So the bigger answer of what type of therapy matters maybe depends on the outcome

1:49:59that we're looking at or how we're trying to show benefit.

1:50:01And in short, data is inconclusive, but all appears to be beneficial for the reasons

1:50:05you stated, whether it is to improve ovulation patterns, which we've seen signs showing that

1:50:11that's more the systemic probably, right?

1:50:13You're sitting in front of your red light panel, that's going to decrease some whole

1:50:16body inflammation. That's the inflammation that's most likely contributing to some of the brain sensitivity.

1:50:22So you're improving the ovulatory pattern.

1:50:24There have been some studies looking at ovarian directed red light therapy.

1:50:28So through the abdomen, but there is now, I mean, we don't have definitive data,

1:50:31but there's even a vaginal ultrasound wand that's got red light therapy.

1:50:35So we don't have data on that yet, but seeing intravaginally, you're much closer to

1:50:39the ovaries. That's why we do vaginal ultrasound monitoring for IVF to try to see

1:50:43if directing the response closer to the ovary can have more benefit or could potentially

1:50:49benefit egg quality more. I think most people are going to say, you know, we

1:50:53don't have definitive data yet, yet everything's pointing to likely benefit.

1:50:58I don't know if this study could be done, but the one arm of this,

1:51:03my podcast company funds research.

1:51:05And one thing I'd love to see the experiment done is either maintaining or doing

1:51:11fertilization of eggs under red light, because so much of the proper chromosomal arrangements seem

1:51:17to be dependent on mitochondrial health.

1:51:19That's a short -term exposure.

1:51:21But the more I learn about the different wavelengths of light and how they impact

1:51:24mitochondria, and I think about the horrible lab lighting that I lived under for many

1:51:28years of my life, I think, oh, these such precious embryos, is there a way

1:51:33to put them under beneficial lighting as opposed to either neutral or I'm not saying

1:51:38detrimental lighting, but I don't know.

1:51:40It would be a fun study to fund if there's a way to do it.

1:51:43Could it be done? I think it definitely could be done.

1:51:45I mean, we have incubators.

1:51:47That could definitely be done and where you fertilize too.

1:51:50I was going to say off topic, my daughter did her science fair project on

1:51:53chicken eggs, but they looked at blue light, green light, and natural light to see

1:51:58if they, you know, they're all fertilized, but to see if their hatchability was different.

1:52:03And the group that was exposed to blue light actually had the highest hatchability.

1:52:07And, you know, UV light was actually the lowest.

1:52:10But in their research, what's so fascinating is that red light is really detrimental to

1:52:14chicken eggs. So anyways, I think, yeah, well, that's why science is fun.

1:52:17Oh, congratulations to her. She should write it up.

1:52:19You know, there's a journal where kids can write up there to, yeah, I'll send

1:52:22you the link to it.

1:52:23She'll be published. And that's what's so cool about science.

1:52:26Sometimes we think, oh, the red light is going to be the beneficial one.

1:52:29The UV light is going to, or the blue light is going to be the

1:52:31bad one. But then, you know, vitamin D production is dependent on blue and UV.

1:52:36So, you know, nature's mysterious.

1:52:38You know, that's awesome. It keeps it interesting for us.

1:52:41Awesome. Is she going to become a scientist?

1:52:43Or she's already a scientist.

1:52:44She's 11, but she's a scientist right now.

1:52:46I love it. I love it.

1:52:47I'll send you that link.

1:52:48It'd be cool if she would write that up.

1:52:51So red light, maybe. Yeah.

1:52:53And I should point out red light and infrared comes from sunlight.

1:52:56So then, of course, there's circadian, good circadian effects of getting sunlight.

1:53:01All circadian benefits of getting sunlight are pro fertility, pro hormonal health.

1:53:05Yes. Yeah. I don't want to give people the impression that they have to purchase

1:53:08a panel. Correct. There's no hidden agenda here.

1:53:11So those are the things that one can take that do not, I think, broadly

1:53:16as don't smoke, don't drink.

1:53:17I was shocked, but I need to ask to learn what I found was that

1:53:2415, 1 ,5 % of women in the United States report having used cannabis in

1:53:29some form or another while pregnant.

1:53:30Does that concern you? Cannabis use is probably the most concerning thing that I see

1:53:34in clinical practice. So both, you can just say, if that many are using it

1:53:38in pregnancy, let's extrapolate to how many are using it beforehand.

1:53:43And ultimately something that we are just now getting robust data on, because it's hard

1:53:47to study something when it's illegal.

1:53:49All cannabis use is hugely detrimental to sperm, for sure, across the board, right?

1:53:54Both production, the quantity of sperm, testosterone production, also the quality of the sperm, specifically

1:53:59the DNA fragmentation inside the head of the sperm, to the degree that female partners

1:54:03who conceive from a male partner who's using cannabis have much higher miscarriage rates than

1:54:08partners who do not utilize cannabis.

1:54:11And I will say clinically in the IVF lab, when I see embryos halt at

1:54:15that male developmental stage on day three, we say, oh, here's a young couple, they've

1:54:19got no embryos, and we were expecting them to have some.

1:54:22When we go back nine out of 10 times, he is using cannabis that he

1:54:26previously denied. So it is one of the most movable factors right now in this

1:54:32country for improving, you know, fertility outcomes.

1:54:35For women, cannabis use in the...

1:54:37A prior year can decrease the eggs you get at egg retrieval by 25 %

1:54:42and can decrease fertilization rates by 28 % and can increase miscarriage rates, therefore decreasing

1:54:49live birth rates. So huge numbers in science, right?

1:54:52I mean, like we get excited when there's a few, you know, percentage points different,

1:54:56but these numbers are really high to the degree that it's really easy to sit

1:55:00here and say, if you're trying to get pregnant the fastest, if you want to

1:55:03have the best pregnancy outcomes or even you want to have the best hormones you

1:55:08can, have longevity of your ovaries or have the best sperm counts or the most

1:55:12testosterone, cannabis use should not be a part of that.

1:55:15And THC crosses the placenta directly and THC levels and, you know, edibles are usually

1:55:21the highest. So I think it's really important that sometimes people are like, oh, I

1:55:24don't smoke it, so I'm okay.

1:55:26We want to be really careful that this is not something your body is meant

1:55:33to be exposed to when we want to think about the core of how your

1:55:36body is meant to function.

1:55:37Critical message. Thank you so much.

1:55:39I've been put through the ringer around this cannabis thing because I've hosted people that

1:55:43said it does increase the risk of psychosis in certain typically young males, although not

1:55:49everyone. I've been accused of all sorts of things related to that, then had someone

1:55:53on who confirmed that, someone who refuted it.

1:55:55And cannabis, I believe, is recently rescheduled from Schedule 1.

1:56:00No, at the federal level, it's assigned a no medical application to Schedule 3.

1:56:06So there's going to be a lot more cannabis use going forward.

1:56:09It's so critical that people hear this.

1:56:11And the argument I always hear, and it's always dudes, typically on X, they'll say

1:56:16that they smoked a lot of weed and they got their, or took edibles, and

1:56:21they got their wife or girlfriend pregnant X number of times, and it sort of

1:56:24becomes this sort of point of boasting.

1:56:26And then I never want to make the comment, but I'll make it now.

1:56:28It's like, yeah, but you're talking about brain development in your kid.

1:56:32And I'm not saying your kid is dumb, but I'm saying they're maybe not as

1:56:35smart as they could be or as healthy as they could be.

1:56:38I'll just say that because I'm talking to the guys out there, and that's how

1:56:41we talk to one another.

1:56:42Yeah, you had a bunch of kids, but they could be a lot healthier.

1:56:45And so I think, to me, it just seems like anything that one could do,

1:56:49since it's ostensibly a short -term decision, certainly for the man, right?

1:56:54The woman who's going to breastfeed should probably avoid cannabis during breastfeeding too.

1:56:58You see where I'm going with this?

1:56:59Look, the outcome is so important, right?

1:57:01And we want to think about even just male cannabis use.

1:57:04Yes, sperm count, et cetera, decreases the sperm quality.

1:57:08That sperm quality is important for programming of the embryo, for how the placenta develops,

1:57:12if the placenta is not as good, you know, association with earlier birth.

1:57:16I mean, it's just not worth the risk when the outcome is so important, right?

1:57:22We're all weighing risk every day with different decisions.

1:57:25To me, there's a lot harder decisions you have to make, but, you know, nicotine

1:57:30use, cannabis use, alcohol use, like the data here, none of that is advantageous for

1:57:34your health, especially if we're looking primarily through a fertility lens, a hormone lens, or

1:57:40even, or specifically a pregnancy lens.

1:57:42Like, there's no place for it.

1:57:44You can choose to do what you want with that data, right?

1:57:46And people will always say, I know so -and -so, who did this, and they

1:57:50got pregnant, and there will always be those people.

1:57:52I mean, you're the one making decisions for your journey.

1:57:54And the recommendation is even stronger if you are having infertility, if you are older,

1:58:00depending on your scenario, because you want to control what you can because you can't

1:58:04control everything. So I call those the behavioral toxins, that there's really no place that

1:58:09we need to add these to the world if we're talking about how do we

1:58:12get my body to function optimally.

1:58:13It's interesting that certain substances get politicized.

1:58:19You know, in the past, I experienced this thing that you can tell with some

1:58:23degree of friction. In the past, cannabis was associated with the left.

1:58:28It was like pro -cannabis was left.

1:58:29Now, pro -cannabis is actually very strongly correlated with the laws anyway, this rescheduling.

1:58:37And you watch the media just kind of pivot, and it's just very clear that

1:58:41they're not paying – that the media isn't – that traditional media isn't paying attention

1:58:45to the actual data. It's sort of like how can we use this as a

1:58:49weapon on both sides, on both sides.

1:58:51And so depending on where people get their news, it can be very confusing to

1:58:55people along those lines. For whatever reason, nicotine has become kind of this right -wing

1:59:01associated thing. I know. I recently spoke to about 4 ,000 young men and women,

1:59:05and I would say about 30 % to 40 % of them raised their hand

1:59:10that they're using oral nicotine every single day.

1:59:14Anywhere from – probably I did crude analysis by hand, so these aren't hard data,

1:59:22but it was somewhere between 12 and 70 milligrams of nicotine a day.

1:59:27That's wild. So for women in particular, is oral nicotine use detrimental to either egg

1:59:35quality or probability of successful pregnancy?

1:59:38It's definitely correlated because of how it works in the brain to ovulation, getting pregnant,

1:59:44hormone response. So it should not be something that we're adding to our day -to

1:59:49-day life in any form if we're trying to get pregnant.

1:59:53Most of the egg quality data from nicotine comes from cigarette smoking, so I think

1:59:57it's a little bit more nuanced because smoking directly, if we want to look at

2:00:00that, you know, I would say it's one of the few things that gets into

2:00:03the vault and decreases our egg count.

2:00:05Thank you. Thank you. Chronic inflammation can get in there, but, you know, nicotine, cigarette

2:00:08smoking definitely does. You go into menopause early, you'll get fewer eggs.

2:00:13The egg quality is detrimental.

2:00:15It makes sense based on what nicotine does to your body and how it kind

2:00:18of changes your cellular response that it probably is impacting your egg quality also, even

2:00:22with these oral nicotine pouches, you know, that we're seeing everybody utilize.

2:00:27And it's tanking sperm counts.

2:00:29I mean, that one's really clear.

2:00:32And then, of course, everyone's talking about the reduction in just population growth, which when

2:00:39I was growing up, we were told that, like, the earth is going to be

2:00:41overcrowded. Now we're told that there's not going to be enough people.

2:00:44Everyone's going to be alone on their phones.

2:00:45I don't think either extreme is true.

2:00:48But these are vitally important things for people to think about because these are easy

2:00:52decisions to make, and they can be short -term decisions.

2:00:54They are. You know, we make decisions every day, and you don't have to be

2:00:57perfect, and you don't have to be all or nothing.

2:00:59It doesn't have to be forever.

2:01:00A lot of these things, once you really start making a bunch of them and

2:01:05decreasing inflammation, you will tangibly feel better.

2:01:08I think we are creatures of our own world, and humans by nature adjust to

2:01:13the environment we put our body into.

2:01:14So even things like we talked about sleep, but, you know, chronic stress, how it's

2:01:18directly associated with insulin resistance, how building skeletal muscle is one of the top ways

2:01:23you can reverse insulin resistance.

2:01:25It's the best mechanism for hormonal health we have is to build more skeletal muscle.

2:01:31These things can impact your fertility and your health long term.

2:01:35And so once we start to make these little decisions, eating more fiber, anti -inflammatory

2:01:39foods, cutting down the ultra -processed foods, removing the toxins, changing the toxic behaviors, sleeping

2:01:44more, really trying to manage stress in a more productive way.

2:01:48Together, when your inflammatory burden lowers, people feel better, and then they get it.

2:01:54Then they say, oh, like this running on just caffeine and eating whatever food I

2:01:58could on the go and not getting enough sleep and then using 100 nicotine.

2:02:03Like, that was my body giving me 100 red flags that it is working overtime

2:02:08to deal with what I'm handing it.

2:02:10So how is it supposed to do its normal day -to -day function, which at

2:02:13its purest, that's where your body should try to be, especially when it comes to

2:02:18trying to get pregnant and have the best egg and sperm quality.

2:02:21I would never ask you to assign any validity to something for which there's no

2:02:25data. But in your experience, your clinical and scientific experience, is there something that you've

2:02:31heard from your patients and then observed in terms of outcomes that is intriguing to

2:02:36you that you would like to see more science on?

2:02:38Yes, absolutely. And the reason I ask this is there's this incredible intuition that comes

2:02:45from just being in regular contact with a certain process.

2:02:47For instance, anytime I've spoken to an embryologist who does the kind of work that

2:02:52they do in your clinic, they read journals and there's a process.

2:02:55They learn protocols, but they also develop an intuition to pick that sperm, to wait

2:03:00just a little bit longer, maybe even fertilizing that egg at the end of the

2:03:04day. No, I know. Even though it looks more mature than the other.

2:03:07It's a little small. It's a little gray.

2:03:08This is the art. It's like the Genesequa medicine.

2:03:11Right, the art, not the science of it.

2:03:12The same way, you know, cooking is chemistry, but there's an art to it too.

2:03:17And that nothing can replace those millions of hours in contact with the process.

2:03:22So you've had so many hours in this process at every level.

2:03:26Is there something that intrigues you and that you'd like to see more science on?

2:03:29I love that question. One thing I think I want most people to take away,

2:03:34then I'll answer the question, is that you can make tangible improvement in your fertility.

2:03:40By looking at these lifestyle factors and coming up with a plan to try to

2:03:44decrease your inflammatory burden, you can have a different outcome.

2:03:48And I think that conversation is even more important if you're waiting longer to get

2:03:52pregnant or if you're at an older age or you have lower ovarian reserve, because

2:03:55knowing that you are controlling all these variables to put the best egg and sperm

2:03:58forward is really important. The most intriguing part of the conversation for me right now

2:04:03is GLP -1s and their use for potential chronic inflammatory disease like endometriosis.

2:04:09As a field, we quickly accepted that they are hugely powerful for PCOS and states

2:04:15of obvious insulin resistance for reasons that make sense to everybody.

2:04:18They also help, obviously, patients lose weight.

2:04:21Fat cells make estrogen. They impact the ovulatory process.

2:04:24Fat cells are inflammatory. So all the things that we said were negative.

2:04:28So by simply losing weight, we can restore ovulation.

2:04:31We can have improved IVF outcomes.

2:04:33And it is just a more effective mechanism for weight loss.

2:04:37So easy to jump on and say, I have a patient who needs to lose

2:04:41weight. I have a patient with PCOS.

2:04:43GLP -1 agonist can be a very powerful tool to that.

2:04:46Where I see right now are patients who have known endometriosis or what I call

2:04:51probable endo. They have unexplained infertility.

2:04:5450 % of those patients will end up having endometriosis.

2:04:57Maybe, you know, one of the problems with endo is gold standards is surgical diagnosis

2:05:02only. We don't have a lab test for endometriosis.

2:05:05But when we are getting unexplained IVF outcomes that do not match what we would

2:05:10expect or we have these known chronic inflammatory diseases, I will have patients go on

2:05:15a GLP -1 low dose for three months.

2:05:19We have to take, stop them, and then go through a cycle of different IVF

2:05:24outcomes. We will see more embryos in the lab.

2:05:26And we don't have to study to say that.

2:05:28But talking to colleagues across the country, we know that GLP -1, B1s can be

2:05:34very anti -inflammatory and the way to kind of target that what appears to be

2:05:38that inflammatory burden. And I think that there will be utility there within the context

2:05:44of these chronic inflammatory disease that might be able to help a patient population that

2:05:48we've struggled with, with difficulty to get to a diagnosis or limited data points on

2:05:54what to do with it.

2:05:54So the data is not out yet, but it is a tool I add to

2:05:59the box, especially if we're not getting outcomes we would expect and we don't have

2:06:02another reason why. So do you think there could be direct effects of the GLP

2:06:06-1s on reducing inflammation that are independent of less adipose fat tissue?

2:06:11I do, because some of these patients do not have much adipose tissue.

2:06:13So I think obviously that person is going to get even more benefit if they

2:06:18have adipose tissue to lose that's causing inflammation.

2:06:21But I think especially if we think about autoimmune disease, where people's immune system, their

2:06:27inflammatory response is mis -triggering, I think that there's benefit for the GLP -1s in

2:06:32that population specifically that is giving them an added benefit to decrease inflammation in a

2:06:37really profound way. It's really interesting because I would have thought GLP -1s reducing body

2:06:43fat for a woman who isn't carrying excess body fat, that might actually be detrimental

2:06:48to getting pregnant. It's a fair point that we have to be really careful when

2:06:52it comes to skinny culture.

2:06:55I mean, we are seeing just societal norms shift again to be very thin after

2:07:00being more, you know, body positive, be of a healthy weight.

2:07:03We're definitely seeing celebrities go back to being extremely thin.

2:07:07And we know at both extremes of body weight, again, the hypothalamus is your checkpoint.

2:07:10If you don't have enough body fat, we are worried that you cannot maintain a

2:07:15pregnancy. So it can stop how it's sending off hormones.

2:07:18And again, we can see like a luteal phase defect is that first warning sign

2:07:21before you're in true hypothalamic amenorrhea.

2:07:24So they want to be really careful in that patient group and they have to

2:07:27be done with the right person who has a lot of experience with GLP -1s.

2:07:30There are super low doses.

2:07:32The goal is not weight loss.

2:07:33It's really a different goal.

2:07:35And again, I don't have a paper to like prove it, but we are seeing

2:07:38that clinical experience to say at the end of the day, because there's merit in

2:07:42trying to decrease inflammation, especially in people who we suspect is contributing to the circumstance

2:07:47they are in. And you said low dose GLP.

2:07:50Yeah. Yeah. Are these available in generic form now or are they just still, are

2:07:53they still under patent where they have to be?

2:07:55I don't know the answer to that one.

2:07:56Okay. I don't know. I know compounding pharmacies are making them.

2:07:59I know today, today the gray market for peptides in this country was shut down.

2:08:04So no more, you can no longer buy that just for research purposes.

2:08:07But compounding pharmacies seem to be protected.

2:08:11But I just ask because of the GLPs, at least the non -generic forms in

2:08:15their full dosage, my understanding is that they can be rather expensive.

2:08:19Yes. But the lower dosages from in generic form perhaps are more affordable, have to

2:08:25be more affordable. One would think, yeah.

2:08:26And I think, again, these add -on or there's a lot of kitchen sink approach

2:08:30we do in fertility medicine, right?

2:08:32I've used human growth hormone for years and years and years, right?

2:08:35There's not an FDA approval to use HGH for egg quality, yet we see that

2:08:40it can improve egg quality in the right patient in the lab.

2:08:42So if somebody has a cycle and they don't get as many mature eggs or

2:08:46their embryos don't do as well, my partner actually did a study where she put

2:08:50them through the same protocol, so the same medications in a subsequent cycle, and the

2:08:54only change was adding human growth hormone and had improved embryo development and maturity of

2:08:59eggs. Amazing. So this is like an IU a night or something like that, like

2:09:02some low dose of HGH during the ICU?

2:09:05Yeah, just during the STEM.

2:09:06So it's like two weeks of use.

2:09:07And so now that's starting to be extrapolated and people are starting to look at

2:09:10it longer or before STEM, you know?

2:09:13And so we have to take that.

2:09:15I love the fact that my field's always viewed cutting -edge research.

2:09:19You know, it's a double -edged sword.

2:09:20Like there's some good and there's some bad.

2:09:21We really want to think about mechanistically if it could potentially help having, you know,

2:09:26a low threshold to attempt it in patients who are getting at the end of

2:09:29their journey specifically, right? When they've done all the basics, they're controlling the lifestyle factors.

2:09:34I will say one thing I dislike is this just -do -IVF mentality, meaning nothing

2:09:40you can do can impact your egg quality.

2:09:41Let's just do IVF and then we're compounding dollars and dollars and dollars, yet we're

2:09:47not eating anti -inflammatory food and we're drinking wine every night and we're not getting

2:09:51enough sleep, right? So I think that we've got to really look at these, you

2:09:57know, five non -negotiable areas and optimize them to the degree we can, knowing each

2:10:01day will be different, but building our body the resilience to be able to respond

2:10:05as it's appropriate to. Because sometimes you'll fly to Texas and get less sleep or

2:10:09you'll go out to eat and, you know, you'll eat differently.

2:10:12And your body's meant to handle those challenges, but it can't when it's constantly challenged

2:10:17every single day, all the moments of the day.

2:10:19So there's a ton of experimental stuff that we do that's really cool and some

2:10:23of it will be introduced into practice in 10 years.

2:10:26You know, probably 15 years ago if I had said human growth hormone, people would

2:10:30have scoffed and now it's commonly added on when we're not getting the outcome we

2:10:34want. And that's how medicine should be.

2:10:36We should not be afraid to say that the perfect study doesn't have to exist.

2:10:40If the physiology makes sense, if there's suggested studies, if we explain it to the

2:10:46patients, we help have shared decision -making with them.

2:10:50Because if we're always waiting for the perfect RCT, there will be thousands of patients

2:10:55we could have helped in the interim that we didn't.

2:10:57What are your thoughts on platelet -rich plasma?

2:11:00Oh, such. It's a good question.

2:11:02Which is not stem cells, by the way.

2:11:03Sorry to just shout out there.

2:11:05People think it's stem cells.

2:11:06Stem cells are not allowed by the FDA in the United States, a vision clinic.

2:11:11They were injected into the eye for macular degeneration, and the patients all went blind,

2:11:16and I'm very familiar with those cases.

2:11:17It was that specific clinic that shut down stem cell.

2:11:20You can't advertise stem cells online anymore, so now they just – but PRP is

2:11:25not stem cells. Forgive me for interrupting.

2:11:27PRP has two potential different mechanisms by which it can be used, and it's different.

2:11:32So one is intrauterine PRP, where we are injecting it into the uterine cavity, similar

2:11:37to how we put an embryo inside or how we would do an intrauterine insemination.

2:11:41So small catheter, not invasive, just kind of goes through the cervix right into the

2:11:46uterus. The other is looking at ovarian PRP, which is a more invasive procedure.

2:11:51This is using the same needle like we do for IVF, yet instead of extracting

2:11:55the follicular fluid in the eggs, I'm putting the PRP into the ovaries, looking at

2:12:01it for two different reasons, implantation failure or potential astrum and scarring of the uterus

2:12:06in the uterine PRP group, and looking at it for, you know, low ovarian reserve

2:12:11or age -related fertility in the PRP of the ovary group.

2:12:15Where it shows the most promise is intrauterine PRP, which is nice because it's less

2:12:21invasive. That's the minority of people who are having recurrent implantation failure.

2:12:26You know, most people don't have success because they don't make enough embryos.

2:12:31That's the rate -limiting step for most people with IVF, meaning if you have three

2:12:34genetically normal embryos, almost 95 % of people will have a live birth.

2:12:38So we're talking about a very small subset of the population here, but showing the

2:12:42most promise, though not universally accepted and isn't done everywhere.

2:12:46Ovarian PRP is a little bit more nuanced because clinics can charge a lot for

2:12:53it. It's a procedure. You need anesthesia.

2:12:55I'm putting a needle in the ovary.

2:12:57I'm always a lot more skeptical of potentially damaging the ovary or, you know, potential

2:13:04developing eggs, although no study has supported that it does do that.

2:13:08There are some more hypothetical concerns with that versus uterine, where you're not really damaging

2:13:14any structure. You're just adding it.

2:13:16That being said, ovarian PRP is currently being studied.

2:13:18We don't have definitive data.

2:13:20Potentially could be something to consider if you're really approaching that endgame.

2:13:23You know, you're really not getting the outcome you want.

2:13:25You are older. You have low ovarian reserve.

2:13:27There are people who have some success stories.

2:13:30So I think it's, again, the exception, not the rule, has potential benefit, but yet

2:13:36to be determined. A few years back, there was more discussion about the age of

2:13:41the sperm and the probability of autism.

2:13:44Yes. Could you update me on the data?

2:13:48Yeah. After age 50, we see a few different increases for sperm specifically.

2:13:52So advanced paternal age is real, both when it comes to how you make sperm,

2:13:56but also the quality of that sperm.

2:13:58We see overall in a population -based increases of autism, of autosomal -dominant new mutations,

2:14:05specifically certain types of like dwarfism or very specific diseases that are ultimately overall rare

2:14:12that can happen. And then you also can see an increase in some other mental

2:14:16health diseases like schizophrenia. That data is scary, not the end -all be -all.

2:14:22At the end of the day, when you have an opportunity to bank sperm younger,

2:14:27it would make sense and utilize that preferentially.

2:14:30You know, if somebody came to me and let's say they had bank sperm and

2:14:34it's gone now and I have a 52 -year -old man across from me, I

2:14:37mean, this is who we want to have children with.

2:14:39Then this is who we want to have children with.

2:14:41And we accept that risk because on a population, it's still very low, right?

2:14:44A small percentage point increase means still the most probable chance is you're going to

2:14:49have a very healthy baby.

2:14:50It plays more into the idea that nobody's fertility is finite, that, you know, age

2:14:57-related impacts impact everybody. I would say the same thing is that if the mechanism

2:15:01is the DNA essentially or the quality of the sperm, then those lifestyle tenants in

2:15:07the 90 days prior to getting sperm or banking it or using an IVF cycle

2:15:12probably matter the most. And I would make sure I would want to be controlling

2:15:15all of those factors I was so I wasn't adding to risk.

2:15:18No cannabis, reduced heat, all the things that mutate DNA.

2:15:22Exactly. Yeah. Nicotine out, that kind of thing.

2:15:26Yeah, it's interesting. I think about the sort of high signal to noise anecdotes, things

2:15:33like, oh, you know, so -and -so smoked weed every day and has eight kids

2:15:38or, you know, or, you know, so -and -so had kids when he had another

2:15:44kid when he was whatever.

2:15:45I'm thinking of some actors or something that I don't follow this stuff closely.

2:15:48It was when he was like 78 or something.

2:15:50The problem with stories like that is that they grab people's attention because they're high

2:15:55signal to noise and they distract from the stuff that really matters to most everybody.

2:16:02Like freezing eggs is not going to take more eggs out of your reserve than

2:16:05you need. The NSAIDs, I mean, I'm just like still wide -eyed about this NSAID

2:16:09thing. It's something to avoid while trying to get pregnant.

2:16:11Let's do another one. And biotin levels of taking a biotin supplementation of 300 micrograms

2:16:17or more for seven days can actually influence your lab assays for sex hormones or

2:16:24for any steroid hormone, actually.

2:16:26So when I will sometimes see patients who are going through an IVF.

2:16:28cycle and their estradiol levels are not matching what we're seeing for follicular development.

2:16:32If we go and talk to them and they're taking hair, skin, and nail supplements

2:16:36or something with a high dose of biotin, because commercial supplementation, like, you know, there's

2:16:41certain very popular hair supplements that have, you know, 10 to 30 times that amount

2:16:46in them. This is binding to the lab test.

2:16:50So we're getting false reads on these labs, not changing in your body, but it

2:16:55actually, this is an REI board question, oral board question, is that it binds to

2:16:58the steroid assay. So this can happen to estradiol, to progesterone, to HCG, to TSH,

2:17:03to testosterone. So if you are back where we started and you want to get

2:17:07data about your body, maybe you feel off or you're going through IVF or you

2:17:11want to get a hormone panel done.

2:17:12If you're taking a supplement that has more than 300 micrograms of biotin, you're going

2:17:16to have results that are inaccurate and we cannot trust.

2:17:19So really making sure that you're looking at what's in your supplements and biotin is

2:17:23that specific one that I want to make sure we're not taking excess amounts of.

2:17:27Wow. As long as we're talking about things that people take or put on their

2:17:30body. The last time we sat down and spoke, we had a conversation about endocrine

2:17:34disruptors. Oh man, people really loved and hated us for that.

2:17:37Well, I will say, because it's tricky with comments, again, signal the noise.

2:17:40I think many, many more, meaning millions of people appreciated it as opposed to had

2:17:45issues with it. I mean, it is, you can tell how frustrated I get with,

2:17:49with, my frustration is not with medicine or with science.

2:17:52It's with the lack of open ears in a certain generation of physicians and scientists.

2:17:58I mean, my colleagues at Stanford are very open -minded.

2:18:01And by the way, many of them call me saying like, what should I take

2:18:03for this? Or like, what can I do that's not TRT for testosterone?

2:18:06And like, I mean, it's, they're humans too.

2:18:09And I think the issue around endocrine disruptors for the longest time was seen as

2:18:14kind of hippie science with no data.

2:18:17And then now, because the environmental working group started getting really vocal about this and

2:18:21Shauna Swan, who's a long time researcher.

2:18:24Yeah. But then there was this sort of political backlash because somehow people decide to

2:18:28slot her and the environmental working group as kind of anti -standard science.

2:18:33But you sit down with her, that's the furthest thing from the truth.

2:18:35Like she's all about data.

2:18:36So I think as we tip toe into this, you know, endocrine disruptor thing, I

2:18:42mean, I'll just say it for you.

2:18:44And then if you, if you want to add, like none of what we're about

2:18:47to talk about negates anything about standard medicine, it's just ways, ways and places to

2:18:52be additionally cautious about things that you are around and might go into you.

2:18:58You make decisions every day.

2:18:59You should be making it from a place of knowledge.

2:19:01And the things that you're exposed to more frequently matter the most, right?

2:19:05So a one -time exposure, because you used hand soap and it had lavender or

2:19:09tea tree oil or whatever, I'm much less concerned about than the products you buy

2:19:13for your home that you're using every single day.

2:19:16Because when it comes to endocrine disruptors, a lot of it is the quantity of

2:19:19exposure that really adds up.

2:19:21And this typically comes from frequency because typically it's low levels and a variety of

2:19:25different products, but they absolutely can disrupt hormone function.

2:19:29They cause longer time to pregnancy.

2:19:31There's now been robust data looking at, you know, one of the biggest cohort studies

2:19:35we have, and it's, you know, called the earth study where they're looking at different

2:19:38environmental compounds on reproductive health.

2:19:41And they're looking at cohorts of people trying to get pregnant naturally.

2:19:44And they did a sub study looking at endocrine disrupting chemicals specifically of those people

2:19:48who went on to do IVF and show that those who had higher levels of

2:19:52endocrine disrupting chemicals had a harder time getting pregnant, even with IVF and their IVF

2:19:57markers, fewer eggs retrieved, fewer embryos, poorer sperm counts.

2:20:02So it's definitely not hippie science at this point.

2:20:04It's well demonstrated that it impacts our bodies in multiple ways.

2:20:07And as I recall, the things to be cautious of are lavender, evening primrose, or

2:20:13basically anything with a scent.

2:20:14Essential oils for the most part tend to be fine, but it is lavender, tea

2:20:18tree, and evening primrose that have more endocrine properties for them.

2:20:23When it comes to other products, scented products have a lot of phthalates in them,

2:20:26and then that's an endocrine disrupting chemical.

2:20:29And an important note here, which is wild to me because we see so much

2:20:32greenwashing on products where they'll slap a label on it and they'll say unscented.

2:20:38But unscented is a scent to mask other scents.

2:20:43Really? So unscented just means you've masked a scent.

2:20:46What you really want to look for is fragrance -free because fragrance -free means we

2:20:50added no fragrance to it.

2:20:51To be called unscented, we could have added something to counter the fragrance that was

2:20:55in it. Amazing. Amazing. And Uber drivers, I'm not saying riding in your Uber with

2:21:01your terrible air freshener is going to prevent people from getting pregnant or conceiving with

2:21:06their partner, but take the freshener out of your Uber because you might not be

2:21:11able to have children. But also for you.

2:21:12Yeah, no, I was saying for the drivers are the ones exposed to it the

2:21:15most. Well, for these things, you know, another, like one of the top exposures of

2:21:18BPA right now is actually thermal paper.

2:21:20So receipts. So think about receipts at the grocery store or the airline counter.

2:21:24So for one of, you know, getting it one time and touching it, it's probably

2:21:29not a big deal. But for the people who do that job and are exposed

2:21:32all the time to thermal paper, that actually can be such a high -level exposure.

2:21:37So that's a good example where I say you need to use gloves if that's

2:21:40your industry that you're going to be exposed to thermal paper a lot.

2:21:43So same thing for, let's say, the Uber driver.

2:21:46This is what you're spending your time doing.

2:21:48You don't need that fragrance for your own health.

2:21:50And certainly we don't want to get in the Uber with, I know I'm so

2:21:54mean. If this smells, I'll like, oh.

2:21:56I'll star them lower, which because it's like, I think you should know, you know,

2:22:00you're paying for a service.

2:22:02I mean, I usually roll the window down, stick my head out the window.

2:22:04If they're coughing, I hate being sick.

2:22:06And I'm like, I didn't pay to get sick.

2:22:07So, um, I, I try to be polite about it, but you know, there's just,

2:22:12but again, we control the things we can, right?

2:22:14So let's control the fragrance in our home and in our products, because to your

2:22:18point, we can't control what's in the Uber.

2:22:20And so we're not going to stress about it.

2:22:21That's the argument I get.

2:22:22Number one is that you're causing people to be stressed about toxins that otherwise they

2:22:27wouldn't be. And I, again, like that's paternalistic, like toxins are impactful to your health.

2:22:32I should give you the data so that you can cultivate the day -to -day

2:22:34life that is to the degree where you don't stress about it when you're on

2:22:38the plane or you're in an Uber or you're at a party because that one

2:22:42-off isn't such a big deal because you're not exposed to it every single day

2:22:46inside of your home. I like to think that people want information.

2:22:50Um, I realized they can feel overwhelmed by too much information, but in the end,

2:22:55even though what we're talking about here seems like a lot of to -dos and

2:22:58not to -dos, there's a logic to it.

2:23:00I think the logical backbone is you do what you can.

2:23:03Um, you do your best to control the, the key variables.

2:23:05Um, I mean, the point about cannabis I think is really important that especially men

2:23:10here, um, because I think most people don't know and women don't know they should

2:23:14get their AMH checked. I mean, that's changing because of people like you being out

2:23:18there doing public education, but I like to think that people want knowledge.

2:23:21I really do. I actually think people do want knowledge and I don't think they're

2:23:24the ones giving the counter argument, to be honest, right?

2:23:27I think it's our colleagues who say, oh, people don't want to hear that or

2:23:31they make assumptions. And again, in today's world where we have data, like, why are

2:23:35we talking about assumptions? Let's give people data and let them make the choices they

2:23:38make. Yeah. Ignorance is not bliss when you're running up against a health challenge.

2:23:43Yeah. If you haven't had your own health challenge, maybe it's hard to understand what

2:23:46it is. And for infertility, for most people, this is their first time their health

2:23:51is really being challenged, usually because of the age range of which it is.

2:23:54I mean, that was my story.

2:23:56A decade later, I got diagnosed with celiac disease, despite having unexplained recurrent pregnancy loss.

2:24:03I can tell you that this, you know, collided with my fertility fellowship when I

2:24:08advocated for doing vitamin research and all this epidemiology.

2:24:11I saw the word inflammation and all of that text, yet we weren't talking about

2:24:14it with our patients. And I went on this journey to get rid of Teflon

2:24:19in our kitchen because I studied PFCs and we changed the foods that we ate,

2:24:23changed how we exercised and how we slept.

2:24:26And one of the things that I cut out learning to listen to my body

2:24:29was gluten at the time, even though I would have never said I had like

2:24:32GI symptoms from it. I just said, oh, I felt more inflamed, like vague symptoms,

2:24:37kind of headache, kind of more fatigued.

2:24:39And when I conceived my children before we ever had to do IVF, we got

2:24:43pregnant naturally in that time period when I didn't have gluten.

2:24:48So decade later, get the diagnosis that was actually contributing to why we had these

2:24:54different pregnancy losses. So it wasn't unexplained at all.

2:24:56And not that everybody needs to cut gluten out, but understanding how chronic inflammation impacts

2:25:02our bodies and learning to listen to our body is one of the most powerful

2:25:08tools that we have. And it starts with, you know, education and knowledge, learning how

2:25:13to advocate for ourself, right?

2:25:14When you know what's normal, you can sit in front of somebody and say, this

2:25:17isn't normal and mean it with your full heart.

2:25:20And then how do you optimize all the things at home?

2:25:23Because back to the other point, even if you need IVF, I can only work

2:25:27with the eggs and sperm you give me.

2:25:28And maybe if we're focusing on some of this stuff earlier, there's probably a subset

2:25:32of people who can get pregnant without IVF or who can freeze eggs and have

2:25:36an easier journey because they had this information and they made choices based off of

2:25:40it. What I'm realizing hearing you today is that we need to listen to our

2:25:43bodies. Women need to listen to their bodies because we're mainly talking about women's health

2:25:46here. Men do too, but we're talking about women, but also learn to be scientists

2:25:51of our bodies. And when it comes to nutrition, I'm very curious because of your

2:25:55example, do you think there's any value to people experimenting with a quote unquote cleaner

2:26:02diet if for no other reason than to figure out which ingredients don't work for

2:26:06them? Meaning if you have granola for breakfast and a side of eggs and some

2:26:11toast, or one day you have eggs and the next day you have toast or

2:26:14both, whatever. And then for lunch, you're having a sandwich.

2:26:17And then for dinner, you're having some pasta with some sauce and you don't feel

2:26:20well. You don't know what the problem was.

2:26:22So I'm not advocating for, you know, a Spartan diet where it's like, you know,

2:26:26chicken breast next to rice next to broccoli with a tablespoon of olive oil next

2:26:29to it. Although that sounds pretty okay for steak, there's worse.

2:26:34But when you eat that way for a short period of time, the sort of

2:26:38cleaner and more or less individual ingredients, I do think that you can get insight

2:26:43into what works for you and what doesn't, independent of all the other information out

2:26:48there. Like for instance, there are certain forms of fibrous foods, I definitely believe in

2:26:51fiber, that I just don't feel well.

2:26:53And then my sister, who is not a scientist, she'll chuckle at that, but she

2:26:58had this intuition about histamine that has now been confirmed by two guests on this

2:27:02podcast who are MD PhDs who work on these sorts of issues.

2:27:06In one case, pain, in another case, gut inflammation.

2:27:09And she was convinced that she had some histaminergic thing that she read about in

2:27:13some book, suggested I take this histamine enzyme tablet before I eat.

2:27:18And it's opened up this whole array of other foods that I can eat.

2:27:21But for years, I would get super sleepy after I would eat certain foods.

2:27:24I'm like, this makes no sense.

2:27:25I like starches. I like fiber.

2:27:27Turns out I have a sort of mild histamine sensitivity to like four different foods.

2:27:32I don't think you can figure that out unless you separate out the ingredients.

2:27:36Absolutely. It's like I planted this question for you, even though I didn't, because I

2:27:39advocate, especially if you are falling off the curve, right?

2:27:43I think if you're trying to learn to listen to your body, you say, I

2:27:46want to optimize my own health for a very temporary, but restrictive clean eating pattern

2:27:51where you're having lots of fruits and vegetables and fiber, and you're cutting down some

2:27:55of the things that cause more commonly cause certain reactions, cutting out gluten, cutting out

2:28:00dairy, cutting back on red meat, and then you add them back in and start

2:28:04to listen to how your body is functioning.

2:28:06But you have to really kind of eliminate first, and then you can add back

2:28:09and see, oh, I feel better, worse, the same.

2:28:12Okay, well, if it's worse, that's maybe not something you should have, and then learn

2:28:16to listen for it. The tenants of a fertility diet are really not eye -opening,

2:28:20right? Fiber is hugely important for the gut microbiome and hormone health and inflammation and

2:28:25insulin resistance. So high fruits and vegetables, high fiber diet, whole grain carbohydrates, over your

2:28:30refined carbohydrates, ultra processed foods don't have a place in the modern diet, added artificial

2:28:35sugars, those non -nutritive sweeteners, they don't have a place in this.

2:28:39We want to have quality of our protein.

2:28:41Most people could benefit from some increased plant protein due to the increased fiber than

2:28:45they actually get in the standard American diet.

2:28:47But meat is not universally bad, nor necessarily good.

2:28:51It's the quality of the meat that probably matters a lot.

2:28:54The meat data to notice is that for every serving of plant -based protein over

2:28:57animal, people tended to ovulate better and had higher fertility rates, probably more suggestive of

2:29:02an overall healthier fiber -first dietary pattern on the population -based level, because ultra processed

2:29:09foods don't have a lot of fiber in them or any fiber in them.

2:29:13Animal -based products don't have fiber in them.

2:29:15So we want to be mindful of that ratio.

2:29:16Red meat's the really controversial one, and increased servings of red meat, of course, dietary

2:29:22studies, quartile it, lowest exposure, highest exposure.

2:29:26Highest exposure groups had poor embryos develop, worse outcomes with IVF, and an increase in

2:29:32staging of endometriosis when they went to surgery.

2:29:35That doesn't mean to me that all red meat is bad, but it probably is

2:29:38for a subset of people, more inflammatory, causes more IGF -1.

2:29:42We want to be mindful of it.

2:29:43The question I always get is, does source matter?

2:29:46I mean, probably, but we weren't looking at it in any of those studies.

2:29:49So I think being very mindful of where your animal -based protein is coming from

2:29:54is really important in today's kind of food world.

2:29:58Not all foods are created equal, even when they fall into the same category.

2:30:02And it's worth saying that healthy fats are really, really important, right?

2:30:05Cholesterol is the backbone for steroid hormones.

2:30:07So you need cholesterol in your body.

2:30:09So we really want to encourage those monounsaturated, polyunsaturated fatty acids.

2:30:14So the nuts, olive oil, fish, algae, chia seeds, flax, those things have such, so

2:30:22many benefits when it comes to the omega -3 fatty acids they have, but also

2:30:25that they're great healthy sources of cholesterol, which your body needs.

2:30:28And in fact, if you don't intake enough, you're not going to make progesterone as

2:30:32well. We want to be really minute, need progesterone for implantation, don't have enough unsaturated

2:30:37fat in your diet, you're not going to make as much progesterone.

2:30:39So there's some nuance there, but to the heart of your question, I'm a huge

2:30:43advocate for that, especially if you're struggling with something, you're not feeling your best.

2:30:48If you say you kind of hit the marker on a lot of these inflammatory

2:30:51symptoms and you don't know what's going on, it can be a really helpful tool

2:30:55once you're controlling the other ones to try to leverage.

2:30:58But again, sleep, stress, building muscle, avoiding those excess toxins, those are a huge piece

2:31:04of the puzzle too. And a lot of them go hand in hand, right?

2:31:07A lot of times we eat a food that's also wrapped in something that has

2:31:12toxic chemicals in it. So we really want to think about the fact that when

2:31:17you work from home, when you have access, whole foods is really important, as always

2:31:21leveraging processed or ultra -processed versions.

2:31:24Would you say that what you just described, in fact, everything we talked about, also

2:31:30pertains to perimenopause menopause? Absolutely.

2:31:32Absolutely. It's so fascinating because when I sit with a lot of people who just

2:31:35do menopause, we have the same recommendations for lifestyle and decreasing inflammation because it's going

2:31:41to improve ovarian response. It's going to improve how your body feels, decreasing inflammation.

2:31:47We know that when you go into menopause, estrogen has such profound anti -inflammatory benefits

2:31:51that one of the biggest problems is a baseline increase in your inflammation.

2:31:55So don't wait until you're in perimenopause or menopause to start to learn these things.

2:32:00Learn them. Whatever point you are now is the perfect time where we can start

2:32:04to make a difference, both for hormonal health now, fertility now or later, but also

2:32:10your ovarian function long -term.

2:32:13Amazing. Dr. Natalie Crawford, thank you so, so much.

2:32:17I mean, I can't tell you how much I learn every time you speak.

2:32:21On this podcast and elsewhere, people should definitely get your book.

2:32:24Again, I've read it. I've read it cover to cover.

2:32:27The fertility formula, take control of your reproductive future.

2:32:30Natalie Crawford, MD, did all the training, runs a clinic, is out there doing public

2:32:36education amidst everything else, co -managing a family and just really expanding the field.

2:32:44I mean, you're taking it in new directions, which is really, to me, the most

2:32:47important thing, right? That you're out there teaching people, but you're also going back to

2:32:51the clinic. And you're paying attention to the science and evolving the science because this

2:32:55field is just going to improve over time.

2:32:57But you've given people so many actionable things to contemplate, to definitely do, if I

2:33:04may insert my own beliefs there.

2:33:06And just a lot to think about in terms of the general landscape of how

2:33:10we think about reproductive health, both our own and societally.

2:33:13So thank you so much for coming back.

2:33:15We will do it again, if you're willing.

2:33:18And just grateful to you.

2:33:20Always. Thank you so much for having me and holding space for this discussion.

2:33:23I appreciate it. Absolutely. Thank you for joining me for today's discussion with Dr.

2:33:27Natalie Crawford. To find links to her podcast and her new book, The Fertility Formula,

2:33:32please see the links in the show note captions.

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2:34:10For those of you that haven't heard, I have a new book coming out.

2:34:12It's my very first book.

2:34:14It's entitled Protocols, an Operating Manual for the Human Body.

2:34:17This is a book that I've been working on for more than five years, and

2:34:20that's based on more than 30 years of research and experience.

2:34:23And it covers protocols for everything from sleep to exercise to stress control, protocols related

2:34:30to focus and motivation. And of course, I provide the scientific substantiation for the protocols

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2:34:40There you can find links to various vendors.

2:34:43You can pick the one that you like best.

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2:35:20call protocols in the form of one to three -page PDFs that cover everything from

2:35:24how to optimize your sleep, how to optimize dopamine, deliberate cold exposure.

2:35:28We have a foundational fitness protocol that covers cardiovascular training and resistance training.

2:35:33All of that is available completely zero cost.

2:35:35You simply go to HubermanLab .com, go to the menu tab in the top right

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2:35:45Thank you once again for joining me for today's discussion with Dr.

2:35:48Natalie Crawford. And last, but certainly not least, thank you for your interest in science.

2:35:54Thank you.

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