Video URL: https://www.youtube.com/watch?v=w8h4qksd6Yw
people are waiting longer to get pregnant but if we can imagine that there is a vault of your eggs by the time you're born you have 1 to 2 million in your reproductive years 300,000 this means if you and your partner wait till 35 your chances of getting pregnant are going to be approximately I feel like I better get a move on but there are things that we can do to improve your reproduction and this is information that nobody talks about so let's get into it let's do it Dr Natalie Crawford is a double certified practicing fertility doctor helping people to optimize their lifestyle to improve fertility rates of infertility are increasing one out of every eight women would have infertility and now it's one out of every five and there's multiple factors that are contributing including irregular or lack of having a period there's more autoimmune disease obesity chronic stress people are waiting but at 40 your chance of miscarriage is 50% and suddenly you're left behind and I know that because I had four pregnancy losses and I'm going to cry now lots of people will be struggling with a variety of the things that you've talked about what would you tell them you can't control everything but you should be able to control the factors you can so what would my daily habits look like I love that question so what have I got misconceptions around how to increase our odds of getting pregnant yes there's so many myths if for female orgasms does that increase the chance of fertility this is super interesting and then what is the number one thing that people don't do that impacts their reproductive system it seems is so straightforward it's not a pill that you take or a major change of behavior it is simply we've just hit 6 million subscribers on the dire of a CO um so me and my team would like to do something we've never done before as little thank you and we're calling it The dire of a CEO subscriber raffle and here is how it works every episode this month we're going to pick three current subscribers at random and we'll send one of you a 1,000 voucher one of you tickets to come and watch the dver SE behind the scenes live with our team and one of you will have a 10-minute phone call with me to discuss what ever you want to talk about
if you're a subscriber you're in the raffle thank you from the bottom of my heart for allowing me to do something that me and my team love doing so much it is the greatest honor of my lifetime and I hope it I hope it continues uh off into the Future Let's get to the episode Natalie who are you and what is the mission that you're on hi Stephen I am a fertility doctor which means that I help people grow their family or plan for their family no matter what that looks like but my mission started because early in my career I realized I was seeing people when they were already behind the game they didn't have the basic knowledge about how their body worked their hormones their reproductive system and I had to bring them up to speed and every time somebody said I wish I'd known this earlier I can't believe I wasn't taught this why isn't this the stuff that we're taught because I might have made different decisions earlier in my life and that was a pivotal moment for me about 8 years ago when I started wondering if I could reach people earlier in their Journey before they had infertility before they were in my office if maybe that could change the trajectory of their course if they could be more empowered with that education to make the decisions that are right for them versus just letting time pass which ultimately makes some decisions for people and when we talk about getting started earlier and thinking about this earlier when we we we hear the topic of fertility I think most of us think it's something that people over the age of 35 need to start worrying about or you know once we get up until close to our 40s then we need to start thinking about our fertility more consciously but what you're saying is is that fertility or infertility starts much earlier in the decisions we make 100% if we view fertility as the ability to get pregnant and infertility is a disease the World Health Organization the CDC everybody defines infertility as a disease the inability to get pregnant so then we can view fertility as more of the health the wellness State and just like we're trying to prevent disease and other aspects when it comes to cancer Alzheimer's many other diseases we need
to be approaching our fertility as a preventative action taking steps to make sure that if having kids is one of your life goals you're not making choices that is going to make that impossible or extremely difficult when you get to that stage and what is the sort of macro social cultural backdrop to this because the conversation around fertility and infertility to me and this might just be a sort of perspective bias seems to have suddenly increased over the last couple of years um and I don't know whether that's because I'm in that age range now where my friends are having the conversations or that I think socially we're starting to think more about it because there is some pretty alarming data that's emerged around people struggling more than ever to conceive children because there's like social factors at play exactly what are what is that social backdrop so it's very interesting when you try to put the whole picture together one because we are more aware of fertility we have social media people are sharing their stories 20 years ago you didn't know somebody might have infertility or be struggling similarly there was less access to reproductive technology things like egg freezing didn't exist you couldn't do IVF unless you travel to a city that had a big enough program and so when there were limited ways to treat something there was less access to get into care to even be evaluated so one we do have people more aware about their fertility getting diagnosed earlier and easier finding out problems sooner and some of that is well I think all of that's wonderful socially yes rates of infertility are increasing we used to say one out of every eight women would have infertility and now in the US it's one out of every five who's just trying to conceive for the first time will have infertility so that's a huge increase it stays even when you confound studies for age so the number one thing everybody says is well people are waiting longer to get pregnant which is absolutely true I think only 5% of people started their family overage 30 back in the 70s and now it's 25 to 30% so we see a huge increase and the number of people who are waiting to start their family I did you are especially as women are being power to chase other dreams go to professional school they're delaying
entry into childbearing so part of this is that people are waiting later diseases develop later but then also as a society people are less healthy we see more obesity we see more diabetes we see more environmental toxins than we ever have so I really think this is something where there are multiple factors that are all contributing to this alarming rise of infertility that we're seeing and are we having less sex than we used to I think people are having less sex yes especially as they age in the reproductive age range it depends people when they get married tend to be having less sex but interestingly there's been a really good study looking at marijuana so we'll use it for example people who smoke marijuana tend to get pregnant less even though they're having more sex than people who don't so when you say this group's not smoking marijuana and they're getting pregnant even though they're having less sex than this other group it's showing us that it's not just timing or not having intercourse there really are other factors at play that are very socially acceptable that are influencing the ability to get pregnant I was reading through some research earlier about fertility and the sort of global Trends and I read this one St that said the global fertility rate has decreased from 4.84 live births per woman in 1950 to 2.23 in 2021 and it is expect to drop to 1.59 births per Woman by 2100 which means that we're there's clearly a traj I mean if this is true then there's a trajectory to having less kids yeah in the US it's 1.3 is the average right now for a single woman or one person will have on average 1.3 children that's very alarming when you start thinking about is that number just people are waiting or what about all the people who just can't get pregnant and I see those people in my office over and over and over again that are not able to get pregnant even if they're starting young so I think that we really have two factors going into that statistic you saw when it comes to sperm you know study came out last year looking at sperm counts and they've decreased 50% in 50 years what's most alarming about the sperm count decrease in men is that in the past 10 years it's decreased at Double the rate that it did the 40 years
prior so when we start looking at more recently the rate of decline is accelerating and that's got to be the world around us and you in 2020 founded the fora Fertility clinic which is based over in Austin how many couples women people have you seen since you've opened that clinic and what is the typical sort of case study of why someone will come to you in that clinic what are they searching for what are they struggling with I love that question so yes it started fora in 2020 with my partner Amanda Skiller and she and I have been practicing for quite a while at this time and realized that there wasn't an approach at least in Austin for personalized care because of that probably the number one type of patient that we see is coming in who's already had lack of success somewhere else meaning went to a clinic has been trying the average patient is going to be overage 36 has been trying for one to two years learned about their Cycles tracking their Cycles relatively normal evaluation trying to do IVF and now is not getting the result they wanted what I find the hardest thing for people is the isolation you're suddenly being left behind in your friend and your peer group when you're trying to have a child and those in your world have succeeded and suddenly you're left behind and the stress and the isolation that causes really makes the entire process so much harder than many other medical diagnosis that somebody might get and you give me some more color on how that feels because you you know how that feels I do know how that feels so I had four pregnancy losses before I have my two children and this was a long time ago and I was in the middle of training so I was a resident and a fellow definitely was not taking care of myself very well because that was the life style of a doctor in training and I didn't tell anybody I was pregnant minus my husband for the first three pregnancies because people weren't sharing about their pregnancies I had this idea I need to wait till I'm in the safe zone I'm out of that first trimester and so when I started losing those pregnancies nobody knew I was pregnant so it was so hard to come and tell somebody that I was losing the pregnancy when I hadn't even opened that door to trust them with the first
piece of information it was very hard to come in with that subsequent request for support or help and I just felt like that wasn't what people were sharing or talking about my fourth pregnancy loss was an ectopic pregnancy which is a tubal pregnancy so this is a pregnancy that implants in the fallopian tube instead of in the uterus those pregnancies cannot grow the fallopian tube doesn't have the blood supply to support a placenta and the fallopian tube can rupture and it can become a surgical emergency in and be very scary that was diagnosed for me when my husband was off in a bachelor trip in Las Vegas and I had to receive a medication in order to try to stop the pregnancy from growing but there was still a risk of the tube rupturing and I was forced to call friends have somebody come with me be with me and sharing it there was so much support given that I realized that was such a mistake of mine not that you need to post every pregnancy announcement on the Internet or tell everybody your job but there are people in your life who want to support you and they can't show up if you don't let them know what's going on and that's one of the things that I tell my patients is that give the people in your world the opportunity to show up for you tell the people who are asking who you turn to in other times of Crisis tell them that you're struggling with this let them show up and support you because most of the time people will they care about you and that is going to lessen the burden because that isolating peace the doubt and the fear especially if you're a goal oriented person I have set so many goals and I'm going to do this and here's my path to do it so to feel like I was failing at becoming a mother when I didn't fail at anything and now my body was failing me felt so shameful so so much guilt and I had nobody to share that with or to help alleviate that burden from me you use the word guilt there there's um complex set of emotions that I've had described when someone finds out that their their pregnancy or even their sort of their sexual organs more broadly are struggling with something and I've got lots of friends that have been diagnosed with a variety of different conditions um in that in that sort of with their
sort of sexual health and you almost observe a feeling that they can often feel like they are broken in some way like they're not they're not you know working they're like a broken person and I I I say that to try and highlight the fact that those that's there's so many people going through that exact same thing and that all of these conditions are very um a lot of people are struggling in Silence with that feeling of of inadequacy you're so right there's so much stigma to infertility there there's so much misinformation and uncertainty when it comes to reproductive Health together that makes it difficult for people to talk about or ask questions and when you feel like one of the things that you always thought was certain about your future if you were a child and you envisioned your life 30 years from there something if you envisioned having children and suddenly you're faced with the potential reality that that might not happen or it might not happen without intervention that really crashes down a piece of your own identity and and who you saw yourself to be who you wanted to be and trying to struggle with that true identity crisis at that moment really brings out so many emotions it's what so many of the people who sit across from me every day say I just I don't feel like myself I feel like I'm stuck while everybody else is moving on because I'm broken my body is failing me it's so hard to watch somebody go through it and even if I can't get everybody pregnant or control the outcome the thing that I always say is that at a minimum you need to understand how your body works at a minimum you can know that you're making the choices that are right for you you can feel good that you did everything that you could and that there wasn't education you needed or choices you would have made looking back in the rearview mirror and even when somebody's deep in the midst of failed IVF Cycles or sitting across from me I say the same thing that's that's our minimum you deserve to understand why we're making the choices so that this can be a process where you can advocate for your care and we can collaboratively do everything we can to try to achieve this goal for you I had um got a good friend who's just um because OB I'm at
the age now where my friendship cycle is starting to go and get fertility tests done and such and they're trying for kids many of them are have been very successful but I've got one particular friend who has been trying for some time they're struggling so they went and got the the tests done and it turns out that one of them in that relationship has some has some issues which are complicating their chances of getting pregnant and when I heard that God I can't imagine how that person feels in that relationship because it I can imagine in your head how you can start to overthink and you can feel that word again that word guilt towards your partner and you can start thinking oh my God this person's going to leave me because I can't give them what they want and all of that sort of complex those complex slightly irrational but completely understandable thoughts the relationship aspect is so hard even going through it myself because my husband wanted to support me and of course he did but I felt like I was the one failing not him right I'm the one who's not bringing my aame to the table this is a me problem and even though it's an us problem it felt like a me problem to the point where I really try to level the playing field to all of my patients at least when I see them and say it's the two of you you're a team this is a team it doesn't matter whose diagnosis comes back as what we are trying to get us pregnant and really reframe everything that way I have a patient story from the Past who had been going through infertility been going through IVF because she found out she was running out of eggs early and she had taken a lot of blame for not freezing her eggs earlier for waiting longer and going through IVF her husband turns out his sperm wasn't functioning the way that it should and we didn't know that until you fertilize the eggs with it and really see how embryos grow in the lab and she said to me at our follow-up visit even though the outcome of that cycle was devastating to have no embryos developed because they found this sperm issue it improved their marriage so much because For the First Time her partner and her they felt like they were on even playing field that
they were both part of the reason they were in this situation and whether it was imposed by him or not she had carried that guilt that shame that broken feeling alone like it was just her so let's get into it then let's do it let's talk about fertility where do we need to start I was going to assume where I need to start here but I'm an absolute muggle and idiot as it relates to fertility and female and male reproductive health so where do we start if we want to understand fertility I always like to start with the ovary and understanding the difference in eggs and sperm so we'll do sperm first and we'll do eggs okay do you know how many sperm you make in a day do I know uh how about how many you make in a second no I have no idea the average man makes 200 to 300 million sperm in a day and 1,500 sperm a second so men 1500 a second you're just like so men in their testes have germ cells meaning they can just produce brand new sperm at very high rates every single day and in the ovary for women it's so different because you are born with all the eggs you're ever going to have and you run out of them over time and this means that one the number of eggs you have raining is a part of the picture and two your eggs sit inside your body and they absorb the wear and The Tear and the world around you your whole life where your sperm lifespan is 90 days takes 72 days for a sperm to grow across the testicle and then 18 days to get out the ejaculatory system so you have three months so you could change your life and change your sperm counts in three months why does it take 18 days I thought if in my little idiot head I thought that I make my sperm okay today and then if I ejaculate that's the sperm out no yeah those sperm those sperm were made a couple months ago really yeah they're like in storage lockers so that you have some for every day so they kind of get put in line so that you can send them out at that right time period okay so but if you ejaculate multiple times eventually you can't keep producing more but so let's imagine that you have lockers and we'll just pretend that there's 200 million sperm in each one if you ejaculate every single day you're ejaculating 200 million sperm each time now if you're saving up for a
couple days you're going to ejaculate 400 million and now if you've waited three days 600 million the catch here is sperm are so fragile they're so fragile they like to die they get tadp oh those little tadpoles so if you wait too long you're just going to have a bunch of dead guys and then they're going to impair the ability of the better sperm to even function and I use the analogy of imagining that this is a Highway and the dead sperm are stalled cars all over the freeway even if your sperm counts normal if you're having very long abstinence periods in between your intercourse times you're going to have a sample that has so much debris and dead sperm in it that it's going to make it hard for the good guys to do their job okay so there is so you do need to keep ejaculating to remain to optimize your fertility your chances of fertilizing an egg yes oh I didn't know that and how often G I always say it's going to there's a fine balance here somewhere between every day to every 3 to four days is going to be the best whether that is ejaculation in any form what whatever suits your fancy we see that longer than seven days for the most for most people will severely increase the amount of debris that you see and the proportion of the ejaculate that is dead sperm super interesting so let's go we'll stay at the the foundations we're talking about sperm and eggs so is that sperm covered off is there okay and sperm counts as you said earlier have been reducing over the last 50 years by 50% which is horrifying um why is there something in particular in our environment that's causing that it's all the things and some of them are changeable and some of them are not so we have to view the world as it is certainly we see we've got more men who are unhealthy who are overweight who have other medical comorbidities that are also impacting their ability to make sperm like if you have high cholesterol if you have diabetes some of those things are going to impact your overall health and the production of sperm so this goes for sperm or egg the hormone access from the brain to your gonad your gonads are either your testes or your ovaries your brain is constantly interpreting signals from your whole body and is trying to determine can stepen have a kid right now and if you
become very stressed now back in the day what was that there was a bear attacking you there was a famine so you had no food there was a plague going around then it say this is not a good time to have a child right now because because you can't support your own body or the world around you your adrenal glands are making cortisol because it's so stressful or your calorie intake went down so your brain says this is too difficult I'm going going to shut off the system to make reproductive hormones and that happens in both men and it can happen in women so the brain is constantly interpreting the world around you and then sending out signals to make eggs or sperm like to make eggs grow or to be making sperm and the hormones that are associated with them so estrogen and progesterone for women and testosterone for men and so one we have anything that interferes with this pathway people are more ill there's more autoimmune disease more inflammation there's more stress chronic stress there's more obesity but then we also see the environmental impact as well so certainly there's so many toxins in our world from the foods we eat from the air we breathe from the type of you know kitchen wear that we use what we put in and on our body all of it makes a little bit of a difference and we know some people if you live in an area with high pollution you're going to have lower sperm counts and a reduced fertility rate but that might not be something you can change because that's where you live but it might be even more important for that person to understand it and then want to not also smoke marijuana or drink out of plastics or do other things that might be adding to that burden so smoking marijuana and smoking cigarettes are no NOS if I absolute no no know so I think cigarettes most people are pretty aware cigarettes are pretty bad for your health if we talk about reproductive Health in general cigarette smoking for for women and your eggs are going to decrease your egg count your egg quality and the rate of miscarriage significantly significantly for men what we see is it decreases your sperm count your sperm motility and the quality the shape of the sperm also increasing miscarriage marijuana does this as well if you smoke marijuana even if your
partner does not and is never around you when you're using it she has a higher chance of a miscarriage just because you're smoking marijuana how because of DNA damage inside the sperm's head okay I'm giving out bad sperm you're giving out bad sperm what about vaping we don't know as much about vaping but it appears in all the preliminary studies to be similarly very bad that what is in um what you're breathing with vaping might even be more harmful than cigarettes potentially what about phones and laptops oh I love this one okay so that's a great question and people ask about it two ways to look at it there was a study that was published last year that actually looked at this and we'll talk about just having your phone using your phone and then location of the phone in the study what they looked at is phone usage from 2005 to 2018 so we have to remember in 2005 phones were different it wasn't quite the same but they had a much higher uh radiation emitted from them so modern phones actually emit much less radiation so even though we keep them on our person they're ultimately safer than what we saw as origin phones from 2005 to 2010 in this study that they looked at the number of times that you used your phone which is wild to us because we use our phone constantly now but the number of times you use your phone the more you used it the less firm you made okay however that was most impactful for the early generation phones from 2005 to 2010 so when they stratified and looked at some of the phones we have now we're not seeing that same impact and I think that is because there's less radiation and also everybody uses their phone more than 20 times per day right you're using it all the time location didn't matter there was no difference of location whether you kept your phone in your pocket your back pocket the counter off your body there was no difference so I think that helps us understand some of the radiation aspect of the phone and if that is impacting sperm heat of the testicle is of course something very very different I do think you talked to Reena about this so when it comes to the testicles they live outside your body for a reason we know that men who have an undescended testicle even if it's
surgically removed sorry what's an undescended testicle you can be born with one of your testicles in your abdomen instead of in your scrotum okay and that's usually surgically corrected before the age of one because if it stays internally the heat of the body is too hot and it destroys the cells the inability to make sperm inability to make testosterone so the testicle is outside the body in the scrotum so that it can be kept at a lower body temperature we know that things that increase the temperature of the scrotum do impact sperm production and testosterone production testosterone and sperm are made together so one thing is going to influence one it will influence the other this is sauna use every day hot tub use every day laptop in your lap if you are putting your phone exactly by your scrotum every single day then it might be having an impact if it's heating up and it's the heat that's causing the problem not the radiation that's being emitted from it so we always are asking if I see somebody for infertility I'm going through any behaviors that are significantly increasing the temperature of the scrotum to see if that is a modifiable factor what about hot baths if we're having lots of hot baths if it's daily and you sit in there for you know more than 15 minutes then I would cut that down to not be daily I see this a lot in Austin from people who love to cycle so they're on a bike they're outside they want to go ride for two to three hours at a time time numerous times a week that's a lot of heat contained right to the scrotum area and we often see significantly lower sperm counts in men who cycle at that intense level interesting right very interesting um what about trt you talked about the the correlation there and the relationship between sperm and um testosterone levels if Men start taking trt which is hormone replacement therapies testosterone repl therapy um does that impact the quality of my sperm and my chances of fertility stepen at least one time per week I will see a couple who comes into my office who has been trying to get pregnant and the male partner went to a Hormone Clinic a men's health and he was put on trt for libido or fatigue or something and essentially
that is male birth control because taking testosterone yourself is telling your brain that there is testosterone present because naturally testosterone is made as sperm is made if your brain thinks there's a lot of testosterone it says hey we don't need to make much more we're doing really good so the hormones from your brain stop being sent out and no longer tell your testicle to make any more testosterone or any more sperm so trt use makes men aspermic meaning having no sperm in the ejaculate you still have an ejaculate it looks the same to you but when we go look at it under the microscope there's no sperm in it sometimes that is irreversible the longer you've taken trt for there is a chance that I might not be able to get sperm to return to your ejaculate it might be permanent let's talk about eggs let's talk about eggs you have this um wonderful example where I guess it's a bit of an analogy called The Vault yes I've got um some marbles over here in a jar which I thought would um help us to visualize this idea of a vault so I've put about I don't know there looks like there's about how many marbles do you reckon there're in there if you uh get it right you win the whole lot uh 200 marbles 200 I'm going to say we'll count after um well now you're counting that's different than guessing no no no no I'm not I'm not just go on have a guess how many marbles are in there we'll count after see who's right okay I said 200 okay anyone in the comment section below Al so you can you guys can also guess don't cheat don't skip to the end I think there's about he is counting that is not I can't count them all can I cuz I can't see them all seven times nobody else can see them all and count them 140 okay this is the analogy I'm going to pass them over to you um I'd love you to use this as an a visual aid to explain to me this idea of the vault as a as a way to understand how many eggs women have and how that changes over the course of Our Lives love it all right so I like to think about the ovary as inside your ovary if we can imagine that there is a vault of your eggs so that is what this jar is representing so again in contrast in men testes are making brand new sperm every single day in women when you are a five Monon baby inside your mother's womb you have the most eggs you're ever going to
have you have six to seven million eggs by the time you're born you have 1 to two million by the time you start puberty you have half a million your reproductive years you're going to start with about 300,000 and by the time you go in to menopause you'll have less than a thousand left so you still have a few eggs left women only ovulate about 400 to 500 eggs over the course of their lifetime so if you're born with 1 to two million and you only ovulate 400 to 500 that seems like confusing math so the way that I think about it is that every single month you are losing eggs from this Vault and what is happening is that the eggs are coming out in proportion to how many are inside so when the vault is more full more eggs come out that month and when the vault is less full less eggs come out so if we can imagine one month you're going to have a group of eggs all come out of the Vault and so if this is our ovary what we would imagine is that the Vault sent out all of these small eggs and each egg grows inside a follicle the brain is going to send out follicle stimulating hormone once you start puberty so before puberty all of these eggs are just going to die after that month is over but once you've started puberty FSH so follicle stimulating hormone from the brain will come and stimulate one of these eggs why only one because humans are not meant to have litters you can only carry one child at a time in our uterus so this is the protective mechanism by which humans don't have multiple children most of the time so each egg grows inside what we call a small follicle so the brain sends out follicle stimulating hormone this is one of the rare times where in medicine hormones are named for what they do in women not men because you have FSH and lh2 FSH controls the production of sperm for you and LH the production of testosterone but for women FSH controls the stimulation of one follicle so this follicle will grow and this one will ovulate and the rest of them will die so that's one of the 400 that I'm going to lose these just go away I want to make sure I understand this so in the J is the Vault that's inside the woman y um at every month this is what's available this month okay she produces quite a few like when you're younger
yeah CU there's more in my jar proportionately there's like okay there's 20 or 30 and they're proportionately to a jar that has 200 these numbers aren't obviously ratioed but and then one of them is basically selected to ovulate at random at random so it's one of the great Mysteries if we could control which one because it doesn't have any more likelihood to be genetically normal or good just because it responds so what is interesting when we think about this vault is as we said when we have less eggs less are coming out every month so you're going to start to dump out less eggs and the jar gets emptier what age was I then and what age am I now so we can say that you you know were 30 at one point and now we're starting to get to about age 34 at this point okay what starts to happen just for numbers so at age 30 you're going to have about 20 eggs come out of the Vault every month one EG will ovulate 19 will die next month another group okay when you get to about 35 you're going to have about 14 to 15 so still pretty close when you get to 40 it'll be about 8 to 10 per month 44 closer to three to four per month so you start to see that after age 37 specifically a more rapid decline in how many eggs are remaining therefore less are coming out every month this idea is really for two reasons one is that all women run out of eggs when you run out of eggs you're an ovarian failure also known as menopause average age of menopause is 51 to 52 I've seen somebody have menopause at age 13 so I've seen primary amenorrhea where somebody was born with ovaries that never made follicles I've had women who had their periods and then they ran out of eggs in their 20s so some people are on different Pathways now maybe they were born with less maybe something happened to them along the way to make them run out of them faster so certain things can get in the vault and impact our ultimate egg count so as we already said smoking cigarettes marijuana use endometriosis which we haven't touched on quite yet but we will chemotherapy environmental toxins so certain things can get in here and make us run out of eggs faster what's also important to understand is that the eggs that are out in one month are all the eggs we have to work with so
when we start talking about egg freezing or IVF I can only get the eggs that have been sent out of the vault in that month to grow I cannot tap into the Vault and this is why if you've had friends go through IVF or egg freezing and it sounds random somebody got six eggs and somebody had 24 somebody had to do multiple Cycles or months sometimes in order to help somebody get enough eggs to have a normal embryo what we have to do is multiple months so the 10 eggs that are available this month I'm going to get them all to grow not just the one you are normally going to ovulate take those eggs out of the body and then next month when your body gives me another group of 10 I'm going to get them all to grow again and take those eggs out of the body that is ovarian stimulation for for either egg freezing or IVF trying to say hey in this month I don't want to let any of these eggs die because I need more of them to get the job done or we're running out of time and I'm trying to expedite your opportunity for conception so women have this decline in the total number of eggs you're going to have when you're 37 I think the number is that you have close to 20,000 eggs remaining so what a huge drop from when you started puberty at half million so it's just going down so fast every single month what is also happening is that because these this vaults inside our body when you smoke the cigarettes when you eat processed foods when you get sick if you have chronic inflammation you're losing some but the ones that are here at the bottom they've been here the whole time and so in addition to number of eggs we have to talk about the quality of the eggs because these eggs down here at the bottom once you get older they've been sitting here a long time and that means that their chromosomes inside of them are much more likely to be abnormal than normal and that's really the rate limiting step in people getting pregnant when they're older not that my vault is more empty not that I'm sending out less per month but that the ones that have been sitting here have have been sitting here longer and they aren't as good I I use the analogy for the chromosomes so if we imagine your eggs hold your chromosomes
in perfect position so that they're ready to then go be fertilized by sperm it is like having kindergarteners stand in a line for 40 years somebody's going get out of line and when that happens that increases the rate of genetic abnormalities and most of those do not fertilize do not implant or misc carry at age 40 if you see a positive pregnancy test your chance of miscarriage is 50% because they've been sitting here even if you're very healthy just time and normal life impacts things but there's choices you make that cause them to degrade faster and there's things that you do that might be protective and that is something that we don't ever talk about we when you're 35 your chance of miscarriage is 25% so there's a huge change that happens between AG 35 and age 40 when you're 35 and you start trying to get pregnant so if you and your partner wait and you say everything's good we're going to wait till we're 35 your chances of getting pregnant per month are going to be approximately 10 to 15% per month that's not not very high it's not great not great at 40 it's about 5% per month so we've dropped dramatically and just see the positive test and then if you see it 50% are abnormal so the odds of the body is going to choose from the eggs that are sent out that one month when you're 40 the odds that your body is going to choose one of the two eggs that is genetically normal because six of them are abnormal it's not very probable so most months your body's ovulating one that's not going to have the potential to become a liveborn baby I feel like I better get a move on Jesus Christ it's not information to scare people but it is information that nobody talks about well as you were sat here talking to me about this the opposite of confronting the truth is Regret yes and I can't imagine how much regret you've seen I wanted to ask you about about that regret because you must have to deliver so much bad news to people and you must see the retrospective Clarity that those people suddenly get when they realize that those decisions they could have made earlier especially for people who are not used to not being
in control of things and who just didn't have the data they needed to make the decision there are people who have been with their partner for very long time and maybe kids weren't in the plan earlier but they could have been had they known that it would have been so hard or potentially impossible later on one thing that I think is important to discuss here when it comes to regret is testing female fertility because there is a marker of how many eggs do you have we call this your ovarian reserve how many eggs are left in the vault and one way you can test this is with a blood test called amh or antim malarian hormone and the other way is to do an ultrasound and see how many eggs are outside the vault at that month so both of these are actually quite important when you're thinking about how many eggs somebody has that number does not impact you getting pregnant in one month and I think that that's important because if you have we'll use a whole group you could have a whole group of eggs or you could have less how many eggs is your body ovulating in each group so this person crazy this person who has more is ovulating one this person who has left is ovulating one so if I have two people who are the same age and they have different ovarian reserves meaning they have a different number of eggs left in their vault they're going to send out a different number of eggs each month how many eggs are they ovulating each month one one yes look at me learning look at you so they're each going to ovulate one egg so what are their chances of getting pregnant the same the same so having a lower egg count does not impact your monthly chance of getting pregnant that's determined by age by the proportion of these eggs that are normal or abnormal however if you have fewer eggs there's fewer that I can get to grow with IVF and you have overall less of an opportunity to grow your family this is important because a lot of societies will tell people not to check somebody's ovarian reserve and this blows my mind I have a really hard time with this because they say if it doesn't impact your monthly chance of pregnancy having a low ovarian reserve is only
going to cause undue stress so the American College of OBGYN recommends not checking an amh level in women who are not trying to get pregnant and who are not having infertility I completely disagree with this because you can't make decisions on data you don't know and if you know you're running out of eggs faster you very well might make different decisions you might freeze your eggs you might try to get pregnant sooner you might try to just be healthier if you are doing behaviors that you know are decreasing your egg count you might stop smoking pot but if you're never giving that opportunity you're going to live in the regret category where when you find that out later I wish I'd known this earlier I wish I'd been able to make a choice when I had the opportunity and I had the eggs remaining and so by not testing by not knowing we are hurting more women and I always tell my obgy and friends this conversation should be hand inand with Stephen are you'all trying to get pregnant yes or no no what birth control might you want let's talk about it oh should we check your ovarian reserve to make sure that your time is okay again having a good account does doesn't mean you're going to get pregnant your chance is the same however it means you have more opportunity of time to try to grow that family and ultimately a greater chance of success when it comes to IVF or egg freezing because the factors that determine success are how many eggs you have and how many are normal a lot of people do ask that question they ask um you know they'll say things like well my parents didn't have to worry about this or my grandparents didn't have to worry about getting checked and seeing how big my ovarian reserve is so you know why do we have to all start doing that now we know a lot more now and I think the honest answer here is that one way to look at this is that when I was your age egg freezing didn't exist so I could not have Frozen my eggs and my early 30s had I wanted to meaning would you check it if you really can't offer somebody things to intervene or way to make a change however now we know factors that impact how many eggs you have and we have the ability to freeze eggs with very high success rates now it's accessible in almost all fertility
clinics with really great egg survival so this poses the question of should you know earlier we also have Generations where people are curious and they see things online they're not afraid of scary health information instead younger Generations want to understand their bodies and I love that but there's so much misinformation online too that it's really saying that this is personal we can talk about eggs and ofal every single day but until somebody comes in to my office or somebody else's office to get their own evaluation done they're not going to have the true data they need to make that decision but I think it's great that we are approaching fertility as a health marker trying to look for signs earlier that things might be wrong especially given the opportunity to try to intervene if you find out your sperm counts lower we might be able to try interventions for 3 to six months and see if we can get a new group of sperm that potentially has fixed that problem so say I'm starting out in life with a full ovarian reserve or say you know here's my ovarian reserve at say 20 years old if I start engaging in unhealthy lifestyle choices if I start eating process food if I become obese Etc does that take marbles out of this jar does that take eggs out of my Reserve or does that just damage the quality of the eggs in the jar both both okay so it pulls them out and it makes them less effective the way I think about it is not that it's pulling them out giving them an opportunity but essentially let's imagine it's getting you smoke cigarettes the cigarette smoke is getting inside the Vault it is damaging the DNA and some of your eggs but it's also just killing some of them inside the Vault themselves so that you are running out inside the vault ultimately people who smoke cigarettes go into menopause years earlier than the average age really because they have had a destruction of the eggs inside their vault if I wanted to make sure that my ovarian reserve was 10 out of 10 you know I did if I was to live a perfect life in terms of what my aarian Reserve needs to be healthy how would I live what what what would my daily habits look like that's a great question I love it so what can you try to do because you can't control everything but you should
be able control the factors you can so number one we're going to say avoid toxic behaviors so toxic behaviors that's going to be your cigarettes your marijana cocaine you're going to H not have any alcohol definitely alcohol especially in proportion is showing an increased risk of damage so a drink here or there like that's not studied as well but we know moderate to high drinking levels is associated with reduced egg quality what's moderate to usually considered four drinks a week four drinks a week so if I have four glasses of champagne a week yep so you have four glasses tonight at dinner you've hit moderate that is I mean most people especially in Britain oh well here too and I mean honestly with Co especially we saw so many people increase their drinking substantially so you would limit the toxic behaviors number two is you're going to limit the toxins in your world that you can again if you live in an area that is a high pollution area that just might be where you live but you should not cook in plastic put plastic in the microwave or the dishwasher you shouldn't use teflon on your pans you shouldn't touch thermal paper receipts like at the airport if they print off a ticket for you or a receipt from the grocery store that has chemicals in it itself takeout food so when you order your takeout food and it comes to you and it sits in the containers that it comes in if you're not eating it right away or even when you do eat it you should take it out of that container and put it in something else put it in glass put it on a plate because especially with heat we see leeching of those toxic chemicals into the food and then you're consuming the food even if it's high quality good food it now has absorbed chemicals from the packaging that it was in so microwave meals in plastic you know you take the plastic and you microwave it shouldn't do it how do we we know this have they have they done research on this or is this just so there is research done on it it's always hard to study lifestyle factors in humans and when it comes to fertility because what is the outcome is it the positive pregnancy test the having the baby the absence of getting pregnant that your regular Cycles there's so many different variables you
can look at at an endpoint a lot of the environmental chemical studies are done on animal studies looking at some of these chemicals but also we can see in populationbased studies we do have now where they've done cohort studies mean they take a group of people and they follow them for years taking blood and urine samples to measure some of these chemicals and then watching what's happening with their normal behavior no intervention are they getting pregnant when they're trying to or are they not and we see that greater exposure to these known toxic chemicals are making it harder for people to get pregnant when it comes to other factors to try to have your healthiest Vault possible decreasing inflammation is going to be very important so we think about inflammation and there's two types so you have acute inflammation you cut your arm and it's going to react and heal and that's a normal bodily process but then you have chronic inflammation where your body is constantly spending its energy fighting that inflammatory State and that inflammation markers the prostaglandins the factors in your body that get really high that's actually pretty toxic to our quality as well and that can be disease States as well so things like endometriosis or other inflammatory or autoimmune diseases what um what ways do we voluntarily increase our inflammation is that dietary predominantly yes so number one is going to be not sleeping enough so sleep is when your body heals sleep is when your cells repair their damage so you need to get S and a half to eight hours of sleep per night I heard you say in a sleep is probably the number one thing that people don't do that does impact their reproductive hormone system yes it seems so straightforward to say it's not a pill that you take it is not a major change of behavior it's not missing out on something in your life it is simply giving your body the time that it needs to heal from the normal inflammation that you're going to encounter during the day simply prioritizing getting enough sleep is the simplest things somebody can do to try to improve their reproduction and how their hormones are made and interpreted we talked about stress earlier stress impacts the brain in a
similar way there's different types of stressors very similarly you have your acute stressor the bear you have the stress of everyday life and modern world is a lot more stressful in a lot of different ways constantly we also see that that stress is so individualized so it's not like I can say you need to go to yoga or you need to do acupuncture or you need to go to therapy I tell my patients for stress reduction understanding that having a constantly stressed State constantly may have having cortisol be made is not going to allow your brain to in to interpret the other signals that are being sent it's clouding its judgment and it's going to think that you're not at a place to maybe support a pregnancy and your reproductive hormones are going to show for that what that comes down to is that you've got to modify stress in some way for you so everybody's different and maybe it is acupuncture maybe it is Yoga I I like to sit on the back porch in the morning hours with a cup of coffee and hear the birds people like to go on walks therapy mindfulness meditation journaling everybody's different but you deserve taking 20 minutes every day and dedicating it to something that doesn't have your iPad your cell phone your computer the TV and putting yourself in an environment where you can say like have that feeling of release you get when your cortisol drops that's important so that your body can then properly respond when you do have a stressful situation and can allow you to heal not be under a constant attack diet's going to be one of the hugest things that people can make a change in processed foods refined sugar processed Meats those are not natural foods and those are things that come with a lot of chemicals inside of them a lot of contaminants we know that processed Meats for example type 1 carcinogens all these sugars have a direct correlation with somebody's ability to get pregnant when it comes to the direct cause it's usually going to be sperm quality or egg quality depending on the study looked at what about red meat oh I love that question number one I think it's really important that nutritional studies people qualify meat differently so it might be all meat it might be types of meat so we have to take it with a in
perspective of the limitation of the data we know that process Meats impact fertility we know that red meats appear to impact both sperm production and egg and embryo quality there was an IVF study done and the more servings of red meat you had in a week the less embryos you had developed throughout the process than somebody who had fewer servings so that's telling us that it's maybe not one red meat in general is bad one serving but it's about the amount right everything in moderation nothing in excess we know that the healthiest fertility diet high in fruits and vegetables fruits and vegetables are fiber sources they are antioxidants they are helping our body function appropriately they're helping our gut function they are lowering inflammation I say meat is okay I don't eat meat but that doesn't mean that none of my patients should eat meat I give them this diet because I think you have to make dietary change accessible if I told everybody stop eating meat nobody's going to listen to anything but we know that it's the amount the quantity so I say if you're going to eat an omnivore diet which is going to be the majority of people have a meatless Monday meatless Monday you automatically can do and you're going to have to substitute in some of those other sources of protein that are ultimately better for you fish fish is great we should limit fish to three times per week just due to risk of mercury but fish is a wonderful option it does have a lot of good omega-3 fatty acids in it and ultimately eating more fish and less red meat is such a great substitute what about skimmed milk and fertility I heard uh I've heard you speak a little bit about that past so what's interesting and I think that we've grown up in this you know fat obsessed culture that has prioritized lowfat no fat foods and number one fat is important in the production of steroid hormones estrogen progesterone testosterone are steroid hormones so they need cholesterol the source of that cholesterol is important so we should have those healthy fats the nuts the avocados the oils fantastic healthy fats are wonderful but when it comes to Dairy we've seen that whole fat Dairy is associated with better fertility better
ovulation than the skim dairy products probably due to the processing if we View skim milk as the processed version if I'm going to take out the fat that normally comes in the milk but still want it to retain looking like milk it's not just minus fat right it's minus fat plus something else so in the production process it's that or it's potentially that the only benefit the dairy really has is being a source of a healthy fat option and that when you take out that fat you lose that so I recommend that if you consume Dairy that you stick with the whole fat versions you don't do skim or lowfat and in moderation for for dairy consumption I say that if you do meatless Monday the rest of your meals for the week you should have one serving a meat per day that's going to make you just force you to eat more fruits and vegetables and then one of those meals you should have red meat if you like red meat not multiple times a week and then you should limit processed foods sugars processed Meats all those refined carbohydrates all the packaged things that are totally fake that should be very rare those are your if occasion type of foods not your everyday Foods um the other thing we didn't talk about regarding lifestyle choices is exercise oh yes now there's kind of two schools of thought here because I have some friends who exercise a lot and they have seen a disregulated menstrual cycle yes all their periods have completely stopped um but I also read that exercise is good for fertility this is a great opportunity to just think about how the ovaries work like we've talked about having your eggs but if we think about in a given month you have that group of eggs that comes out of the Vault each eggs in the follicle we already said FS or follicle stimulating hormone is the hormone from the brain that goes and stimulates that one egg to grow as that egg grows the follicles growing and making estrogen that process takes approximately two weeks in the majority of women and when you're estrogen level gets high enough it tells the brain you have a mature egg your brain doesn't know what's happening in your ovary it can't see I always say it's like having your best friend who doesn't go on Instagram they have no
idea what's happening in your life unless you tell them so the only way that the ovary communicates with the brain is actually through the production of hormones so as that one follicle is starting to grow it is making estrogen and that estrogen is then telling our brain we have a follicle growing that follicle then is going to open up it bursts it ruptures and what's a follicle sorry oh a follicle is if we can imagine this is a follicle the egg is microscopic inside of it it is the fluid filed structure that keeps your egg so for people that are are just listening and not can't see yes you're holding one of the little eggs in your a marble I'm holding a marble so if we can imagine a follicle is a small fluid filed structure in which the egg is kept okay so the eggs inside the follicle exactly and so the follicle gets bigger as the egg gets more mature sure it makes more estrogen that estrogen at a high enough level and it's very specific 200 PS for 50 hours tells the brain you have a mature egg the brain will then send out LH or lutenizing hormone it allows that follicle to open up then the egg is going to be released and hopefully get captured by the fallopian tube so it'll be sucked up into the fallopian tube but that fle reforms so the egg is gone the follicle reforms and it becomes a cyst in your ovary called the Corpus ludum and it is now stimulated by LH from the brain telling it to make progesterone okay and what am I going to do with the progesterone progesterone opens and closes the implantation window without progesterone a pregnancy cannot implant into the uterus so this progesterone is going to allow your body to have that egg if it becomes fertilized and develops into an embryo the egg gets fertilized in your fallopian tube it has to grow and develop into a stage of an embryo so the SP comes along sperm swim through the uterus into the tubes and that's where fertilization happens okay so the sperm comes through the fallopian tube it meets the egg which is chilling there chilling there and then what happens then well hopefully fertilization happen which is like the sperm which is like the tadpole's head hits the egg it's the egg it actually has a little fusion reaction and pushes its DNA in there pretty cool it then has to grow and develop so you have a single
cell egg a single cell sperm they come together you have two different DNA components and then you start seeing cell division just like you would expect exponentially two cells four cells eight cells 16 cells into the point where on day five or six that embryo is now a what we call a blasticus it's 300ish cells and it is now at the stage where it can implant into the uterus what is so interesting is that most your eggs are never going to fertilize they're not going to grow appropriately they're not going to get into that uterus but what's so important is that if an egg is coming in or the embryo is coming in and there's not just the right amount of progesterone it cannot implant that's really important because that's the mechanism behind a lot of birth control but when you think about progesterone starts being made from this Corpus ludum perfectly timed after you ovulate to open and close that implantation window so that when the embryo gets there it's ready and if the embryo doesn't implant hangs out too long it's going to close the Corpus ludum only lasts for 2 weeks if it is not supported by a pregnancy meaning if we pretend this month you don't get pregnant you're just having natural periods then the Corpus ludum after two weeks it dies your progesterone levels are going to drop and that's the signal to your uterus to shed the lining in preparation for the new group of eggs that's your body saying we did not get pregnant this month let's try again when a pregnancy implants that embryo makes a hormone called HCG which is what we check on a pregnancy test and HCG can stimulate the Corpus ludum to keep making progesterone and that is what allows you to sustain an early pregnancy until there's a placenta the point of thinking about that which there's a lot to go into about optimizing intercourse and trying to get pregnant is that things that disrupt the brain's interpretation of estrogen is going to impact your ability to sense ovulation or to ovulate and going to lead to menstrual irregularities or absent periods like you mentioned in some of your friends who exercise maybe more frequently so on one end of the spectrum if you are intensely exercising you're training for the Olympics you're an elite athlete
your body is going to stop sending out FSH and LH altogether it is going to say that the calories you're receiving to the energy you're expending do not match up and you cannot support being pregnant with another human so it is going to stop the production of FSH and LH and you're not going to ovulate you're probably fine because you're training for the Olympics and you don't want to be pregnant right now this also happens though with eating disorders anorexia for example we can see that I will say when the brain is turned off when your brain has decided that you can't be pregnant right now it takes years of being in recovery for it to turn back on it has to be convinced for years that the system system is going to be intact again in the part of the brain that controls if FSH and LH are released from the pituitary called the hypothalamus so we call this hypothalamic dysfunction I like to think about the hypothalamus as the you know airport control station they're watching the planes come in and sending out other signals it is interpreting what your body is giving it and then it's directing what is happening estrogen is also made from fat cells and this is one of the reasons why being overweight is so impactful when it comes to your reproduction because if your body is making extra estrogen your brain thinks an egg is on the process of growing so it's because right the brain thinks estrogen's only made from an egg so if it sees some extra estrogen because you're obese it's not going to send out a strong enough signal to get an egg to grow because the brain wants to send out just enough to get the one egg to grow it doesn't want 20 eggs to grow so if it sees that estrogen it's going to say ooh an egg's already growing I'm going to send out less but there is no egg because you're overweight it's the fat cells making estrogen and so exercise comes into this play where exercising if you're overweight can be extremely beneficial for your fertility because if you lose weight you drop that Baseline estrogen level down and now your brain can more clearly interpret this signal from the ovary so suddenly your system is back in check same thing for men estrogen when men are overweight Coes to the brain and
the Brain estrogen and testosterone are on the same conversion pathway so the brain says oh Steven's gained some weight I I see his estrogen he's making enough sperm we're good and it's not going to tell you to make as much testosterone or as much sperm as you need and then you get on this pathway where you have less energy because your testosterone is low but you're gaining weight and you can't get that testosterone higher you go to The Men's Health clinic and they're going to draw your blood and your testosterone will be low and they're going to put you on that trt and now your sperm Count's going to go to zero so sometimes that entry point to the whole problem was having extra fat tissue so exercising to lose weight can be very beneficial for your fertility for men and women there's a lot of talk on hit exercise or moderate activity and for the regular person whatever you will stick with is the best if you're trying to get pregnant you should not be trying to stress your body to new goals training for the marathon doing something if you think going going to the gym every single day is that too much no I usually say going to the gym every single day if we think about 60 Minutes or Less is a normal amount of inflammation from your muscles that is good your body should encounter some challenge along the day having more muscle is also going to help combat insulin resistance and other issues that come in and interfere with our brain's interpretation of our hormones as well so we see that both overe exercising and not exercising are the extremes that are not going to be helpful for you but moving your body in addition to helping your hormones function better less chance of becoming overweight better interpretation by your brain of your body's signals it's also a great way for stress coping and lowering your cortisol levels so exercise we should put there right up there with the top thing somebody can do get more sleep exercise every day you mentioned menstrual cycles there and how they can be disrupted for long periods of time um my partner shed quite openly um on her social media channels her battle with this and she I think she had a couple of dietary changes she had some struggles with eating and that resulted in her period basically stopping for I think three or
four years um it's returned after sort of three three or four years and she's very happy about that but um lots of people are going through irregular period Cycles irregular menstrual cycles what can you say to this I mean what is what is quote unquote normal as it relates to a normal healthy healthy menstrual cycle into people that are struggling what what would you advise them and what would you tell them I love it a normal period is one that is regular and predictable so I'll tell a patient you can look at a calendar and you can say within a couple days of certainty when you're going to have your period now each individual person is going to have a different cycle link length meaning the day from the start of your bleed that's day one of your cycle until the last day before your next period bleed you'll hear 28 days used a lot that's not the average for every single person usually it's going to be between 24 to 35 days for the average person can you explain this to me like I've never heard of a menstrual cycle before what is it what happens so the menstrual cycle is essentially what we've talked about with our whole eggs right so you have your group of eggs come out the ovary each eggs in a follicle brain sends out follicle stimulating hormone that egg is going to grow develop and ovulate that's going to put you a couple weeks into your menstrual cycle from there it's going to then make progesterone get you into that back half of it that ludal phase because the Corpus ludum is always set at two weeks and then when you're not pregnant you're going to bleed so bleeding is the shutting of the lining that's your period your ovaries are doing something different throughout that process so while you're bleeding and on your period period your ovary is already starting to grow the egg that's going to ovulate in that month and as that egg makes estrogen that's what stops you from bleeding okay so when you have your period That's the shedding of the lining from the last month because you didn't get pregnant and growing an egg this month once there's enough estrogen is going to stop that process and stabilize that lining okay so typically when you if if there's no other interventions if you don't have your period it's because you're pregnant because you're pregnant
or you didn't ovulate because you have to have that progesterone drop as the signal for your body to bleed exactly so you either problem a I didn't ovulate so that is either I'm out of eggs I don't have any eggs to ovulate or my brain didn't send out the signals like we said hypothalamic Amara that's often that OV ex exercising or that calorie restriction or chronic illness stress stress sometimes I I like to think about that one often more as hypothalamic dysfunction like irregularity versus absent but yes stress and then we've got pituitary end thyroid disease prolactin these are hormones from the pituitary gland which is where FSH and LH come from and if your pituitary sends a lot of energy to making thyroid stimulating hormone it's not going to send out FSH quite as well and then you have polycystic ovarian syndrome which is going to be one of the most common causes of female infertility and of irregular periods and that is when your ovary and your brain have a miscommunication and so when we talk about irregular Cycles because we should dive into PCOS what we're saying is that for one single person it's not occurring at this regular interval for them so maybe it's 25 days for Jill and 30 days for Mary and 34 days for Susie but each of those people should be able to know when her period is coming the fertile window for all of them is this is different and that's why apps and cycle tracking can be really problematic because what the fertile window is is going to be the 5 days before and then the day you ovulate so an egg lives for 24 hours the five days before you ovulate okay okay so the 5 days before you ovulate and then the day that you ovulate the egg lives for 24 hours it has to be fertilized while it is in the fallopian tube in those first 24 hours sperm can live in the female reproductive tract for 5 days so that is why we will tell people to have sex before and then during ovulation put some of that sperm from the locker there a little bit earlier and then get some there right right at the time when you're ovulating to see if you can fertilize that egg if we think about understanding when your fertile window is based on your cycle length so if we say your cycle is
the the entire process and then your period is just the bleeding days the entire process if your Cycles are on average 28 days the Corpus ludum lives 14 days so 28 minus 14 you on average would ovulate on day 14 so the 5 days before and then day 14 are going to be your most fertile days to try to Target intercourse or avoid if you don't want to be pregnant and if your Cycles are 35 days though it's very different right because now 35 days minus 14 is going to be 21 here you go 21 so your fertile window or for that person is going to be cycle day 21 so now the 5 days before and day 21 those are very different fertile Windows days they should be having sex it's a lot isn't it do we just have sex every day if we can so absolutely like if you can have sex every day or every other day and you don't have to track your Cycles if they are coming regularly and you're putting sperm in the presence of the egg by every day or every other day sex absolutely and that's one of the things that I see people do wrong the most is have less sex in the idea that they should save it up to put more sperm present when the egg is arriving I have to say I mean there's a few things I wanted to say about this so I think what's the first thing I wanted to say the first thing I want to to ask is how long on average do different age groups need to try before they hit the Bull's Eye if you're age 30 and you're trying to get pregnant you have a 20% chance of pregnancy per month okay this means that the majority of people should be pregnant within 6 months infertility is defined as trying for a year and not getting pregnant within that year so kind of going off the curve of that standard deviation importantly trying to get pregnant means that you're having intercourse you're ejaculating inside and you're having regular periods if you're not able to complete the active intercourse and you're not having regular periods people should not wait x amount of time to come see a doctor you should go be seen right away when my friends tell me that they've started trying I always think God that doesn't doesn't that just ruin the fun you know what I mean because I have this one friend who was telling me that um because they're trying now sex has become such a like chore like a chore
and if he's away when she's most fertile then she gets annoyed at him and I just think God it's so crazy what's happening with sex in that regard that it's we're now because we're having kids later and later and we're leaving things a little bit later than ever before we're now having to treat making kids almost like as you say like a chore it's becoming like I don't know there's something about that I'm like oh gosh like well it's a point because if you're waiting later and you still want to have more than one child there's a lot of pressure on it if you're starting at 35 and you have that 10 to 15% chance per month if you're starting at 38 and now it's 5 to 8% per month if you're 40 it's 3 to 5% isn't pressure like the opposite of sex right it doesn't sound very fun I think that one having realistic goals is helpful because if you're trying to start your family at 37 and you want four kids it is very unlikely to happen without intervention like IVF saving embryos for the future which we can absolutely do and we do that for people sometimes so that they can go have fun with their sex life again two you feel like you have to track your cycles and time intercourse appropriately when you're older because there's so much that you can't do right you only have so many eggs you only have so much time and you're trying to do what you can understand your cycle tracking for a woman is a reflection of her full health how's your brain interpreting your entire body so it is helpful because if you have irregularity it is a sign that things are not working normally that being said regular sex is good for so many reasons and in a relationship that if you can establish sex more frequently as just part of your relationship it becomes less burdensome that you're here recording a podcast at this time or somebody's out of town this one given month if we remember that sex or if we remember that sperm live in the female reproductive tract for up to 5 days most of sperm is going to live there for two to three days so five is kind of like the longest it can what we have is that okay have sex two or three times a week what what about couples that can't because I I've sat here and interviewed so many sex therapists and sexologists if that's even a thing and we often speak about sexlessness people having
sex less and less than ever before because they're so busy and they're so stressed in their lives and you must meet so many couples in your practice that you know you you look at them and go well really the problem here is you're just not having sex with each other 100% and sometimes it's situational truck drivers Pilots there's just a job where it is too hard to have that intercourse during the fertile window but then also yeah High performing people or who just don't prioritize or don't enjoy that part of the relationship we certainly do what we call IUI or intrauterine insemination and this is where you take the sperm and you're putting it inside the uterus so instead of intercourse we are taking an ejaculated sample and then processing it and putting it in the uterus wait so yes I could just ejaculate in a Petri dish get get a little pet and I mean you can't do it yourself but why Well because most of the ejaculate of your sperm is actually meant to protect the sperm from the acidity of the vagina so most of that is not ever going to see the inside of a uterus and if we put the whole sample up in the uterus it would cause a huge inflammatory or infectious process but if we clean that sample and we pel it out centrifuge it and get just the sperm we can then put the sperm into the uterus and avoid having all that protective ejaculate sample with it you must hear couples doing this kind of thing people do the craziest things tell me about some of the crazy things people do crazy things I mean definitely people are having intercourse and then they're putting they're putting tampons in afterwards to try to keep the sperm in place or diaphragm cups people are trying to get their own versions of pipets or turkey basters right that's what people call it and try to pull up sperm and put just put in their vagina the craziest stories of sperm procurement come from people who are using donor sperm as you may not know there is an entire like dark web of sperm donation being connected on Facebook groups and other places is where people are not going down traditional roads of using a sperm bank a sperm bank pros and cons but if you're using sperm if you're using donor sperm a sperm bank is going through a process to make sure there's
no infectious material in there that the information is tested that there's limitations But ultimately like legally too that that is your sample these Facebook groups people are just connecting where you can meet in a Walmart parking lot and drop somebody your sperm out of the goodness of your heart so that they can get pregnant and there was a case in Oklahoma where there was a lesbian couple who wanted some sperm in their relationship and they felt like going through the fertility clinic or buying donor sperm from the sperm bank was too expensive because it is expensive and so they found a sperm donor how much is it roughly for some I have no idea so purchasing a violet sperm itself is about $1,000 and then each cycle goal with a clinic to kind get the sperm inside is typically going to be $1 to $2,000 so that's for each month you're going to look at 2 to 3,000 and your chance of it working is based on your age so if you're 35 it's about 10 to 15% so you're going to need to do it numerous times so this couple in Oklahoma they found a sperm donor on a Facebook group went and conceived a child and despite having some paper document they signed saying that he gave them their rights he sued for custody of that child later and and won so they now split custody with their sperm donor and I think that this is why he changed his mind he had who knows well he didn't get he didn't get paid for this right so it was out of the goodness of his heart he just met them and gave the sample so part of the issue too is that it's not a exchange of a service for for a fee or a good right it's just you're giving the sperm so I believe in that case he said he interpreted that was the situation and they said of course it wasn't but when we look at Family building a lot of people are using what we call third party options so donor X donor sperm gational carriers donor embryos even and there's a whole world to go into there but protecting somebody's parental rights is one of the top things that I'm always thinking about when it comes to helping them grow a family we were talking about PCOS yes what I've I've got a very close friend of mine that struggled a lot with PCOS and I've been there with them um as they've been diagnosed and as they've kind of battled with that over the years but I'm aware
that a lot of people struggle with PCOS I think it's up to sort of 20% of the population so officially people will say that it's about 10 to 133% of the population but that's 70% of people who have PCOS are undiagnosed so much higher than either of those numbers you I said is going to be the real number and what is PCOS there's a couple different ways that PCOS presents so how I like to describe PCOS in essence is being born with more eggs in your Vault okay so if you're born with more eggs in your Vault you are going to send out more eggs every single month right because you're sending out eggs in proportion to how many you have why do you have pcus likely this is due to something your mother did when she was pregnant with you or something she was exposed to because you didn't have that normal decline in eggs from 6 to 7 million at 5 months to 1 to 2 million at 9 months so you have more eggs more eggs come out of the Vault every month the brain doesn't know you have more eggs so it is sending out the same amount of FSH as it normally would for a normal egg count but that FSH is getting diluted amongst the more eggs that have come out if we can imagine the same signal is going to 20 eggs or it's going to 30 eggs so FSH is the thing that basically picks the egg yeah it's like food for the egg okay the thing that selects the one egg and gives it um Waters it like a plant exactly so you have the same amount coming but there's more eggs eating it so nobody's getting a strong enough signal to grow reliably predictably meaning you're not going to have that regular predictable cycle when an egg grows that's when your body makes estrogen that's when your ovary makes estrogen and the ovary is a hormon producing Factory everybody thinks about the ovary as oh it's what makes the eggs but its real job Its Real Love Is to make hormones it makes estrogen as it grows the egg it makes progesterone after you ovulate if you have too many small eggs come out of the Vault there's not enough FSH to stimulate any of them the ovary is not making estrogen and it gets bored so what happens is the pathway to make testosterone becomes upregulated it starts making testosterone in its boor time what testosterone does in women
with PCOS is it then increases the risk of insulin resistance it increases abdominal weight so not that maybe like female body shape we think about like weight on the hips and thighs but more of that man beer belly style abdominal weight you also then are going to have increase in acne facial hair and then even male pattern baldness so you start to see that you have these Androgen symptoms that are negatively impacting quality of life immensely and then as you gain weight the estrogen confuses the brain and it sends out even less FSH so you get into to this really cyclic pathway where the insulin resistance and the testosterone change your entire body's metabolism but you're not going to go in and make yourself have less eggs so how do you combat PCOS one way from if you're trying to get pregnant is to try to give medications that have the brain send out a stronger signal of FSH so you might have heard of medications like Clomid or lrel these medications tell the brain to send out more FSH so in essence that's what we call ovulation induction helping somebody ovulate by having the brain send out a stronger signal but what we try to do if you're in this PCOS pathway is break down some of the production of testosterone from the ovary stop that cycle and try to see if you can reverse back into having healthier normal Cycles so sometimes that's from medications like metformin you can have spironolactone which is a medication that stops testosterone produ ction this is why women with PCS are given birth control pills because birth control pills one can come in and provide estrogen and progesterone but two they also make something in the liver called sex hormone binding globulin that binds to testosterone drops your testosterone levels and clinically they make you feel better your acne goes away some of those Androgen signs go down and it can help break the pattern and I see that people with PCOS when they come off the birth control pill they actually ovulate more regularly at the beginning and then it starts to get worse as more time goes on as their androgens start to rise back up to their Baseline because the birth control pill was keeping them down so focusing on some of the other factors that really influence insulin resistance
and hormone production and PCOS PCOS patients I always tell my patients it's it's like a teeter totter of balance meaning when you're too stressed or or you're exposed to something it can tip your hormones into not ovulating so you have to view that system as just very sensitive extra stressors like the cortisol that's coming in really influence people with PCOS a lot as does being overweight and that's why there's a lot of information on trying to encourage PCS patients who are overweight to lose weight importantly not all women with PC are overweight you definitely can be thin be born with a lot of eggs inside Vault and have the exact same problem and I want to stress that some people even if you live the healthiest life you don't ever see inflammation you're not stressed but you have PCOS it's a disease and you may not ever get to a place where you can reliably or regularly ovulate in your reproductive years that you're wanting to and that's not your fault it's not a failure of you it's not your fault some people truly do need intervention to try to help them get pregnant and there's interventions are freezing their eggs IVF those kinds of things yep ovulation induction freezing your eggs IVF when you scan the ovaries can you see PCOS mm PCOS is diagnosed by having two out of three criteria so number one seeing a lot of eggs on ultrasound yeah number two having high Androgen signs so whether it's a blood value of testosterone that's higher than a normal female should have or just having acne or hair growth M and then then three is irregularity or absent periods so two out of the three of them so if you have irregular periods and acne you've met the diagnostic criteria what causes PCOS you talked about maybe it's something your mother might have done but there's a lot of thought that PCOS is largely genetic or epigenetic meaning that when you're a baby inside your mom that that environment influenced a lot of how your OV is going to function later and there's a huge correlation between different exposure or whether it is insulin resistance and pregnancy and then women being born later in life with a higher risk of PCOS certainly you can back into PCOS by by being overweight and what I mean by that is often patients will present they'll
be diagnosed with PCOS but the ideolog is a little bit different if you're very obese that fat is going to make estrogen the brain is going to send out less FSH you're not going to be ovulating because it's not a strong enough signal and the ovaries are going to start making testosterone because they're bored so you have a PCOS presentation but that mechanism is not really necessarily having a large number of eggs in your Vault when we have syndromes we have to remember polycystic ovarian syndrome syndromes are based on the symptoms you present with so often syndromes do have different Origins for how they present is there a way to completely heal from polycystic ovary syndrome for some people yes but have you seen that yes I have seen people but most of it correlates with an all women at some point you're still losing eggs every month right so at some point you are going to get to a number where the eggs that are coming out of the Vault are a number that the brain is going to respond to so what's interesting is I'll have people say I cured my PCOS and I say well really you just are age 38 and at this point you don't have enough remaining eggs to to ca cause this dysfunctional problem anymore the eggs that are coming out are now responsive to your hormones yes they did do lifestyle changes and improve things and probably made it so that their ovaries could respond to those signals so I think it goes together but PCOS women still go through menopausa the same age they're born with more eggs and they go through menopause at the same age so what's happening is they're simply just losing eggs at a more rapid Pace because they have more and what impact does that have on your ability to get pregnant when you have more eggs and number one is what we call an ovulation so the irregular periods or lack of having a period altogether that is one of the top causes of infertility and certainly PCOS is the top cause of that it's important to say that not having a period is not normal so if you're taking birth control or contraception we'll just put that in a different category for a minute but if you're not taking any hormones and you're not having a period it is extremely bad for your health on both ends and what what I mean by this is
It's either because your body has PCOS and has all of these little follicles making a tiny bit of estrogen each day and in that scenario you're not making your normal hormones but also you're at risk for metabolic disease high blood pressure cholesterol diabetes but also that constant estrogen production even though it's not high levels but it's enough to confuse the brain is stimulating the lining of the uterus to grow and if you never ovulate you don't make progesterone so there's never the signal to shed or to bleed the lining cancer cancer so endometrial cancer is a very significant risk in women with PCOS who do not have periods and this is why you will see people come in and say that you need to take progesterone or you must be on birth control pills because we've got to give you that progesterone in some form or fashion to bleed off those cells so that they don't develop into cancer so there must be a pretty strong link then between PCOS and in demetrial cancer uterine cancer yes if you think about the other end of when people are not having periods so I'm exercising and I lost my periods for 3 to four years you're not making any estrogen during that time your brain shut off those FSH signals the ovary never made estrogen from those eggs and having low estrogen is detrimental to your long-term Health we see this even when women go through menopause at the normal age right suddenly you now have an increased risk of heart disease stroke osteoporosis dementia Alzheimer's once you've entered menopause because estrogen was protective against all of those if you had that estrogen or that lack of estrogen even earlier in life those risks especially bone disease osteoporosis hip fractures later in life they can be extremely high so it's very important that women know that if you're not having periods that it's harmful for your full body Health very often I see young women their 20 say I'm not having a period but who wants to bleed every month anyway so not a big deal but their brain's not functioning as great as it can having estrogen helps the brain think sharp and be productive and if you're constantly lacking estrogen you're going to be fatigued feel cloudy you're not going to feel like yourself replacing
estrogen in somebody whose ovaries are not making it whether it's because the brain's not sending the signals to or you're simply out of eggs early replacing estrogen is extremely important for your quality of life and your longevity you mentioned a word earlier that I've not heard before endometriosis endometriosis yes what is this endometriosis is essentially an inflammatory autoimmune condition so we already talked about I've said endometrium a couple times do you know what endometrium is no so the endometrium is the lining of the uterus so it is what grows in preparation for that pregnancy to implant and it is what bleeds when somebody has a period you're shedding the endometrium okay so it's that inside portion of the uterus in every single person they bleed some of those cells are going to migrate out the Fallopian tubes which is pretty normal if you can imagine the uterus is Contracting it's squeezing some of those cells are going to migrate out and in cells from the endometrium endometrium some of the cells from the endometrium in addition to bleeding as that uterus is Contracting you know the tubal opening to the top some of the cells are going to come out the Fallopian tubes and that's that's normal okay so if I go and do an appendectomy I take out somebody's appendix while she's on her period I'm going to see menstrual blood in her abdominal cavity and that's totally normal what is abnormal about endometriosis is that your body has an abnormal reaction to that and instead of saying oh Natalie's on her period no big deal your body would say oh my gosh there's blood in here it's foreign cells attack attack attack and so it becomes a process where every time a woman is on her period the body starts to attack these cells and then because it is endometrial tissue it's responsive to estrogen so it grows with every ovulatory cycle every follicle you make it's characterized by inflammation and inflammation is what causes pain so very painful periods is the Hallmark of the disease although importantly not everybody who has Indo has pain pain with intercourse is another one especially in certain positions so not pain with like insertion or penetration but but deep pain so he's like oh the
classic is when a patient will tell me I don't like being on top it's painful inside because of the angle that intercourse is happening it is where she has these implants of endometriosis inside her body these inflammatory implants endometriosis because it causes inflammation makes the environment more toxic so the number one way that all autoimmune disease is contributing to infertility is by this inflammatory process which is just toxic to cell growth and toxic to early embryo growth and we see infertility rates and higher miscarriage rates in Demetrio is as inflammation lives there can also turn into scar so you can have destruction of the internal anatomy and total blockage of the flan tubes so it can go from an inflammatory process to also a complete destructive and obstructive process it is only a surgical diagnosis and that's one of the hardest things is that you can't just say I'm going to run a blood test and see if you have endometriosis we don't know what markers to cheuck in your blood yet so the only way to diagnos the disease is by looking doing surgery putting a camera in somebody's abdomen and physically seeing these endometriosis implants the hard thing is sorry just on the point of surgery where does the camera go in the camera goes in through the belly button so that's called laparoscopy so you put a camera in through the belly button inflate the abdomen and you can go and see what is going on and so somebody who's got very significant pain your period pain should not impact your quality of life to the point that you want to cancel plans not participate in your normal activities if you're canceling dinner not going to school those are not normal findings and if that is the level of pain somebody is experiencing I'm very concerned that she could have endometriosis many people don't ever go to surgery and get that diagnosis and that's okay too if we think we have it or your doctor's approaching it in a certain way because by the time that you can even diagnose it the damage is done the inflammation is there you've been living with it and one of the hardest things for us with endometriosis treatment of the disease there's treatment but I have to stop you from ovulating because estrogen will
always stimulate even if there's one little cell so if you're trying to get pregnant you have to ovulate so the treatment for the disease does not allow you to get pregnant and be treated so if you stop that and you're trying to get pregnant each ovulatory month the disease is progressively getting worse so it's one of these places where it is very tough because we don't want people suffering in pain but also getting pregnant is so difficult in those circumstances in prevalence of endometriosis we say is about 10% of all women in fertility clinics patients with infertility it's a 30 to 50% prevalence so in my mind there are a ton of people walking around with endometriosis or inflammation who do not know that they have it this is why that falls into the category of sometimes what we call unexplained infertility somebody has regular periods because endometriosis does not impact your period pattern it might cause pain but nothing about that process is interfering with your brain and your ovary communicating and your ovulatory pattern so you're still having regular periods and you're having sex even if it's painful but you're not getting pregnant that there's something else going on and so a lot of patients with endometriosis end up having to come to the fertility clinic and many of them end up going through IVF because it is one of the only ways we can change the environment of which EG and sperm meet is to allow them to meet in a non-inflammatory environment in an IVF lab I can then drop your inflammation and treat your indom rosis and then put an embryo back inside because I don't need you to ovulate as a part of that process so IVF controls So Many Factors at once because I take the eggs I grow them I take them out of the body now I can fertilize them in the lab in that perfect environment with the perfect temperature and pH grow that embryo I can then have you have a period and suppress your endometriosis I don't care that you're not ovulating now cuz I can give you some estrogen and grow the lining and then just put the embryo back in at the right day and I can see wonderful success rates with that with patients with endometriosis just on that point you said about you'll give them a
medication that suppresses the cycle and but it stops the pain could you be on that medication for say 5 10 years and then come off it when you want to get start getting pregnant yes and no one thing that's very interesting so a good example of one medication not our drug of choice but one thing that's used for endometriosis is the combined birth control pill the birth control pill is estrogen and progesterone if you're taking that pill your brain is no longer ovulating because it's seeing estrogen and that's not the same estrogen that the ovaries make so it's not the type of estrogen that stimulates those endometriosis cells women who've been on the birth control pill for prolonged periods of time do not have diminished fertility when they come off of the pill and in fact most of them have higher fertility rates than their age Rel ated peers who were never on the pill and if we think about it the hypothesis is that if you suppressed ovulation for 10 years versus your best friend who didn't and you both had endometriosis you are now starting your ovulatory cycles and you put a pause in the development of your endometriosis it's not going to get rid of it no medication's going to reverse the process or treat it per se like cure it but we can halt it from getting worse and so if you're on the birth control pill or you're on a medication called Lupron there's some different options that essentially stop the body from ovulating therefore you're not progressively letting that Indo get worse and then you do have higher rates of success when you come off of that than people who are your age who weren't so that's one strategy if you know you have it you have to know you have the disease or have a high suspicion that you do in order to be preventing ovulation all those months someone comes to you and they've been diagnosed with endometriosis what is your first sort of Port of Call for them what's the first piece of advice you you'd give them or the first suggestion you'd make medically or otherwise yeah so for real honest talk about how old they are how many kids they want we know that women with endometriosis run out of eggs at a faster pathway because endometriosis is inflammatory and destroys the eggs
inside the Vault so you're going to run out of eggs EGS faster I want four kids how old are you I'm 25 that's okay so when do you want to start trying to have them let's say 30 say 30 and you want a large number of children well I want to know how everything is Right This Minute right so we're going to check your ovarian reserve we're going to make sure that we're not already on a pathway of accelerated destruction because if we already have a low egg count now now is the time to intervene egg freezing or embryo freezing meaning taking some of those eggs out so I can save them for later when I know you're going to have a hard time also setting different parameters for the Endo patient I don't let somebody who has endometriosis just pull the goalie and try when they're ready to get pregnant I'm going say we know you have something that increases the odds that you're going to have a hard time so are your fallopian tubes open how is your partner sperm I want that data before you start trying to get pregnant the traditional mentality to infertility is so reactive you have to prove to me you have a problem before I go and test it that's the classic mentality you got to try for a year before we'll go test these different variables of course we're challenging that narrative and we're saying no go get tested beforehand but an endo patient is 100% somebody who should same with the patient with PCOS you're not an average person on the street you have a medical diagnosis that is significantly associated with infertility you need to approach roach your family planning Journey differently you need to test all the variables we can before you start trying to conceive and we need to have an honest talk about your family size because if you want four kids and you start at age 30 and you have no problems and you have your kids really closely together so you what 30 32 when's your next one 35 36 when are you having baby four you're you're pushing 38 to 40 and we know that rates are going to be harder because you're going to have more genetically abnormal eggs at that age so a lot of people don't even talk about this stuff do they like in terms if you use that word Family Planning I think really that's at the heart of what's missing here is we don't do Family Planning we do like
family reaction yeah we're like oh crap no family and then oh my God I want to have a family I want here's what I say to somebody who has will say PCOS or endometriosis and they want to have a bigger family and they're not quite ready to start but let's say they have a partner this is the perfect opportunity to do what we call embryo banking so it's very similar to to egg freezing but it's IVF so it means right now I'm going to get a group of your eggs to grow we're going to go through the IVF process IVF is in vitro fertilization so one month's group of eggs I'm going to get them all to grow people with PCOS are fabulous candidates for this because they have so many eggs the ROI on that investment is very high because number of eggs and age are the two most important factors I'm going to get that month of eggs to grow I'm going to take them out of the body I'm going to fertilize them with sperm grow out embryos and I can do genetic testing to see which ones are chromosomally normal and they can stay in the freezer until you're ready for them what well I can what I can you can put fertilized eggs in the freezer yeah those are embryos you can put embo embryos in the freezer yes sir and that is going to allow us to change the trajectory of somebody who wants four kids and isn't starting till 2 33 because now naturally having that fourth baby becomes statistically very unprobable in order to have four children most people will need to start before age 28 now that's not everybody but most people so if you want that big family because that's like we said a child to person it's a whole different life you're going to have with that person in it then we need to say hey well that's a lot easier to go through IVF right now freeze those embryos then start trying to get pregnant what's the difference between me freezing eggs and sperm versus freezing the embryos so this is a good point so freezing embryos even if you're going to try to naturally get pregnant later is helping you know that you can tap into those embryos you know later in life so versus doing IVF at age 39 where you have less eggs and the vast majority are abnormal you're making those embryos now where they're much better the process for the woman is exactly the same whether you're freezing eggs or embryos you are taking shots of
FSH to get one month's group of eggs to grow that takes about two weeks and then we do a quick procedure to take the eggs out of the body under anesthesia so none of that is different what happens is the differen is in the eggs I always say if you're freezing eggs it is not an insurance policy on your fertility an insurance policy pays off when something bad happens this is an investment you're playing the stock market is it smart to put your money in Investments does it usually pay off well it depends on the environment when you go to pull that money out eggs are potential opportunities it's fantastic and it's much better than nothing but it's not giving us all of the information because even if the sperm looks normal and even if the eggs look normal the real proof of the pudding is seeing how the embryos grow and develop because not every egg is going to fertilize become an embryo or be genetically normal and even every genetically normal embryo is not going to become a baby so if I take an average person who is age 30 and let's say we get 20 eggs from going through egg freezing that is fantastic you feel super egg Rich that sounds awesome now if we make them into embryos or when we go make them into embryos you do often lose some eggs in the freeze thaw of the eggs eggs are a single cell mostly filled with like liquid like water and then DNA and embryo is 300 to 500 cells when we freeze it so embryos are much much stronger they survive over 99% of the time egg freezing I told you earlier it wasn't available 10 years ago when I was your age because eggs didn't survive the free we were trying it but they're so fragile it just took a while to get the tech there eggs now survive 90% of the time going through the free saww which is great way better than 40% but it's also not 100 so we have to kind of account for that loss in our equation so if I have 20 eggs now I go to thaw them whenever we're ready and now I have two that don't survive so I have 18 I'm going to go inject them with the perfect sperm and I would have on average fertilization rates of about 75 to 80% so let's say 14 of them fertilize half of those are not going to make it to an implantation stage embryo even if everything's perfect so now I have seven that have made it to an implantation
stage embryo and then my proportion of normal is based on my age so if I'm 30 I'm pretty good because i' about 60 to 70% normal if I'm 35 it's about 50/50 if I'm 38 it's a third normal if I'm 40 it's about 20 to 25% normal so you can see how that number of eggs that you have and the outcome differs for the 30-year-old the seven embryos if everything falls perfect she should have four normal embryos but that's if everything falls perfect and what if it doesn't what if our ferti I ization rates are lower or not as many embryos grow through the process average means that some people do better than average and some people do below and we don't know that about an individual couple until we put them through the process how many embryos can I put in the freezer you can put as many as you want if you're trying to optimize your chance of success you're going to want two to three genetically normal embryos for every child that you want to have in the future one genetically normal embryo put inside a body has a 65% chance of live birth and what a is there an age component to whether the embryo will be successful so if if my partner put one of those embryos out the freezer into her at 45 are the odds still the same up until 45 yes after 45 you start to see a decline but still ultimately quite successful I need to get some of these bloody embryos in the freezer yes so cumulatively after two embryos are put inside not at once so I put one transfer or you're not pregnant and then you do the second one 88% of people have had a live birth and after three uplate embryos it's 95% of people 95% of people that means that the number one reason why people don't have success with IVF is they don't have enough genetically normal embryos nothing about failure to implant or these other factors but that they didn't have enough the problem with eggs is if I have 20 eggs in the freezer how many embryos do I have you don't know yet I'm making a whole lot of assumptions yeah and what's the the cost difference of freezing eggs it is about half as much to freeze eggs as in okay so if you don't have a partner obviously eggs are the way to go sometimes in somebody who has very low ovarian reserve and they only have a limited amount of funds it makes sense
to do eggs because I could get five eggs and five eggs and have 10 eggs and even if I don't know the outcome of it if that's all the money you had to spend it was better served to get two months worth than to make embryos and find out that I have maybe one normal how much does this cost on average we'll say egg freezing is going to be about 10,000 and IVF is going to be about 20,000 okay I don't know the the UK equivalent for that but um chat GPT is telling us that on average IVF in the UK is about £3,500 and in the US it's about $10,000 IVF is $20,000 $220,000 genetic testing yes freezing the eggs yes how much does that cost it's about half as much and that makes sense because you're doing about half the process you're still growing the eggs taking them the body freezing them you'll have to pay the second cost eventually but it's easier to spend your future money than your current money and do you have to pay yearly to keep them in the fridge you do have to pay annual storage fees how much is that on average it depends typically it's between 500 to $1,500 a year we have to talk about the stigma around IVF we've talked about stigma a few times and I I can imagine that a lot of people when they hear about freezing your eggs and IVF especially people who are maybe in their early 30s or in their late 20s they will reject the idea because of the stigma that that means you're broken and that's not natural and we've got to do it like this and in the movies it happens like this on Instagram and with that couple over there they just had sex and then little Bernie was born like you know all of that stuff and I think a lot of that stuff actually gets in the way of even the conversation in the first place I think um I had this conversation with my partner but I I was scared to have the conversation because turning to my partner and going hey babe I think we should you should freeze your eggs and I should it's there it's like loaded with a bunch of it's a bunch of feelings yeah yeah yeah but the truth is that beat one as a couple beat on the same page is so important so that conversation that you had I'm so proud of you because so people don't have it and I'm the first person to ask them how many kids do you want what does our family size look like and people have never had that conversation so it makes it very
difficult for Family Planning there's a huge stigma about going through fertility treatments having infertility freezing your eggs the whole gamut a lot of that is because stigma often comes from things that are unknown or uncertain so simply by having these conversations and talking about it more that is so impactful and breaking the stigma because we start to normalize these terms and understand for women time matters and yes there's going to be stories of people who are able to wait later and get pregnant and that's wonderful 3% is not no nobody but is that likely to be you and that's the question I always say it's a very inefficient way to try to achieve a life goal let's have a life goal of ours and settle for something that's going to give you a 3% chance of success that doesn't make any sense to me once upon a time if you had a business idea it was exceptionally difficult to get going but now in the age of Shopify it is exceptionally easy as many of you will know Shopify are a sponsor of this podcast if you don't know Shopify it's an exceptionally simple web platform for anybody that's got an idea that wants to transact on a global scale so things like these conversation cards which we sell we've sold using Shopify and it only took us a couple of clicks to get going so why did we choose Shopify for a number of reasons but I think one of the big ones which goes an appreciated is their checkout system converts 36% better compared to other platforms and what I'm going to do to remove the cost for you if you go to shopify.com Bartlet you'll be able to try Shopify for $1 do a month I've seen Shopify completely change people's lives and for many of you I think it could change yours it's also a unavoidable reality of the world we live in I was reading the Time Magazine and it says that in 1970 the average US woman had her first baby age 21 and this increased to age 27 by 2022 so the time that we typically have our first baby has increased by six years most people are having it in their late 20s having their first baby in their late 20s that's again a consequence of the social factors we talked about so because of this there's always trade-offs in life right there are we want longer careers and we want
more quote unquote freedom in you know early seasons of our life then there's going to be a a trade-off well the trade-off shouldn't be that you have one less human in your family that you want it might just be that you have to do something different to make sure that goal is achieved you said in um a recent podcast you did that studies tell us that if you're not ready to have a family by 20 sorry 32 or 33 then that is the optimal time for the average person to intervene and start freezing their eggs it is and it comes from the way that study was based on the odds of you when you'd be likely to start trying to conceive and the rate of infertility coupled with the rate of decline in count an egg quality as you get older than that certainly your eggs are better quality and you have more of them younger than that so if you know you want to freeze your eggs do not wait until you're 32 but if you are approaching that age and want to have children as a life goal and you're not ready to have them now you need to go see a fertility doctor period the end and what I mean by that is maybe you freeze your eggs and maybe you don't but you owe it to yourself to be the one to make the decision and you can't make make it unless you understand how many eggs do I have are things normal for me and evaluate that information hear about what the process will be like you can choose to not do it but then you made the choice and the risk of regret is going to be lower in the future if you actively made the choice versus I didn't know and I never got the chance IVF simply is extracting an egg and a sperm injecting the sperm into the egg and basically putting it back inside the woman that's the simplified version for dummies yes so IVF in vitro fertilization we're fertilizing the egg outside the body so in vitro is in glass but in the lab in the P tree dish now modern IVF we are taking one month's group of eggs growing them to embryos and doing genetic testing and we're freezing them what are you testing them for we're testing them for chromosome number what we call anupy as we talked about the chromosomes getting out of line as you get older you can check the number of chromosomes the presence or absence of each chromosome in a five to eight cell sample from the embryo biopsy
to make sure they're healthy we'll use healthy as the embryo needs to be genetically normal it needs to have the right number of chromosomes to have the highest potential for success if you're missing a full chromosome that's going to end up in a miscarriage if you have extra chromosomes like an extra or copy of chromosome 21 is Down syndrome that carries its own risks and many of those are pregnancy loss as well so we're looking for what we call a upid embryo a genetically normal meaning it has the right number of chromosomes importantly IVF can also be used to eliminate genetic diseases that can be extremely impactful when we talk about genetic testing the way that I just defined it testing for euploidy you have more eggs that are genetically abnormal as you ate that's one of the top barriers to getting pregnant but if you and your partner both carry cystic fibrosis for example that's a disease that you are going to exhibit the characteristics of if you have a copy of the gene from Mom and a copy of the gene from Dad you have about a 25% chance of having a child who would be severely ill or sick with cystic fibrosis we can make a probe for where your cystic fibrosis mutation is on chromosome 7 and then we can apply that probe to that sample that's been biopsied from the embryo and find out which embryos have zero one or two copies of that mutation essentially not transferring the ones that are going to result in the disease State and for lethal abnormalities this is huge and then for autosomal dominant diseases like Huntington's disease or cancer hearing syndromes you can eliminate that from the family line do you then put one embryo into the woman at a time we do and so this has changed over time and I think this is where a lot of misconceptions come from IVF if we can imagine the world where I have a 40-year-old with four Frozen embryos if I've done genetic testing on them I would know that she has one normal and I would just go put that normal one in before genetic testing existed she had the same four embryos but I didn't know which one was normal so her odds of pregnancy for a single Embryo transfer work much much lower so it was common place to put more embryos in then to try
to up the odds that you'd capture the normal one now that we know which embryos are genetically normal we want to transfer one embryo at a time and I always say it's don't make them compete for resources let that embryo have the full surface area of the uterus to have a really nice placenta to grow into decrease the chance of loss or pregnancy complication down the road interestingly if you transfer to embryos of course you have a higher chance of twins you don't see much of a change in the pregnant rate just the Twining rate but even without transferring to embryos a single Embryo transfer significantly increases the chance of identical twinning now overall it's still very low but identical twinning where one embryo splits so you have two children who are genetically the same in nature that happens at about a half a percent in IVF it happens closer to 2 to 3% of the time probably just because of that embryo being loaded into a a catheter maybe its external surface is touched in some way makes it more predisposed to split after we put it inside the body that's still ultimately a very low odds of it happening but if you put it in context of I do 400 embryo transfers a year then I'm going to definitely see some patients who are having identical twinning from a single Embryo transfer also you know importantly justifying just putting one in at a time because if you put two in and one of them split or both of them split you could have triplets or quadruplets if we talk about doing it the old fashioned way yeah you know sex there's a lot of misconceptions around how to increase our odds of getting pregnant you hear about women putting their legs in the air after sex or um things like uh people think if you go for a Wei then you're going to we out all the sperm and that's not going to make you pregnant um are any of these things true there's so many myths when it comes to trying to get pregnant the good old fashioned way with intercourse so certainly we can go through a few of them one of them we already touched on which is oh you should save up sperm for when you're ovulating so we see that sometimes men will ejaculate less or couples will actually not have sex trying to save up
for that exact day of ovulation but there's no need to do that as we know we want to clear the pipes to keep the sperm coming out healthy and alive and not have dead sperm and that you can have sperm survive in the productive track for up to 5 days so you want to be having intercourse up until that ovulatory day so every other day sex everyday sex every 3-day sex those are all fine nobody ever needs to have less sex so if you and your partner have sex every day please don't have less sex because you're trying to get pregnant number two the sperm are inside the Fallopian tubes within minutes they have gone from the vagina gotten through that seminal fluid in the ejaculate through the the cervix through the uterus and into the fallopian tube within minutes under five minutes so there's no need to prop your hips up on a pillow for 30 minutes or put your feet in the air truly the sperm are into the cervix within 2 minutes and the cervix is where they then sit for up to the five days so the two minutes time that it's going to take you to withdraw get up go to the bathroom the sperm are fine you're not going to pee out any sperm you don't need to put any device in to keep sperm in place keep keep your feet up lay in bed you can go and do whatever you want to do and in fact we know that urinating after intercourse for women decreases the risk of a urinary tract infection so we try to encourage people to get up and be normal I also tell people all the time embryos and plant eggs fertilize when you are up and living your life so you don't need to just be horizontal to have fertilization occur so what about sex positions are there any sex positions that are more conducive with uh yeah whatever whatever position uh allows for ejacul ation so this is where variety is the spice of life because as you alluded to earlier sex can feel a little bit more of a chore when you're trying to get pregnant or you're struggling so making sure that ejaculation can happen there's not any position that is going to be better or worse or going to have higher chance of a boy or a girl or any of that kind of knowledge if the female orgasms does that increase the chance of fertility we do know that orgasm does help uterine contractions help get the sperm to the eggs faster so we do know that so how do
we know that we would hyp how do we know that yeah there have been studies looking at there have been studies looking at orgasm and then the speed of which sperm gets to the Fallopian tubes we'll just say that factors it's like maybe it's just bigger and that's just no so yeah just that those contractions are helping kind of propel the sperm up there what about penis size so penis size really doesn't matter what's interesting is that penis size does tend to correlate with different race and ethnicity also with vaginal length so we tend to see different vaginal lengths in correlation with what tends to be a similar penis length based on that ethnicity or where that person originated from which is super interesting but you don't need to you don't need a smaller penis or a bigger penis as long the sperm doesn't need to get closer to the cervix A lot of people obviously think that we when you eulate it goes it gets right where it needs to go okay crazy it's super interesting I've learned so much about um all of this stuff today I think there's probably just two more things I wanted to ask you about one of them is um you mentioned birth control earlier and there's lots of conversation at the moment as to whether birth control is healthy or not and the sort of side effects and risks associated with it we know everything and nothing in life has is a free lunch there's always trade-offs and side effects and would you say that birth control and obviously birth control comes in many forms as well it's not just a pill there's you know the coil and all these other types of birth control is the pill healthy I'll reframe and say the pill is not necessarily unhealthy however it's very important to understand that we now have a generation of women who were given the birth control pill when they had a sign that something was wrong with their body without getting to the bottom of what it was which means we're just kicking that can to trying to find that diagnosis now later in life and causing a of frustration so if your periods were irregular you got start on the pill you took it for 15 years now you're 35 and you come off of it your periods are probably still going to be irregular but now you don't know why you're ready to get pregnant and it can be very
frustrating so the use of the birth control pill as treatment without getting to the basis of diagnosis has been a huge problem in women's health the birth control pill itself does not cause infertility it changes nothing about the Vault the eggs are still coming out every month you're just losing them none of them are ovulating the birth control pill itself combined estrogen and progesterone the brain doesn't send out that FSH so it's not impacting the quality or the quantity of the eggs that you have it does change some of your metabolic parameters it does change some of your vitamins and every person's going to have a different reaction to the pill so certainly some people hate it but some people love it for endometriosis or you can have really terrible PMS or what we call pmdd which is like premenstrual dysphoric disorder where you have these mental health changes as your hormones change having stable hormone levels can be lifechanging so the pill definitely has Medical Treatments it prevents the cancer from PCOS it prevents endometriosis progression it can treat pain it can be something that can be very beneficial and unfortunately we see a lot of stigma with the birth control pill right now on social media we see so many people talking about how bad it is and how negative it is and how you're harming your health by taking the birth control pill you're not harming your health however it's allowing too many people to not have that discussion about their family planning and not understand how their hormones work so I always recommend that somebody stops contraception before they're ready to get pregnant that way you can understand are your periods coming regularly what are the signs and symptoms that something could be wrong so that you're not behind the game when you're trying to get pregnant lots of people will be listening to this now that are struggling with a variety of the things that you've talked about whether it's um PCOS or whether they've been trying to conceive a child for some time um whether it's this new word that I learned today endometriosis whether they're in late
stage sort of IVF treatment and many of the embryos have failed what is your message to those people there'll be I'm sure hundreds of thousands of them that are listening right now number one you can't control everything but you should control what you can so understanding getting the Sleep optimizing your lifestyle you should eliminate those questions from your mind should you do it you should do it number two there's no reason why you cannot ever get let's say a second opinion if you're deep in the fertility treatment two often I see people who do the same thing over and over and it's heartbreaking because they're using their time and their money and you might need a new set of eyes and I'll even tell my patients that if they're not having success if you want to go get another opinion go get it I support you we support our patients getting those extra sets of eyes extra input because this is your one chance there's such a limited amount of time from when most people start trying to when your reproductive window is closed that you owe it to yourself to feel comfortable with the choices that you are making if you are not getting the information you need from your doctor that's a red flag if you can never talk to a doctor that's a red flag if your periods are irregular and you don't know why you need to see a doctor if your periods are so painful that it's interfering with your life you need to go see a doctor if you know you've been diagnosed with something that somebody told you is going to make it hard for you to get pregnant please don't be reactive once you don't get pregnant once you have infertility don't try for 12 months and then come see me if you know you have PCOS let's test you now let's try to is start out on the right foot to know that everything else is working and have a game plan to really try to help you achieve this life goal Natalie thank you we have a closing tradition on this podcast where the last guest leaves a question for the next guest not knowing who they're going to be leaving it for and the question that has been left for you inside the Diary of a CEO is What is the most difficult conversation that changed your life that's such a great question and I I've been in a position to have a lot of
really difficult conversations both for my own personal decision- making changing career Pathways having my own infertility Journey but the most impactful conversation I ever have and one that I react to my patients was after my second pregnancy loss I was the chief resident I was the resident in charge of the busiest labor and deliver unit in America and I started miscarrying while I was on my shift so I was bleeding in the bathroom and nobody knew I was pregnant so I had to carry on so I carried on did C-sections delivered people's babies and I left and went to my own OB when that shift was over distraught because I knew that I was losing this pregnancy and I just had to witness so many families achieve what I wanted to achieve and my my OB when I got there and she confirmed that I was miscarrying and she said to me it's really hard to understand the meaning when you're in the middle of the journey but one day the world makes sense and it's your job to not give up hope and to stay on the path and that I believe that this is going to happen that you're going to be a mom and I may not have all the answers why you're struggling right now but I trust that if you keep going the odds are that you're going to have the baby that you're meant to have and when I went on to have subsequent losses that stayed with me that she believed I was going to have the baby I was meant to have and I'm going to cry now my daughter like if any of those other losses had worked out I wouldn't have my kids the ones that are my everything they're meant to be my children right my daughter that egg that was in the vault I would have lost when I was pregnant because you still lose eggs when you're pregnant so I wouldn't have her if any of those had worked out so the world has a way of sometimes making sense that are so hard when you're in the midst of the pain to understand and I tell my patients that same thing over and over that in the journey it doesn't make sense but that's not your job in the journey to understand the wise it's to to keep going and not give up you must see so much of that pain how do you not you know how does that not come home
with you and oh it comes home with me and I live it in the moment so I'm not going to be the type of person who can experience your heartbreak and not experience it with you so I'm going to cry with you and hug you and I'm going to take it home and hug my kids and know how happy and how lucky I am to have them I frame it for all my patients as I'm never going to sugar coat it for you you know that I'm going to give you the truth it's going to be hard to hear sometimes but we know that we have the type of relationship that you can trust that I am giving you the best information that there is sometimes do you have to tell them that it's not possible I do sometimes I have to tell them it's not possible it's not going to happen we need to look at other alternatives for family building donor egg donor embryo donor sperm I have couples who sometimes had no idea the man had no sperm and we have to completely change what we thought a family would be so I do tell patients you know every week that this plan's not going to work anymore and it's time for us to step back and really think about what that goal is is it a genetic child I mean that was plan a but maybe it's just a child a life you know maybe there's other ways to get there than what we were trying for so there's a lot of pain in the job I always say I have the best job and the worst job in the same day every day what's been your hardest day in work the hard the hardest for me are are going to be mostly in my past you know training and obstetrics you know fetal death still birth loss of a highly desired I mean loss of any pregnancy loss of life um I I those screams of those parents you'll I'll never Escape them so pregnancy is not Health neutral we act like it's our once you get pregnant everything will be fine every single pregnancy could have complications and I think it's really important that we enter into that space with the knowledge of what it is and what it isn't but I the loss of life is always going to be the hardest Natalie thank you thank you so much Stephen thank you so much it's um you're doing you know there's kind of two sides to this there's I I have a
huge amount of gratitude for the fact that you're through your clinic and your work you're helping people to realize these very important dreams that they have and you're Illuminating all of the the darkness that causes the uncertainty and the doubt and all of the the things that come with trying to build a family and you're doing that through information but you're also doing that in such a compassionate human honest way and then secondly because you do things like this and there are so many people that don't have the opportunity to go to a you know a doctor or a fertility expert and sit down with them because of the country that they're in or the or the cost of it or the the time they have or whatever but by making this type of information accessible to millions of people by you know committing your time to do podcasts and things like that I think you're going to be helping so many hundreds of thousands and millions of people that you'll never get to meet so on behalf of all of those people who I can feel at home on the tube on the train on the plane right now that are that want to express their gratitude to you and I'm sure that they will message to do such exactly that I want to say thank you on behalf of all of them as well um I've learned so much I've learned so much and my mind has been changed so I have no doubt that there's millions of people listening right now that have also experienced the same thing so thank you Natalie thank you and thank you for holding space for this discussion there's stigma here it's not the most fun topic to always discuss about and it's something that you're bringing it to those people who might not come to my channel searching for it but they need to know the information so by putting it in a place where they're looking for other things thank you [Music] [Music]