Dr. Natalie Crawford: Female Hormone Health, Fertility & Vitality

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.280 | where we discuss science and science-based tools

00:00:04.880 | for everyday life.

00:00:05.900 | I'm Andrew Huberman,

00:00:10.200 | and I'm a professor of neurobiology and ophthalmology

00:00:13.320 | at Stanford School of Medicine.

00:00:15.120 | My guest today is Dr. Natalie Crawford.

00:00:17.440 | Dr. Natalie Crawford is a medical doctor

00:00:19.560 | specializing in obstetrics and gynecology,

00:00:22.280 | reproductive endocrinology, and infertility.

00:00:24.920 | She also holds a degree in nutrition science.

00:00:27.800 | Dr. Crawford runs a clinical practice

00:00:29.720 | seeing patients daily,

00:00:31.240 | as well as being actively involved in public education,

00:00:34.120 | both through social media

00:00:35.480 | and through her popular podcast entitled "As a Woman."

00:00:38.720 | Today, Dr. Crawford teaches us about all aspects

00:00:41.360 | of female hormones and hormone health and fertility,

00:00:44.760 | beginning as far back as in utero,

00:00:47.140 | when we were still in our mother's womb,

00:00:49.280 | and extending as far forward as menopause.

00:00:52.060 | We discuss topics such as the timing of puberty

00:00:54.360 | and what the timing of puberty in girls means

00:00:56.760 | for their fertility, and we discuss birth control,

00:00:59.100 | both hormonal and non-hormonal forms of birth control,

00:01:01.880 | and how birth control may or may not

00:01:03.660 | relate to long-term fertility

00:01:05.420 | and different aspects of female health.

00:01:07.500 | We also talk extensively about measuring fertility,

00:01:10.400 | that is egg count.

00:01:11.720 | We also talk about egg retrieval,

00:01:13.360 | AKA freezing one's eggs, as well as in vitro fertilization.

00:01:17.080 | And we also take a deep dive into the popular

00:01:19.000 | and important topics of nutrition and supplementation

00:01:21.960 | as they relate to fertility, as they relate to pregnancy,

00:01:25.440 | but also how they relate to female hormone health generally.

00:01:28.960 | Indeed, Dr. Crawford provides us with a masterclass

00:01:32.400 | on female hormones and fertility,

00:01:34.680 | one that I know that all women ought to benefit from

00:01:37.200 | and that men would benefit from listening to as well.

00:01:40.200 | Before we begin, I'd like to emphasize that this podcast

00:01:43.200 | is separate from my teaching and research roles at Stanford.

00:01:45.840 | It is, however, part of my desire and effort

00:01:47.940 | to bring zero cost to consumer information about science

00:01:50.480 | and science-related tools to the general public.

00:01:53.180 | In keeping with that theme,

00:01:54.280 | I'd like to thank the sponsors of today's podcast.

00:01:57.140 | Our first sponsor is Maui Nui Venison.

00:01:59.580 | Maui Nui Venison is the most nutrient-dense

00:02:01.840 | and delicious red meat available.

00:02:03.760 | I've spoken before on this podcast in solo episodes

00:02:06.500 | and with guests about the need to get approximately

00:02:09.780 | one gram of high quality protein per pound of body weight

00:02:13.300 | each day for optimal nutrition.

00:02:15.840 | There are many different ways that one can do that,

00:02:18.080 | but a key thing is to make sure that you're not doing that

00:02:20.740 | by ingesting excessive calories.

00:02:23.020 | Maui Nui Venison has the highest density

00:02:25.240 | of quality protein per calorie,

00:02:27.380 | and it achieves that in delicious things like ground meats,

00:02:30.960 | venison steaks, jerky, and bone broth.

00:02:34.240 | I particularly like the ground venison.

00:02:36.100 | I make those into venison burgers

00:02:38.400 | probably five times a week or more.

00:02:40.560 | I also like the jerky for its convenience,

00:02:42.940 | especially when I'm traveling

00:02:44.040 | or I'm especially busy with work

00:02:45.840 | and know that I'm getting an extremely nutrient-dense

00:02:48.420 | high quality source of protein.

00:02:50.020 | If you'd like to try Maui Nui Venison,

00:02:52.160 | you can go to mauinuivenison.com/huberman

00:02:55.540 | and get 20% off your first order.

00:02:57.800 | Again, that's mauinuivenison.com/huberman to get 20% off.

00:03:02.800 | Today's episode is also brought to us by Helix Sleep.

00:03:05.740 | Helix Sleep makes mattresses and pillows

00:03:07.740 | that are tailored to your unique sleep needs.

00:03:10.780 | Now, sleep is the foundation of mental health,

00:03:12.820 | physical health, and performance.

00:03:14.560 | When we are sleeping well and enough,

00:03:16.500 | mental health, physical health, and performance

00:03:18.500 | all stand to be at their best.

00:03:20.060 | One of the key things to getting a great night's sleep

00:03:21.900 | is to make sure that your mattress

00:03:23.520 | is tailored to your unique sleep needs.

00:03:25.740 | Helix Sleep has a brief two-minute quiz

00:03:27.820 | that if you go to their website,

00:03:29.360 | you take that quiz and answer questions

00:03:31.180 | such as do you tend to sleep on your back,

00:03:32.820 | your side, or your stomach?

00:03:33.700 | Do you tend to run hot or cold in the middle of the night?

00:03:36.180 | Maybe you don't know the answers to those questions

00:03:38.020 | and that's fine.

00:03:39.220 | At the end of that two-minute quiz,

00:03:40.700 | they will match you to a mattress

00:03:42.180 | that's ideal for your sleep needs.

00:03:44.140 | I sleep on the Dusk, a D-U-S-K mattress,

00:03:46.700 | and when I started sleeping on a Dusk mattress

00:03:48.660 | about two years ago, my sleep immediately improved.

00:03:51.380 | So if you're interested in upgrading your mattress,

00:03:53.220 | go to helixsleep.com/huberman,

00:03:55.640 | take their two-minute sleep quiz,

00:03:56.900 | and they'll match you to a customized mattress for you,

00:03:59.140 | and you'll get up to $350 off any mattress order

00:04:02.240 | and two free pillows.

00:04:03.760 | Again, if interested, go to helixsleep.com/huberman

00:04:07.040 | for up to $350 off and two free pillows.

00:04:10.100 | I'm pleased to announce that we will be hosting

00:04:12.020 | four live events in Australia,

00:04:14.380 | each of which is entitled The Brain Body Contract,

00:04:17.220 | during which I will share science and science-related tools

00:04:20.100 | for mental health, physical health, and performance.

00:04:22.800 | There will also be a live question and answer session.

00:04:25.780 | We have limited tickets still available

00:04:27.420 | for the event in Melbourne on February 10th,

00:04:30.100 | as well as the event in Brisbane on February 24th.

00:04:33.580 | Our event in Sydney at the Sydney Opera House

00:04:35.740 | sold out very quickly, so as a consequence,

00:04:38.460 | we've now scheduled a second event in Sydney

00:04:40.960 | at the Aware Super Theater on February 18th.

00:04:43.980 | To access tickets to any of these events,

00:04:46.180 | you can go to hubermanlab.com/events

00:04:49.540 | and use the code Huberman at checkout.

00:04:51.900 | I hope to see you there, and as always,

00:04:54.080 | thank you for your interest in science.

00:04:55.960 | And now for my discussion with Dr. Natalie Crawford.

00:04:59.260 | Dr. Crawford, welcome.

00:05:00.620 | - Thank you so much for having me, I'm honored to be here.

00:05:03.340 | - Well, I've been paying attention to your content

00:05:05.620 | for a long time, and I find it to be incredibly clear,

00:05:10.140 | informative, and for many people, actionable.

00:05:12.940 | So today, I'd like to talk about both fertility

00:05:16.040 | and of course, hormones.

00:05:17.940 | But as we both know, fertility is not limited

00:05:20.940 | to a discussion about hormones.

00:05:22.340 | It actually relates to things like behaviors, sex behaviors,

00:05:26.420 | and other behaviors, nutrition, supplementation.

00:05:28.560 | So we'll get into all of it,

00:05:29.820 | but if we could just back up developmentally

00:05:33.500 | and talk a little bit about female puberty,

00:05:37.360 | because I think pretty much everything

00:05:39.180 | we'll talk about today is related

00:05:41.460 | to what happens puberty forward, mostly in females,

00:05:44.680 | but we will also discuss male fertility and hormones a bit.

00:05:47.860 | And the question I have is,

00:05:50.360 | is there anything about a woman's timing

00:05:54.380 | or let's just say patterns of puberty, right?

00:05:58.700 | How frequently they menstruate early on,

00:06:01.460 | what the timing of menstruation is

00:06:04.860 | in terms of their age, et cetera,

00:06:06.580 | that provides hints or maybe even facts or directives

00:06:11.580 | about her future fertility

00:06:13.920 | or how long her fertility might last?

00:06:16.940 | - This is a great question

00:06:18.020 | and I think defining some terminology

00:06:20.860 | before we begin is helpful.

00:06:22.400 | So if we go all the way back

00:06:23.900 | to when you're a fetus inside your mom,

00:06:26.760 | so when there's a female fetus inside your mom,

00:06:29.760 | you have the most eggs you're ever going to have

00:06:31.540 | at about 20 weeks gestation.

00:06:33.340 | You have about six to seven million eggs.

00:06:35.700 | By the time you're born,

00:06:37.300 | you've already lost more than half of those

00:06:39.500 | and you continually lose eggs all the time.

00:06:41.960 | So the analogy that I always use and you do too,

00:06:45.180 | is imagining that there's a vault inside the ovary

00:06:47.540 | where all your eggs are kept

00:06:49.060 | and every single month since the moment you have an ovary,

00:06:52.800 | you lose a group of these eggs

00:06:54.740 | and when there's more inside, you're losing more.

00:06:57.500 | So you're losing all of these eggs

00:06:59.740 | throughout early fetal development

00:07:02.540 | and then up until the time period even of puberty.

00:07:05.800 | When you reach puberty,

00:07:07.100 | you have a lessening of the number of eggs in your ovary

00:07:09.820 | to the point where it can start to respond

00:07:12.300 | to the signals from the brain.

00:07:14.060 | So we think about puberty onset in females.

00:07:16.380 | First, we have really thelarchy,

00:07:17.820 | which is the development of breasts.

00:07:19.720 | So that happens about two years on average

00:07:22.060 | before you have menarche, which is your period starting.

00:07:25.820 | So what happens is the brain,

00:07:27.980 | as we know from the hypothalamus sends out GnRH

00:07:31.180 | and then we have FSH coming out,

00:07:33.220 | which really starts to stimulate those follicles.

00:07:36.760 | So FSH or follicle stimulating hormone,

00:07:39.220 | well-named hormone for the female.

00:07:41.380 | Of course, men have it too

00:07:42.460 | and it's less well named for them,

00:07:44.260 | but it starts to get those follicles,

00:07:46.060 | which house the eggs to grow and make estrogen.

00:07:49.140 | Women have about two years of estrogen exposure alone,

00:07:52.580 | so unopposed estrogen with no progesterone

00:07:55.220 | because they're not yet ovulating.

00:07:57.060 | And that's when you start to see breast budding

00:07:59.180 | and you start to see the development

00:08:01.700 | of some of those secondary sex characteristics

00:08:04.300 | before you actually have a period.

00:08:06.140 | - What are some of the other secondary sex characteristics

00:08:08.560 | that precede menarche?

00:08:10.540 | So you said breast bud development and then breast development

00:08:13.460 | on average about two years before menarche.

00:08:15.280 | - About two years before you have sexual hair development.

00:08:17.500 | So actually adrenarche is one of the first,

00:08:20.020 | usually comes right before at the same time with breast buds.

00:08:22.480 | So two to three years before you'll see your period.

00:08:25.420 | - So genital hair, underarm hair, typically.

00:08:26.860 | - Exactly, yeah, genital hair usually first

00:08:28.620 | and then underarm hair.

00:08:30.020 | - And we're getting right down into the weeds here,

00:08:32.700 | which is good.

00:08:33.540 | A goal of this podcast is to normalize

00:08:36.740 | all aspects of health, including sexual health

00:08:39.140 | and reproductive health.

00:08:41.260 | Is that commensurate also with the development of body odor?

00:08:46.260 | 'Cause as a young boy who eventually hit puberty

00:08:50.300 | and became a young man,

00:08:51.440 | and now I suppose I'm in middle age, I'm 48,

00:08:54.720 | I can tell you that the locker room smelled a lot different

00:08:57.860 | before and after middle school, right?

00:09:01.460 | Like in other words, boys start to smell stinky, right?

00:09:06.460 | - They do, yes.

00:09:07.300 | And that's usually around that same time

00:09:08.620 | of sexual hair development

00:09:10.220 | is when you start to have those glands around the hair

00:09:12.980 | making some of those odors that start to produce stink.

00:09:16.820 | - Do they reflect hormones themselves?

00:09:20.020 | - Not this, like the smell, the actual smell

00:09:22.500 | doesn't actually reflect levels of hormones

00:09:24.660 | or anything like that.

00:09:25.680 | It is just that your body, your gonads,

00:09:28.340 | whether it is testes or ovaries

00:09:30.020 | are now starting to respond to those brain signals.

00:09:32.880 | The brain is turned on, they're starting to respond

00:09:35.680 | and your body is starting to mature in a way

00:09:38.020 | to get to the point where it can support reproduction.

00:09:40.680 | - The reason I asked that question

00:09:42.000 | is not to get people thinking about stinky smells,

00:09:44.380 | but, and by the way, some people love the musty smell

00:09:47.200 | of their own armpits or others, you know,

00:09:51.060 | we're referring to adults, by the way.

00:09:53.940 | But the reason I ask is that there's a wealth of data

00:09:57.740 | in animal models, including non-human primates,

00:10:00.880 | suggesting that exposure to the odors of others

00:10:05.460 | can either stimulate or accelerate puberty.

00:10:10.060 | Is there any evidence for that in humans?

00:10:12.300 | - So there's mild evidence and it's murky

00:10:15.460 | because we also know that anything

00:10:18.620 | that could be an endocrine disruptor,

00:10:20.260 | which a lot of scents or fragrances are also,

00:10:23.500 | can accelerate the onset of puberty

00:10:26.500 | by disrupting part of this system.

00:10:28.460 | And so we know that toxins and scents

00:10:31.900 | and a lot of the world that we're exposed to

00:10:34.620 | is part of the reason why we're seeing puberty happen

00:10:36.620 | at such a younger age now in females specifically,

00:10:40.260 | but in both, but in females than we have before.

00:10:42.460 | We have young girls seeing their onset of menarche

00:10:45.460 | or their period at a much younger age.

00:10:47.900 | - How much younger?

00:10:48.860 | I've seen the various graphs for different countries,

00:10:50.820 | but can we say that, you know, 10 years ago on average,

00:10:54.760 | girls in the United States and Northern Europe

00:10:58.580 | were getting menarche at about what, 12 to 13 years of age?

00:11:02.940 | - So, you know, we'll use menarche for the purpose of this.

00:11:05.780 | So having your period, you know, 10 to 20 years ago,

00:11:08.420 | you will see most data would say, oh, 13 to 15

00:11:11.180 | would have been kind of the average age.

00:11:13.380 | And now we're really seeing it shift

00:11:14.700 | to be starting at 10 to 11 and completing by 13, 14.

00:11:18.780 | So most girls are definitely going through

00:11:22.540 | the puberty change earlier.

00:11:25.220 | And the other thing to note is that

00:11:27.740 | most girls get their final height growth

00:11:29.860 | right before they start their period too.

00:11:31.460 | So not only are we seeing a change

00:11:34.780 | in this getting, starting earlier,

00:11:37.320 | what we're also seeing is probably some reduction in height

00:11:40.460 | from having gone through puberty at an earlier process,

00:11:43.260 | because once you start actually menstruating,

00:11:46.780 | once the ovaries have really started to learn

00:11:49.060 | how to respond to that FSH and grow the follicle,

00:11:52.120 | and it gets to the point where you can start ovulating.

00:11:54.480 | So about two years later, then that ovulatory period,

00:11:59.100 | those high levels of estrogen are going to go

00:12:01.220 | and they're going to close those growth plates.

00:12:03.380 | So you've really started to limit your final adult height

00:12:06.980 | as well when you go through puberty earlier.

00:12:10.380 | And that's definitely something that's a huge concern

00:12:12.300 | for precocious puberty or very young puberty, right?

00:12:15.780 | And we can use blockers when there are children

00:12:18.560 | who start to exhibit signs of puberty.

00:12:20.820 | And one of the main reasons people do that

00:12:23.120 | is to try to get them to a greater adult height

00:12:26.260 | if they're really starting to go through puberty

00:12:28.000 | at a very young age.

00:12:29.140 | - Is that also true for males?

00:12:31.220 | - That it's happening earlier?

00:12:32.420 | - Yeah, the earlier puberty means that your growth spurt

00:12:35.540 | in terms of height is going to be truncated.

00:12:38.360 | - Not the same.

00:12:39.780 | And you probably, most men will say,

00:12:42.060 | "Oh, but I had my growth spurt

00:12:44.420 | after I started having some of the puberty change

00:12:47.460 | that happened."

00:12:48.720 | But because it is this estrogen-related process in women

00:12:52.460 | that we see that growth spurt,

00:12:53.900 | really your final height is within that year

00:12:56.180 | of when your period starts.

00:12:57.500 | - Interesting, yeah, this discussion

00:12:59.500 | is certainly not about me, but I was one of these,

00:13:01.540 | what I thought was kind of an odd duck.

00:13:02.820 | I hit puberty about 13, 14.

00:13:05.020 | Let's just say I knew I did,

00:13:08.220 | but I didn't shave until I was after college.

00:13:10.120 | My growth spurt between freshman and sophomore year,

00:13:12.260 | I grew a foot, right?

00:13:13.780 | So I was like, you know, I grew a full foot,

00:13:15.700 | but I was the same weight.

00:13:16.820 | So I was like real tall, real skinny,

00:13:18.340 | or pre-tall, you know, real skinny.

00:13:20.020 | And then it seems like, you know,

00:13:22.340 | some people in my life would argue

00:13:23.420 | that puberty is still occurring for me,

00:13:24.900 | but it feels like it's very long and protracted,

00:13:26.700 | which leads me to a very specific question.

00:13:30.920 | If puberty arrives, let's, again, defined as menarche

00:13:35.100 | for sake of our discussion right now,

00:13:37.260 | if puberty arrives early in a girl,

00:13:40.080 | does that mean that her fertility

00:13:42.740 | will shut down earlier as well?

00:13:44.620 | - Great question, it does not.

00:13:46.080 | So the age of which you start the onset of your period

00:13:49.220 | does not impact how long you're going

00:13:51.860 | to have a reproductive lifespan.

00:13:53.660 | And that's because you have the eggs inside that vault.

00:13:57.260 | You're losing them every month, no matter what.

00:14:00.500 | So you lost them all those years before your period started,

00:14:03.420 | no matter if your period came at 10 or at 15.

00:14:06.580 | It's just about when did they start allowing your body

00:14:09.780 | to ovulate, determined by being able to carry a baby.

00:14:13.820 | Your body now thinks you can be pregnant.

00:14:15.280 | - I think this is so important to highlight

00:14:17.040 | because it puts together what you said earlier

00:14:18.620 | about the loss of eggs, even as a fetus.

00:14:22.380 | I think most people sort of assume

00:14:25.300 | that the reduction in egg count is due to ovulation

00:14:29.660 | and the fact that, you know, one egg ovulates typically,

00:14:33.180 | but that other eggs are deployed in that ovulatory cycle.

00:14:36.580 | And then those basically are taken out of the vault

00:14:39.100 | and out of the opportunity for fertilization.

00:14:42.340 | But what you're saying is that the eggs

00:14:44.860 | are constantly being culled from the vault,

00:14:46.980 | starting from early embryonic development,

00:14:50.460 | and that ovulation is a distinct step,

00:14:54.300 | in some sense unrelated to the loss of eggs.

00:14:58.020 | I think this is going to be very important

00:14:59.340 | for our discussion later about potential egg harvest,

00:15:03.180 | because I think some people have it in mind.

00:15:05.020 | - A lot of misconceptions that you're losing eggs

00:15:07.340 | from your vault, and that's not the case.

00:15:09.280 | You're just accessing the ones outside.

00:15:11.300 | - Gosh, so you're not,

00:15:12.580 | so we can just answer this now, perhaps.

00:15:14.620 | It seems, if I understand correctly,

00:15:16.260 | that if one were to harvest eggs for IVF

00:15:18.940 | or for embryogenesis in a dish to set them aside later

00:15:21.780 | or freeze them for later, if they want to use them,

00:15:24.900 | eggs or fertilized embryos,

00:15:27.060 | that one is not reducing their total number of eggs

00:15:32.060 | any more than they would

00:15:34.060 | had they just let their cycles proceed naturally.

00:15:36.540 | - Exactly.

00:15:37.380 | - That's such an important point.

00:15:38.540 | I think a lot of people believe the opposite.

00:15:40.140 | - It's probably the number one thing that patients fear

00:15:42.900 | when they come talk to me about egg freezing

00:15:44.920 | or going through IVF is,

00:15:46.620 | I don't want to harm my future fertility.

00:15:48.400 | I don't want to cause myself to run out of eggs earlier

00:15:51.140 | or going to menopause earlier.

00:15:53.100 | And it's explaining this process to them

00:15:54.940 | that your ovaries are on a pathway that you can't change.

00:15:58.940 | Those eggs are coming out of the vault,

00:16:00.640 | regardless of if you're on birth control pills,

00:16:02.880 | you're pregnant, we do IVF.

00:16:05.660 | What we're modifying is one's not going to ovulate

00:16:09.500 | and have the rest of them die.

00:16:10.800 | We're going to try to give you medication

00:16:12.560 | to get them all to grow so we can take all of the ones

00:16:15.700 | that have been released from the vault that month

00:16:17.340 | and give them a chance for later.

00:16:19.060 | And the next month you'll have another group come out.

00:16:21.340 | - So IVF is not about stimulating hyper release

00:16:25.980 | or excessive release of eggs.

00:16:27.220 | It's about stimulating the growth of the ones

00:16:29.520 | that have been released so that they can be frozen

00:16:31.800 | at stage either for later fertilization or fertilized

00:16:33.960 | in addition than frozen as embryos, is that right?

00:16:35.960 | - Exactly.

00:16:36.800 | And we just use the hormones that your body normally makes

00:16:38.960 | in a different way.

00:16:40.660 | The medications we use are FSH and LH

00:16:43.400 | to get the eggs to grow.

00:16:44.340 | So people will say,

00:16:45.800 | I don't want to take all these weird hormones

00:16:47.740 | or strange medications,

00:16:49.440 | but we're just manipulating that normal process

00:16:51.440 | that happens in the natural menstrual cycle

00:16:53.600 | in order to say, hey, this month,

00:16:55.440 | let's get all these eggs to grow.

00:16:56.760 | Let's try to improve the efficiency

00:16:59.200 | of finding which eggs are going to be normal or not

00:17:01.680 | and help you along this process.

00:17:03.600 | - I think a good number of people

00:17:04.720 | are now going to head to the IVF clinic.

00:17:07.200 | I think, again, I really want to highlight this.

00:17:09.320 | I think most people that I've spoken to assume

00:17:12.460 | that the process of harvesting eggs for freezing,

00:17:16.120 | for fertilization then or later

00:17:18.960 | is going to diminish their fertility

00:17:20.580 | because they're basically pulling

00:17:22.460 | more out of the savings account, so to speak.

00:17:24.320 | - Right. - Okay.

00:17:25.160 | - You're making the withdrawal no matter what.

00:17:26.900 | - Great, well, such an important point

00:17:28.860 | for people to know and propagate.

00:17:30.820 | Getting back to puberty,

00:17:33.180 | a little bit later on,

00:17:35.380 | I wanted to get into endocrine disruptors

00:17:37.540 | and things of that sort.

00:17:38.380 | But since you brought it up,

00:17:40.940 | I've heard things such as, okay,

00:17:42.860 | things like evening primrose oil.

00:17:44.840 | If mom is putting evening primrose oil on

00:17:47.460 | or has it in her shampoo,

00:17:48.960 | that I've heard of young males

00:17:50.580 | getting precocious breast bud development.

00:17:53.760 | Keep in mind, folks,

00:17:54.880 | that some transient breast bud development

00:17:57.480 | is characteristic of some normal pubrities in males.

00:18:00.520 | It sometimes shows up and goes.

00:18:01.700 | I knew some kids like that in the neighborhood.

00:18:03.820 | They got teased a little bit

00:18:04.740 | and then they stopped getting teased.

00:18:05.980 | Hopefully nowadays they don't tease those kids.

00:18:07.300 | But when I was growing up, those kids got teased,

00:18:09.340 | not by me, but by other people.

00:18:11.020 | But it was normal and it passed for some, right?

00:18:13.860 | It occurred normally and then passed.

00:18:16.100 | But I've heard that things like

00:18:18.840 | exposure to evening primrose oil,

00:18:20.320 | maybe even just through contact with mom,

00:18:22.380 | can increase the frequency or degree

00:18:25.180 | of that male breast bud development.

00:18:27.320 | Is it also true that young girls

00:18:30.160 | can undergo precocious puberty

00:18:31.900 | or let's just say accelerated or exacerbated puberty

00:18:36.100 | through contact with things like evening primrose oil,

00:18:38.620 | which I think has some pseudo estrogen-like properties?

00:18:41.740 | - It's important to differentiate

00:18:43.420 | that the secondary sex characteristics we see,

00:18:45.660 | like breast bud development, are from estrogen,

00:18:48.720 | but it's not really puberty being initiated

00:18:51.440 | when it's from an endocrine disrupting chemical.

00:18:53.600 | So being exposed to evening primrose

00:18:57.100 | or lavender or tea tree oil in a male

00:19:00.160 | isn't going to cause him to start to go into puberty,

00:19:03.100 | but it is going to expose him to estrogen

00:19:05.920 | when his body is not,

00:19:07.440 | and therefore stimulate some breast bud development.

00:19:10.220 | Same thing can happen in young girls,

00:19:12.700 | meaning they could show some of those secondary sex signs

00:19:16.180 | earlier than they normally would.

00:19:18.180 | And this is why if that's happening at a really young age,

00:19:21.740 | kids should go to a pediatric endocrinologist

00:19:24.760 | who are gonna check things like bone age

00:19:26.540 | and see if you've really started the puberty process or not,

00:19:29.780 | or is it an outside exposure which is causing it?

00:19:33.360 | Interestingly, about the young child exposure

00:19:37.140 | and development, the other thing to say

00:19:39.300 | that's really interesting and relevant in my field

00:19:42.840 | is that when we think about how many eggs are in the vault,

00:19:45.380 | and everybody's born with this different number,

00:19:47.260 | and I'm sure we'll talk about ovarian reserve,

00:19:49.760 | what we now know is that the vault,

00:19:52.500 | your ovaries are most susceptible

00:19:54.900 | to whatever your mother does when she's pregnant with you.

00:19:58.500 | And that that epigenetic, that programming which is happening

00:20:02.580 | is predisposing young women to probably having,

00:20:06.340 | some of them low ovarian reserve,

00:20:08.820 | some of them having diseases we associate with infertility

00:20:12.740 | like PCOS or endometriosis.

00:20:14.980 | And we haven't yet characterized what all they are,

00:20:17.860 | but if we look at the incidence of some of these disease

00:20:20.520 | that we see now, what we do know is that the time period

00:20:23.880 | of which these people were pregnant, the '80s and '90s,

00:20:27.300 | was not the healthiest time

00:20:28.540 | when it comes to endocrine disruptors and plastic exposures

00:20:32.020 | and chemicals and all of this processed stuff.

00:20:36.380 | Let's just say that people have been exposed to,

00:20:38.940 | that we're really seeing that those,

00:20:40.820 | that ovarian susceptibility to egg quality and quantity

00:20:45.820 | happens in that fetal development period.

00:20:49.540 | - It's interesting because there's some parallels

00:20:54.040 | to male fetal development,

00:20:56.020 | like the fact that you have these early organizing effects

00:20:59.300 | of hormones like dihydrotestosterone,

00:21:01.060 | which essentially stimulate the growth of the penis,

00:21:03.340 | but also then establish a propensity

00:21:06.380 | for hormones during puberty to activate growth

00:21:09.620 | of the sex organs, but also activate the brain areas

00:21:12.940 | that are responsible for a host of different things.

00:21:15.540 | So I only mentioned that because what I'd like

00:21:18.300 | to kind of illustrate in the background here

00:21:19.980 | is that basically our reproductive health

00:21:23.980 | begins really prior to conception, really.

00:21:27.580 | It's dependent on mom and dad,

00:21:29.420 | but certainly to a great degree on mom,

00:21:32.740 | but then fetal development is going to be important.

00:21:34.740 | So sort of us being able to pick our parents.

00:21:38.400 | I do have a couple of questions about lavender tea tree oil

00:21:42.480 | and evening primrose oil.

00:21:43.900 | I was aware that evening primrose oil, excuse me,

00:21:47.140 | can somehow bind estrogen receptors

00:21:50.980 | or mimic some of the estradiol or something similar to it.

00:21:54.180 | I wasn't aware of tea tree oil or lavender.

00:21:57.640 | Here, are we talking about oils?

00:21:59.700 | What about aromas?

00:22:01.340 | And how concerned do people have to be about this stuff?

00:22:03.920 | Because I mean, you'll go into a restaurant bathroom,

00:22:06.800 | there'll be potpourri, some people wear perfume.

00:22:09.860 | I mean, we don't want to set a paranoia.

00:22:11.920 | - No, no.

00:22:12.760 | - But I think people should know about this stuff.

00:22:14.600 | Tea tree oil is in a lot of those natural shampoos.

00:22:17.260 | - A lot of the shampoos. - The ones that burn.

00:22:18.420 | - Yes, the one that tingle your scalp.

00:22:19.900 | - Yeah, I don't like those.

00:22:20.740 | - Some people love them though.

00:22:22.060 | Constant exposure is very different

00:22:25.180 | than a one-time hand washing in the bathroom.

00:22:27.320 | And I think that's the big difference for everything

00:22:29.940 | when we talk about chemicals or toxins

00:22:32.480 | or exposures in the world.

00:22:33.620 | You can't live in a toxin-free world.

00:22:36.180 | But choosing what you put in and on your body

00:22:39.460 | on a regular basis does set the tone

00:22:43.040 | for certain physiologic changes.

00:22:46.180 | And so using unscented products, especially with children,

00:22:51.180 | is really an important thing

00:22:52.540 | because we want to make sure that their lifetime exposure

00:22:55.500 | to some of these things, especially during critical times,

00:22:58.340 | is much less.

00:22:59.320 | And so you'll see people recommend things

00:23:01.100 | like your laundry detergent.

00:23:02.700 | You know, what's sensor in your laundry detergent?

00:23:05.020 | The shampoo and conditioner are a big one.

00:23:07.900 | And the soaps that you use on a day-to-day basis

00:23:10.500 | in your house or the oils you put on your body.

00:23:13.200 | Lavender's huge because there's this whole community

00:23:15.340 | of people, they want to rub lavender oil

00:23:17.500 | on their baby's feet and help them sleep.

00:23:20.180 | But really we can see, and if somebody goes

00:23:22.960 | and shadows a pediatric endocrinologist for a day,

00:23:25.900 | they'll see some kids come in

00:23:27.560 | and this will be the reason why.

00:23:29.300 | - What about cloth diapers versus non-cloth diapers?

00:23:33.980 | I've heard, you know, that you have

00:23:35.320 | your very strong cloth diaper proponents, right?

00:23:38.060 | And that because they seem to feel or believe

00:23:41.860 | that non-cloth diapers somehow contain things

00:23:45.400 | that can get into baby's skin.

00:23:46.780 | And maybe there's a bigger question here.

00:23:49.220 | Is baby's skin more permeable than adult skin?

00:23:52.300 | - Because they don't know that baby's skin

00:23:53.920 | is more permeable or not.

00:23:54.760 | - I don't either.

00:23:55.960 | To me, it seems like it'd be hard to imagine it is,

00:23:58.460 | but babies do seem to have this incredible skin, right?

00:24:01.020 | Their skin is so smoozy and you want to squeeze their cheeks

00:24:03.780 | and all this kind of stuff.

00:24:04.820 | But yeah, the idea that it would be more permeable.

00:24:08.160 | - I think it's more that their development is,

00:24:11.340 | this time is very important and setting the stage

00:24:14.060 | for a lot of what happens later.

00:24:15.900 | Versus in adulthood, those stepwise developmental processes

00:24:19.880 | have already happened.

00:24:20.720 | So I think that's why we pay so much attention

00:24:22.220 | to what happens in the childhood period of time,

00:24:26.460 | because we're now learning about those later consequences

00:24:29.420 | of what you're exposed to.

00:24:31.300 | It's not that regular diapers versus cloth,

00:24:34.380 | whatever we want to say,

00:24:35.380 | one's necessarily better than the other.

00:24:37.660 | It's more honestly a personal preference.

00:24:39.980 | Babies are exposed to them a lot,

00:24:42.600 | and there's been a lot of attention to that.

00:24:44.900 | But similarly, somebody could use cloth

00:24:46.780 | and wash it with a detergent

00:24:48.300 | that then has certain chemicals in it.

00:24:50.940 | So there hasn't been a study shown that this one thing

00:24:53.620 | is an exposure for a baby

00:24:55.000 | that somebody needs to be worried about.

00:24:57.500 | There's definitely companies now which are promoting

00:25:01.300 | and talking about traditional diapers

00:25:03.640 | that they are making sure have less toxins in them.

00:25:07.400 | And I always think anytime you can decrease toxin exposure

00:25:10.220 | to a child is going to be very important.

00:25:12.480 | - Is there any evidence for breast milk versus formula

00:25:17.900 | in terms of impact on future reproductive development

00:25:22.900 | or reproductive status of a child?

00:25:25.620 | - That's a complicated question

00:25:27.100 | because breast milk exposure,

00:25:29.500 | at least for the first six months of a child's life,

00:25:32.860 | certainly helps with the immune system development.

00:25:35.460 | And we know that poor immune development

00:25:37.780 | can lead to higher risk of autoimmune disease later,

00:25:40.940 | what people call leaky gut.

00:25:42.420 | And some of those diseases

00:25:44.780 | certainly are correlated with fertility.

00:25:47.300 | So I wouldn't say we've gone so far to say

00:25:49.680 | that if you don't breastfeed your child,

00:25:51.220 | they're going to have fertility issues,

00:25:52.760 | but we do know that there's an in-between correlation

00:25:55.300 | with things that breastfeeding is protective against

00:25:58.340 | and how those diseases themselves may relate to fertility

00:26:02.420 | in the female later on.

00:26:03.780 | - Okay, so if we're thinking about a young girl/woman,

00:26:09.100 | 'cause we're talking about puberty, right?

00:26:10.420 | So I don't know what the exact nomenclature is there.

00:26:13.520 | My experience is I'll offend somebody no matter what,

00:26:17.220 | but a girl who undergoes puberty, right?

00:26:19.120 | So a young woman who's maybe 13 or so,

00:26:22.940 | so she's early teens, undergoes puberty

00:26:25.740 | and therefore is continuing to lose eggs from the vault,

00:26:30.240 | but now is undergoing, presumably,

00:26:35.760 | roughly every 28 days, menarche.

00:26:37.700 | But let's talk about this 28 days thing

00:26:39.300 | because I think a lot of people think

00:26:41.100 | that quote-unquote normal menstruation is always 28 days.

00:26:46.260 | And we know that's not true.

00:26:47.520 | So what is the range of normal durations

00:26:51.820 | between menstruations cycles

00:26:55.680 | or duration of the menstruation cycle?

00:26:57.620 | And let's also define when the menstruation cycle starts,

00:27:01.100 | probably for the males mostly in the audience.

00:27:02.940 | - Sure, sure.

00:27:03.780 | So let's think through the cycle.

00:27:05.940 | We'll do a quick one over and then answer the questions.

00:27:08.420 | So what we think of as cycle day one,

00:27:10.700 | or when you're going to say this starts

00:27:12.260 | is going to be the day that you start bleeding.

00:27:13.720 | So that's actually shedding the endometrial lining

00:27:16.260 | from what grew the last time.

00:27:18.240 | - So any spotting even would be considered day one?

00:27:20.380 | - Yeah, mm-hmm. - Okay.

00:27:21.660 | - So it is, we can get back to it,

00:27:23.800 | but there's problematic if you have a lot of spotting

00:27:26.000 | before that full flow starts.

00:27:27.580 | A day or so can be really normal

00:27:29.040 | just as the body's adjusting to the drop in progesterone.

00:27:31.780 | But let's just start at the beginning.

00:27:33.300 | Day one, you have a period of menses.

00:27:36.180 | This is when you're actually bleeding.

00:27:38.180 | At this time period, we like to think about

00:27:40.520 | all of those new eggs being out of the vault,

00:27:43.360 | being susceptible to that FSH,

00:27:45.220 | which of course is that well-named hormone

00:27:46.860 | because it stimulates the follicle to grow

00:27:48.840 | and each egg is in a follicle.

00:27:50.700 | That egg starts to grow and makes estrogen.

00:27:53.300 | That estrogen stimulates the proliferation

00:27:55.860 | of the lining of the uterus in preparation

00:27:58.020 | for potentially that pregnancy that may come.

00:28:00.780 | And also that estrogen makes you feel really great, right?

00:28:03.580 | That's the follicular phase,

00:28:04.960 | name so because that follicle is growing

00:28:07.160 | and it's an FSH dominant phase

00:28:09.860 | where you have a lot of estrogen.

00:28:11.480 | - And people feel great when they have a lot of estrogen.

00:28:14.380 | - Yeah, women feel good with estrogen.

00:28:16.740 | - Because of the relationship between estrogen

00:28:18.940 | and other neuromodulators like dopamine and serotonin.

00:28:22.100 | And is that happening in parallel

00:28:23.580 | or are they somehow related?

00:28:24.700 | Is estrogen controlling the release of serotonin somehow

00:28:27.160 | and vice versa or are they just kind of coincidentally

00:28:30.140 | happening in parallel?

00:28:31.240 | - We definitely think that there's

00:28:33.220 | more of a correlation causation than just coincidence

00:28:37.060 | because we know there's time periods of people

00:28:38.940 | are more depressed within your cycle,

00:28:41.360 | correlating with those low estrogen levels.

00:28:43.540 | And we know that when you go into menopause

00:28:46.000 | or you run out of eggs

00:28:47.060 | and you're now in a low estrogen phase,

00:28:49.080 | we see a lot more of a depressed mood

00:28:52.100 | and anhedonia, lack of response to things

00:28:55.160 | which would normally give you pleasure

00:28:56.820 | happens more frequently.

00:28:58.500 | The female brain loves estrogen

00:29:00.420 | and it's protective against things like dementia.

00:29:02.740 | So this is a time period where women

00:29:05.140 | are going to be more energetic,

00:29:06.980 | they're gonna have more energy, more focused.

00:29:08.620 | This is the estrogen dominant phase of the cycle.

00:29:11.340 | And when you have seen that estrogen at its high levels,

00:29:14.660 | which it's only made from a mature follicle

00:29:16.660 | and it's very specific,

00:29:18.580 | 200 picograms per milliliter for 50 hours,

00:29:21.720 | that's the brain's clue.

00:29:22.820 | Okay, we must have a mature egg

00:29:24.940 | and it can send out that surge of LH or luteinizing hormone.

00:29:28.700 | And now you ovulate.

00:29:30.100 | And when you ovulate, the follicle opens up,

00:29:32.420 | releases, closes back, and then it's the corpus luteum

00:29:35.780 | and we've entered the luteal phase.

00:29:37.340 | - And the corpus luteum, as the name suggests,

00:29:39.000 | a corpus, it's like a body that's basically the,

00:29:41.500 | it's basically the corpse of what,

00:29:45.900 | - It's the dead follicle, yes.

00:29:47.100 | - Yeah, and sheathed the egg before.

00:29:48.980 | And what I find so amazing, I mean,

00:29:51.740 | biology is so beautiful, right?

00:29:53.900 | Instead of just taking that tissue and saying,

00:29:56.260 | okay, like, let's just discard this,

00:29:58.120 | or that becomes the trigger for the next phase of the-

00:30:01.180 | - It is essential for life, right?

00:30:03.100 | The corpus luteum, which makes progesterone,

00:30:05.760 | opens and closes the implantation window.

00:30:07.800 | It is what allows somebody to get pregnant

00:30:09.820 | and for our species to continue.

00:30:11.960 | So it's extremely fascinating.

00:30:14.520 | And that corpus luteum gets stimulated

00:30:16.640 | to produce progesterone impulses

00:30:18.580 | throughout the entire luteal phase

00:30:20.260 | because it's still controlled by the brain

00:30:22.720 | unless you get pregnant.

00:30:24.320 | And then in that luteal phase, progesterone is fascinating.

00:30:28.320 | It's trying to protect you from things

00:30:30.380 | which could potentially harm your baby.

00:30:32.720 | So suddenly now you have less energy,

00:30:36.000 | you wanna sleep more, you wanna eat more,

00:30:38.640 | you maybe do not wanna have sex as much

00:30:40.820 | because your body is suddenly saying,

00:30:43.000 | let's just protect this potential implantation

00:30:45.940 | that you're going to have.

00:30:47.520 | If that pregnancy doesn't come,

00:30:48.960 | the corpus luteum can only live 12 to 14 days.

00:30:52.200 | It has a very distinct lifespan.

00:30:54.540 | And then it dies, your estrogen and progesterone both drop,

00:30:59.100 | you bleed starting over the next cycle,

00:31:02.080 | and a new group of follicles comes out to be released.

00:31:05.440 | And the reason why walking through that very succinctly

00:31:08.720 | but is important when you're asking

00:31:10.380 | how long is the normal cycle?

00:31:12.200 | Because the luteal phase is pretty set at 12 to 14 days.

00:31:15.440 | The follicular phase can vary in person to person.

00:31:19.000 | And what we know though is for one individual,

00:31:22.320 | if your menstrual cycle,

00:31:24.960 | your reproductive hormones are working right,

00:31:26.640 | it should be relatively constant for you.

00:31:29.200 | And so if your periods are every 24 days,

00:31:34.080 | but they've always been every 24 to 25 days,

00:31:37.080 | then that's not concerning.

00:31:38.640 | And if your periods are every 33 days,

00:31:40.740 | but they've always been every 33 days,

00:31:43.000 | then that's not concerning.

00:31:44.600 | But we do get concerned when there's a change in your period

00:31:47.760 | or we get concerned when people have,

00:31:49.800 | what I like to say is irregularly regular periods.

00:31:53.580 | Because what you'll see textbooks tell you

00:31:55.640 | is that your periods could be as short as 21 days,

00:31:59.760 | as long as 35 days, and that can all be normal.

00:32:03.440 | But people will hop between them

00:32:05.460 | and they'll have one cycle that is 24 days in length

00:32:08.640 | from day one to the last day before the next day one.

00:32:12.000 | Then the next cycle is 32, and then it's 26,

00:32:15.220 | and then it's 34, and that's not normal.

00:32:17.360 | That's too irregular.

00:32:19.200 | And that can be a sign

00:32:21.280 | that something is not communicating correctly

00:32:23.460 | within your reproductive hormones.

00:32:25.540 | So what I tell patients is, in general,

00:32:28.040 | your period should be less than 35 days apart,

00:32:31.380 | and you should be able to look at a calendar,

00:32:33.580 | and with your finger, put a finger on the date,

00:32:36.800 | and within a couple days of accuracy,

00:32:38.740 | be able to predict when your period's coming.

00:32:41.000 | And if you can't, there could likely be something

00:32:44.680 | that is interfering with the hormonal signals

00:32:47.240 | between the brain and the ovary.

00:32:49.200 | And one of the biggest, really one of the only things we see

00:32:54.220 | as women start to have fewer eggs in the vault

00:32:56.800 | is a shortening of their cycles.

00:32:59.020 | So you have a regular period,

00:33:01.120 | and suddenly now you have less eggs in the vault,

00:33:03.760 | so less are coming out each month.

00:33:06.200 | And when the brain sends out that FSH signal,

00:33:08.960 | now there's fewer eggs, so it's not getting as dilute,

00:33:11.620 | and you have one starting to respond sooner.

00:33:14.120 | So suddenly, you're ovulating shorter, faster in your cycle.

00:33:18.960 | You're ovulating on cycle date nine instead of 14.

00:33:22.520 | Your luteal phase is still set,

00:33:24.640 | but the person who comes to see me and says,

00:33:27.240 | "My periods have always been 28 to 30 days,

00:33:30.060 | but now they're every 24."

00:33:32.780 | I just figure it's no big deal.

00:33:34.700 | I have red flags going off everywhere

00:33:36.760 | because I'm now really concerned

00:33:38.740 | that potentially their ovarian reserve has dropped

00:33:41.640 | to a point where we are starting to see clinical changes.

00:33:45.200 | Now, of course, things like thyroid and prolactin

00:33:47.760 | and other hormones can also cause such changes,

00:33:50.600 | but that's why you'll hear most reproductive

00:33:52.920 | endocrinologists say your period's a vital sign.

00:33:55.360 | And what we really mean is the regularity at which it comes

00:33:59.480 | and the predictability of it is telling us

00:34:02.200 | if your hormones are all communicating in a normal fashion

00:34:05.720 | or if something could potentially be off.

00:34:08.240 | - As we all know,

00:34:09.080 | quality nutrition influences, of course,

00:34:11.160 | our physical health, but also our mental health

00:34:13.400 | and our cognitive functioning, our memory,

00:34:15.260 | our ability to learn new things and to focus.

00:34:17.640 | And we know that one of the most important features

00:34:19.800 | of high quality nutrition is making sure

00:34:21.740 | that we get enough vitamins and minerals

00:34:23.740 | from high quality unprocessed or minimally processed sources

00:34:27.360 | as well as enough probiotics and prebiotics and fiber

00:34:30.440 | to support basically all the cellular functions in our body,

00:34:33.520 | including the gut microbiome.

00:34:35.360 | Now, I, like most everybody,

00:34:37.500 | try to get optimal nutrition from whole foods,

00:34:40.560 | ideally mostly from minimally processed

00:34:43.280 | or non-processed foods.

00:34:44.740 | However, one of the challenges

00:34:45.840 | that I and so many other people face

00:34:47.700 | is getting enough servings of high quality fruits

00:34:49.760 | and vegetables per day, as well as fiber and probiotics

00:34:52.720 | that often accompany those fruits and vegetables.

00:34:54.920 | That's why way back in 2012,

00:34:56.940 | long before I ever had a podcast, I started drinking AG1.

00:35:00.800 | And so I'm delighted that AG1

00:35:02.400 | is sponsoring the Huberman Lab podcast.

00:35:04.560 | The reason I started taking AG1

00:35:06.280 | and the reason I still drink AG1 once or twice a day

00:35:09.600 | is that it provides all of my foundational nutritional needs.

00:35:12.360 | That is, it provides insurance

00:35:14.320 | that I get the proper amounts of those vitamins, minerals,

00:35:17.120 | probiotics, and fiber to ensure optimal mental health,

00:35:20.800 | physical health, and performance.

00:35:22.960 | If you'd like to try AG1,

00:35:24.380 | you can go to drinkag1.com/huberman

00:35:27.640 | to claim a special offer.

00:35:29.200 | They're giving away five free travel packs

00:35:30.960 | plus a year supply of vitamin D3K2.

00:35:33.800 | Again, that's drinkag1.com/huberman

00:35:37.120 | to claim that special offer.

00:35:39.020 | Let me see if I have this correct.

00:35:40.720 | We've got this thing that we call the menstrual cycle

00:35:44.720 | or the ovulatory cycle.

00:35:47.160 | There's two phases, a follicular phase and a luteal phase.

00:35:50.840 | Follicular precedes the luteal phase.

00:35:52.340 | The luteal phase tends to be, if I heard correctly,

00:35:55.340 | fairly fixed, about 14 days.

00:35:57.080 | The follicular phase can vary in duration,

00:36:00.440 | maybe 10 to 14 days, maybe even 10 to 18 days,

00:36:03.920 | depending on something about their brain

00:36:07.080 | to overrecommunication.

00:36:08.340 | For those that aren't familiar with this,

00:36:13.680 | I always learned that estrogen primes progesterone.

00:36:16.920 | That's kind of the really basic top contour description

00:36:20.020 | of the ovulatory cycle,

00:36:21.060 | that estrogen is going to slowly climb

00:36:23.480 | toward the point of ovulation,

00:36:26.120 | and then there's a peak and then a drop,

00:36:28.480 | and then progesterone is going to dominate

00:36:30.120 | in the luteal phase, the second half.

00:36:32.180 | You said that estrogen is associated

00:36:34.720 | with a psychological level and a physiological level,

00:36:38.120 | more energy, feelings of vitality,

00:36:41.720 | and some of that estrogen increase

00:36:44.160 | is actually coming from the one egg

00:36:45.920 | that got stimulated the most,

00:36:47.400 | the one that got selected, right?

00:36:48.960 | So it picked for the team, potentially for the team,

00:36:51.560 | but got picked potentially for fertilization,

00:36:54.380 | and that egg sheds its corpus luteum,

00:36:57.320 | which is this piece of the egg,

00:37:00.600 | that then triggers the progesterone

00:37:02.880 | that dominates the luteal phase.

00:37:04.600 | Do I have that right?

00:37:05.440 | - Mostly, mostly. - Okay, yeah,

00:37:06.500 | please correct me where I'm wrong.

00:37:07.340 | - The follicle in which the egg grows, right,

00:37:09.680 | when you ovulate, it ruptures, the cyst bursts.

00:37:13.280 | A follicle's a cyst, a cyst is a fluid-filled structure,

00:37:16.160 | follicle's a fluid-filled structure that holds an egg.

00:37:18.400 | So when you ovulate and you get that LH surge,

00:37:20.520 | the cyst bursts, it opens up, and the egg comes out of it,

00:37:24.180 | and then it re-heals and becomes the corpus luteum.

00:37:27.400 | - Got it.

00:37:28.240 | - So just a little bit different in timing.

00:37:29.800 | And you're right with estrogen primes progesterone,

00:37:32.520 | but really, we think about it at the layer of the uterus,

00:37:35.120 | because estrogen stimulates the growth of that lining,

00:37:37.800 | and then progesterone stabilizes it

00:37:40.120 | and allows implantation to occur.

00:37:43.040 | But the sequence of events of when you're estrogen dominant

00:37:47.320 | and progesterone deficient, which is the follicular phase,

00:37:51.180 | and people will come in having labs drawn randomly,

00:37:54.400 | and they're all concerned that they don't have progesterone.

00:37:57.040 | And when you talk to them about where they are

00:37:58.400 | in their cycle, you say,

00:37:59.320 | "You're not supposed to have progesterone.

00:38:00.700 | "That's your follicular phase.

00:38:01.960 | "This is perfectly normal."

00:38:04.280 | - Okay, great, thanks for that clarification.

00:38:06.480 | I get a lot of questions about birth control,

00:38:10.680 | but on my social media handles.

00:38:12.800 | - Don't we all, don't we all?

00:38:14.600 | - To be clear.

00:38:15.440 | It's a vast topic for exploration,

00:38:19.780 | but along the lines of what we're talking about now,

00:38:23.320 | I've heard, and I suspect it may not be true, but tell me,

00:38:27.620 | is there any evidence that taking birth control

00:38:32.160 | can disrupt the process that you just described?

00:38:34.360 | And when we talk about birth control,

00:38:35.520 | we should probably define what we're talking about.

00:38:37.040 | So there are hormone-based birth controls, AKA the pill.

00:38:41.460 | There are also hormone-based birth controls

00:38:42.960 | that are not in pill form.

00:38:44.260 | There are IUDs that are copper IUDs.

00:38:48.240 | There are other IUDs.

00:38:49.200 | Let's just talk about hormone-based contraception

00:38:52.960 | in females, which many of them, as I understand,

00:38:57.960 | are estrogen mimics or estrogen themselves

00:39:01.260 | that suppress ovulation.

00:39:02.840 | Do they diminish or increase the number of eggs

00:39:06.240 | that are taken from the vault?

00:39:07.600 | - Fantastic question.

00:39:08.820 | Let's talk about what people say is the pill.

00:39:11.800 | So let's specifically talk about

00:39:13.340 | combined oral contraception,

00:39:15.320 | the pill which has ethanol estradiol

00:39:17.560 | and some type of progestin.

00:39:19.560 | No, contraception does not change

00:39:22.420 | the release of eggs out of the vault.

00:39:24.120 | They are occurring at the same process and the same pathway.

00:39:27.800 | You're not ovulating because that estrogen does prevent FSH

00:39:31.440 | from coming from the brain.

00:39:32.920 | So you have the group of eggs still come out of the vault.

00:39:35.480 | There's no FSH.

00:39:36.640 | They just all die.

00:39:37.860 | The next group comes out.

00:39:39.960 | So when you are saying,

00:39:42.300 | are you gonna run out of eggs faster?

00:39:43.760 | Is it gonna harm your fertility?

00:39:45.360 | Does birth control impair the process?

00:39:47.780 | The answer is no.

00:39:49.020 | But there's a couple important caveats.

00:39:51.220 | One is that the birth control pills,

00:39:53.000 | especially if you take them continuously

00:39:55.600 | or for a prolonged period of time,

00:39:58.120 | the body's smart and the ovaries start to say,

00:40:00.920 | well, we're not really doing anything.

00:40:02.760 | And one of those markers of ovarian reserve we have is AMH

00:40:06.040 | and that's antimalarion hormone.

00:40:08.100 | And AMH is made from the granulosa cells

00:40:10.380 | or the cells that surround every follicle.

00:40:13.000 | So in the shortest way possible,

00:40:15.280 | more eggs in the vault, more come out every month,

00:40:17.760 | higher AMH.

00:40:18.960 | Fewer eggs in the vault, fewer come out, lower AMH.

00:40:22.480 | If your AMH is being suppressed

00:40:24.880 | because of the birth control pill,

00:40:26.520 | because it's decreasing the activity

00:40:28.120 | of those granulosa cells,

00:40:30.040 | you might get a low AMH value

00:40:33.040 | when you've been on the birth control pill for a long time.

00:40:35.760 | That is completely reversible.

00:40:38.220 | But it can be significant.

00:40:39.740 | So if somebody is wanting to get an AMH level,

00:40:43.380 | let's say somebody comes to my clinic,

00:40:44.940 | they're not trying to get pregnant and they're on the pill

00:40:47.060 | and they're considering freezing their eggs

00:40:49.320 | so we're going to check their ovarian reserve.

00:40:51.880 | If we draw it, I always say this,

00:40:55.560 | AMH may be up to 30% lower

00:40:57.640 | than somebody who is on the birth control pill.

00:41:00.120 | So we can still draw it.

00:41:01.580 | And if it comes back in the normal range, we feel good.

00:41:05.080 | But if it does come back low,

00:41:06.520 | we're going to have to make a decision.

00:41:08.420 | Are we going to stop the birth control pill

00:41:10.520 | for a period of some months,

00:41:12.340 | use alternative contraception

00:41:13.800 | if you don't want to be pregnant,

00:41:14.920 | and then repeat this test to see if this is a true low

00:41:19.080 | because we do see that young women

00:41:21.120 | do have low ovarian reserve sometimes,

00:41:23.720 | or was this just suppressed

00:41:25.060 | because you were on the birth control pill?

00:41:27.780 | So we see it impact some of the hormone testing

00:41:30.960 | that we can do.

00:41:32.060 | And I think that's an important distinction.

00:41:34.480 | And we can see that the longer you take it,

00:41:37.020 | that potentially it might actually improve your fertility

00:41:40.940 | if you had underlying endometriosis

00:41:43.180 | or some medical conditions

00:41:45.160 | that we see associated with infertility.

00:41:47.460 | So prolonged pill users

00:41:49.740 | can potentially improve their fertility

00:41:53.020 | versus people who are trying to get pregnant

00:41:55.040 | that same age who were not on the pill.

00:41:57.680 | Those studies are complicated, right?

00:41:59.940 | Because of selection bias.

00:42:01.080 | Because if you've been on the pill for 10 years,

00:42:02.940 | you're a little bit older.

00:42:04.560 | So is it that they were preventing pregnancy

00:42:06.740 | and the other group potentially had some exposures?

00:42:09.080 | So they were inherently more infertile

00:42:11.200 | than the group that was on the pill.

00:42:13.440 | But we do know that the pill doesn't cause infertility.

00:42:16.360 | And I use it all the time.

00:42:17.700 | All the time in IVF cycles,

00:42:19.260 | we put people on the birth control pill

00:42:21.560 | because we can actually synchronize that group of eggs

00:42:24.480 | that comes out of the vault to grow together.

00:42:27.240 | Because your body doesn't want to have

00:42:29.300 | 20 babies at one time, right?

00:42:31.180 | And what we're trying to do with IVF,

00:42:32.540 | get 20 eggs to grow if that's what's out of the vault,

00:42:35.300 | really goes against the check and balance of the human body

00:42:39.540 | to not have 20 babies at once.

00:42:42.500 | - Why is it that males who take testosterone,

00:42:45.900 | synthetic testosterone,

00:42:47.400 | it shuts down their own testosterone production

00:42:49.580 | and sperm production,

00:42:50.540 | but females who take estrogen

00:42:52.020 | in the form of birth control pills,

00:42:53.280 | doesn't shut down estrogen production by the ovaries?

00:42:56.100 | - So I love this question.

00:42:57.780 | You know the answer, so I like it extra

00:42:59.400 | because I know you're asking.

00:43:00.900 | Spermatogenesis is a constant and ongoing process, right?

00:43:04.780 | So in women, you're born with all the eggs

00:43:06.700 | you're ever going to have.

00:43:07.960 | And what we're talking about is if we stop FSH

00:43:11.860 | at that moment,

00:43:12.880 | we're just impacting the ability to ovulate at that time.

00:43:15.600 | But we're not changing this constant loss

00:43:17.420 | throughout the vault.

00:43:18.540 | Spermatogenesis, right?

00:43:19.880 | The sperm is made every single day.

00:43:21.700 | You're making brand new sperm.

00:43:23.060 | So 72 days for the sperm to be created in the testes

00:43:26.180 | and 18 days to find their way out the ejaculatory system.

00:43:30.220 | And so exposures that you have

00:43:33.300 | that stop the production of FSH and LH

00:43:36.100 | inhibit the development, the creation of new sperm.

00:43:39.920 | So somebody who's been on testosterone

00:43:43.080 | will tell the brain,

00:43:45.140 | the brain doesn't know it's from your taking it.

00:43:46.860 | It says, "Hey, we have plenty of sperm, we're good.

00:43:49.140 | We don't need any more."

00:43:50.440 | So the brain then gets suppressed

00:43:52.100 | and doesn't make that FSH and LH,

00:43:54.660 | therefore not stimulating both further testosterone

00:43:58.220 | production 'cause you don't need that.

00:44:00.260 | But testosterone production and sperm production

00:44:02.060 | go hand in hand.

00:44:02.940 | So therefore you're no longer making new sperm.

00:44:05.940 | And in fact, the longer you're on testosterone,

00:44:09.680 | the harder it may be to get sperm production to come back.

00:44:12.100 | And in 25% of people, they may not get it back

00:44:14.980 | if they've been on prolonged testosterone exposure.

00:44:17.860 | So it's really because of what women will sometimes say

00:44:21.560 | is unfair, which is the fact that you're born

00:44:23.940 | with all these eggs and you run out of them.

00:44:25.760 | They accumulate the wear and tear of your life, right?

00:44:28.660 | We see egg quality being a huge issue

00:44:31.060 | in female reproduction,

00:44:32.820 | yet men get to have new sperm every 90 days.

00:44:36.360 | They get to wash away whatever bad deeds they did

00:44:38.820 | and can change their lifestyle and their exposures

00:44:41.080 | and have very different sperm.

00:44:43.160 | But because of that same process,

00:44:45.120 | things that shut off the production of FSH, LH

00:44:47.500 | really impact sperm quite significantly.

00:44:50.940 | - You mentioned bad deeds for sperm, not by sperm.

00:44:55.560 | I said for sperm.

00:44:56.900 | And we know that heat is a pretty dramatic insult

00:45:03.320 | to the spermatogenesis cycle,

00:45:06.860 | saunas and hot tubs and whatnot.

00:45:08.800 | I did receive the question as to whether or not

00:45:11.260 | heat exposure, saunas, hot tubs, et cetera,

00:45:14.120 | are they detrimental to ovulation

00:45:17.480 | or egg production in any way?

00:45:18.780 | I mean, obviously things are more internal in females.

00:45:21.100 | The ovaries are internal,

00:45:22.040 | but is there any evidence for that?

00:45:23.460 | I mean, the body does heat up.

00:45:24.820 | - Yeah, it doesn't harm the ovulatory period or the ovaries.

00:45:28.340 | And just like we know,

00:45:29.520 | the reason why the testes are so susceptible

00:45:31.940 | is because they're supposed to be at a cooler temperature.

00:45:34.340 | That's why they're in the scrotum outside the body.

00:45:36.660 | That's why the testes are so susceptible to heat changes.

00:45:40.840 | But the ovaries being inside the body,

00:45:42.900 | they're not in the same way.

00:45:44.140 | Now, when somebody's pregnant, important distinction, right?

00:45:47.300 | We know that the development,

00:45:49.820 | especially organ development of an embryo,

00:45:52.460 | can be more sensitive to certain things.

00:45:54.580 | And that heat exposure at that time,

00:45:56.460 | whether it's hot tub use or extreme fevers,

00:45:59.420 | even can make a difference in development of a fetus.

00:46:03.700 | But when it's coming to the ovulatory cycle

00:46:05.660 | or hormone production,

00:46:06.980 | heat in the female doesn't make any difference.

00:46:09.820 | - I want to be clear before I ask the next question

00:46:12.860 | that I don't want to be responsible

00:46:14.380 | for any unwanted pregnancies.

00:46:15.700 | But when I was in high school,

00:46:18.020 | they told us that women can get pregnant

00:46:21.620 | even while they have their period.

00:46:23.980 | Is that true?

00:46:24.800 | It seems like a lie based on everything you're saying,

00:46:26.700 | but I don't want anyone to run out

00:46:28.140 | and test that hypothesis without having the facts first.

00:46:31.560 | - So in general, if somebody has extremely regular cycles,

00:46:36.740 | then that's a complete lie.

00:46:38.460 | You can't get pregnant on your period.

00:46:40.420 | The reason why they tell us this is one,

00:46:43.020 | especially when you're younger,

00:46:44.540 | your period cycles tend to be irregular.

00:46:47.500 | They're not, your body hasn't fully matured

00:46:50.220 | to have that regularity.

00:46:52.020 | And that we know that sperm do live

00:46:55.460 | in the reproductive tract for much longer than the egg does.

00:46:57.780 | So sperm can live there for up to five days.

00:47:00.780 | So if somebody did have a shorter period window,

00:47:04.100 | let's say their normal periods are going to be 24 days,

00:47:07.980 | they're ovulating on cycle day 10.

00:47:10.260 | If they have a regular period that's five or six days,

00:47:14.020 | they could potentially have intercourse

00:47:15.660 | that end part of that period.

00:47:17.300 | The sperm could live for five days

00:47:18.820 | and be right there when you have the egg en route.

00:47:23.100 | So it's not the most fertile time for sure.

00:47:26.700 | And in most people that is considered a time

00:47:28.560 | when you're not going to get pregnant,

00:47:30.540 | but especially when you're younger

00:47:31.740 | and you have more irregularity

00:47:33.180 | or in people who have a short cycle window,

00:47:35.120 | that might not be the case.

00:47:36.900 | - So by extension, can we conclude then

00:47:40.020 | that the most fertile time is going to be

00:47:42.380 | when sperm meets egg,

00:47:44.460 | let's say timing of intercourse for the time being,

00:47:49.300 | but 'cause there's can be a delay there,

00:47:51.580 | when sperm meets egg on obviously day of ovulation

00:47:56.340 | or day after?

00:47:58.420 | - Day of. - Day of.

00:47:59.580 | - The egg lives for 24 hours.

00:48:02.160 | So the egg can only be fertilized for 24 hours

00:48:05.500 | while it's in the fallopian tube.

00:48:07.300 | Once the egg has entered the uterus,

00:48:08.780 | it can't be fertilized anymore.

00:48:10.460 | So it has this very short window of time

00:48:12.820 | where it will allow sperm to enter it.

00:48:15.760 | Now, sperm can live for five days.

00:48:18.380 | So we'll say the fertile window is this five-day period

00:48:21.760 | ending on the day of ovulation.

00:48:23.840 | You will hear a lot of us, a lot of doctors

00:48:26.380 | say the day after ovulation,

00:48:28.060 | because do you really know exactly what time

00:48:30.020 | you ovulated on?

00:48:31.040 | And if the egg has 24 hours,

00:48:33.140 | then that extra day could potentially be helpful.

00:48:36.340 | But really it's five days ending on the day of ovulation.

00:48:39.100 | And people with very regular cycles or who can track them

00:48:42.060 | and they know when that ovulation is happening,

00:48:44.620 | the day before and the day of ovulation,

00:48:47.120 | those are the two top heading days.

00:48:48.500 | So if you're kind of not in the mood to have lots of sex,

00:48:51.460 | those are going to be the days you target

00:48:53.640 | to have the highest chance of conceiving.

00:48:56.100 | - And what is the relationship between estrogen, libido,

00:48:58.460 | and ovulation in females?

00:49:00.260 | - The higher your estrogen is,

00:49:01.980 | the increased libido that you're going to have.

00:49:04.740 | And of course you see those peak estrogen levels,

00:49:07.220 | which are going to trigger that LH surge.

00:49:09.400 | So the body is made to get pregnant.

00:49:11.860 | You're going to have that peak estrogen,

00:49:13.400 | that peak libido right before

00:49:15.960 | and right at that ovulatory time period

00:49:18.420 | so that hopefully you also want to have intercourse

00:49:21.840 | and get pregnant.

00:49:23.340 | - I've heard before, let's just say,

00:49:25.300 | that some people, I have to be careful here,

00:49:27.900 | can sense the, literally the deployment of the egg,

00:49:33.620 | the ovulation, they report that they can feel

00:49:36.660 | that the, let's just say, the departure of the egg.

00:49:41.620 | Is that an imaginary thing?

00:49:44.100 | - No, no, that's very real.

00:49:45.700 | - I always liked that image

00:49:46.620 | that people can know when that happens, right?

00:49:48.220 | - It's so real it has a name.

00:49:49.060 | - I mean, after all, men generally know

00:49:50.140 | when their sperm are leaving their body.

00:49:53.540 | Let's hope they do.

00:49:54.500 | But why wouldn't there be an internal sense

00:49:59.620 | for women also of what's going on?

00:50:02.460 | I mean, we have interoception.

00:50:03.620 | There's a ton of nerve innervation of that area.

00:50:06.740 | - It doesn't communicate to the brain, excellent,

00:50:09.100 | as far as tracking to where that sensation is.

00:50:11.500 | But you're right.

00:50:13.100 | I already said ovulation is the rupture of assist, right?

00:50:16.600 | It is rupturing and the egg is being released

00:50:19.060 | and those follicular fluid is also exiting

00:50:22.080 | and going into the peritoneal cavity.

00:50:24.020 | And so there is a group of women who can feel that,

00:50:27.180 | especially people who are very in tune with their body.

00:50:30.900 | And it has a name, it's called middle schmertz.

00:50:32.660 | The pain almost feels like a crampy pain

00:50:36.340 | that happens in the middle of the cycle.

00:50:38.680 | And that is your ovulatory pain.

00:50:41.340 | - How interesting, what is it called?

00:50:42.780 | - Middle schmertz.

00:50:43.820 | - Okay, we'll put that in the show note captions

00:50:45.520 | and whoever does it is going to have to

00:50:47.340 | get the spelling right, middle schmertz.

00:50:49.220 | Amazing, amazing, amazing and foreign to me,

00:50:53.340 | but for obvious reasons, but amazing.

00:50:55.720 | I'm always astonished in how incredibly well

00:51:02.420 | orchestrated this whole process is.

00:51:04.020 | It's just such an incredible feat of biology.

00:51:08.360 | I mean, the number of things that have to be timed correctly

00:51:10.300 | and the use and I don't want to say reuse,

00:51:12.260 | but the repurposing of tissues for different things

00:51:15.260 | and like it's, what an incredible dance.

00:51:18.340 | That's just amazing. - It's beautiful.

00:51:20.020 | I mean, I'm so nerdy because I just love

00:51:21.780 | how everything has to communicate just perfectly.

00:51:24.600 | It makes you in awe of all the pregnancies

00:51:26.040 | that just happen just all the time

00:51:28.140 | because really things have to synchronize

00:51:30.580 | really at the wonderful time period.

00:51:33.380 | And even though this isn't what we're talking about,

00:51:34.700 | I've heard you say this, so I want to say this.

00:51:36.660 | People always ask every single day,

00:51:38.840 | well, how much sex should you have?

00:51:40.700 | When should you have sex?

00:51:41.900 | Is there too much sex?

00:51:43.260 | And what we know is that you definitely should not decrease

00:51:47.460 | your sexual intercourse interval.

00:51:49.580 | So if you are in a relationship

00:51:51.300 | and you are sex everyday people, have sex every day.

00:51:54.700 | You will 100% hit intercourse

00:51:57.140 | throughout your entire fertile window

00:51:58.640 | on the day that you ovulate.

00:52:00.180 | You're depositing the same sperm there

00:52:02.740 | because you're not generating new sperm.

00:52:05.660 | It's whether the load went half and half and half and half,

00:52:08.380 | or if it went in one big group.

00:52:11.660 | But if you're constantly putting more sperm out there,

00:52:14.860 | you have a higher chance.

00:52:16.060 | And so studies go back and always say daily intercourse,

00:52:20.380 | as I say, with the highest chance of fecundability,

00:52:22.620 | especially during the fertile window.

00:52:25.840 | However, for couples who are not sex everyday people,

00:52:29.880 | that idea can cause a lot of stress.

00:52:32.560 | Stress, of course, impacts the system

00:52:34.460 | in a lot of different ways.

00:52:35.940 | It can also cause sexual burnout,

00:52:37.580 | where they no longer feel like being intimate or having sex

00:52:41.560 | on the day they're actually ovulating,

00:52:43.120 | because they've been doing it this whole time leading up.

00:52:45.720 | And that's where the time period of saying,

00:52:48.760 | have sex every other day throughout the fertile window,

00:52:51.620 | so starting five or six days

00:52:53.120 | before you think you're going to ovulate,

00:52:55.200 | and then try to target having intercourse

00:52:57.040 | on the day before and the day of ovulation.

00:53:01.020 | And the reason why people said every other day

00:53:03.580 | or a few days prior to kind of get some sperm exposure there

00:53:06.660 | in case you ovulated early,

00:53:08.400 | but really to try to prevent some of that increased stress

00:53:11.220 | that can happen when you're trying to conceive,

00:53:13.900 | especially if you have programmed or timed intercourse

00:53:16.800 | that needs to happen on an everyday interval.

00:53:19.620 | But the odds of getting pregnant

00:53:22.340 | by saving up sperm for two or three days, that's not higher.

00:53:26.660 | - I'm curious then why, if let's just say hypothetically,

00:53:30.380 | someone is donating or freezing sperm or doing IVF,

00:53:34.100 | why they instruct the male to not ejaculate

00:53:37.580 | for 48 to 72 hours prior to,

00:53:40.660 | let's just say depositing sperm is such a funny word,

00:53:43.740 | but it works, so.

00:53:45.920 | - Two points.

00:53:46.760 | One, if we're doing a semen analysis,

00:53:48.660 | now we're trying to evaluate the sperm,

00:53:51.060 | and any test has certain normal parameters,

00:53:54.140 | and these are all based on a 48 to 72 hour abstinence period.

00:53:58.900 | So yes, if you ejaculate more frequently,

00:54:00.980 | you're going to have less sperm,

00:54:02.980 | and that can be very normal,

00:54:06.180 | but if we're looking at a test with set normal parameters

00:54:09.100 | that are based on two to three days

00:54:11.740 | of not having intercourse,

00:54:13.180 | that's why we want you to do it for that.

00:54:15.260 | If we're doing, let's say, IUI or intrauterine insemination,

00:54:19.380 | also known as artificial insemination,

00:54:21.880 | or where we take the sperm and put it in a catheter

00:54:24.180 | and put it in the uterus,

00:54:25.800 | we're trying to get more players further down the field,

00:54:28.940 | and in that case, I know when you ovulate

00:54:31.500 | because I'm timing it perfectly,

00:54:33.360 | and I am trying to get as many possible in this process,

00:54:36.440 | because we're not just having them deposited in the vagina,

00:54:39.680 | we're trying to get them further.

00:54:41.420 | So we want more

00:54:42.340 | because that's part of that treatment process.

00:54:44.380 | And similarly with IVF,

00:54:45.860 | I want to have as many sperm as possible to sort through

00:54:48.180 | and pick out the best looking, the most modal,

00:54:50.200 | the most normally shaped ones.

00:54:52.260 | So we're trying to get just a better sample.

00:54:54.720 | And by having these normal guidelines,

00:54:56.720 | we're able to judge this is low for what it should be,

00:54:59.820 | which can also be a clue to other problems.

00:55:02.940 | - I definitely want to talk about chemistry,

00:55:04.420 | both sort of interpersonal chemistry

00:55:07.020 | and literally ejaculate and vaginal chemistry.

00:55:10.340 | But before we do that,

00:55:12.220 | I'm curious whether or not we can just touch on

00:55:15.480 | a few of the things that a lot of people wonder about

00:55:18.340 | in terms of egg quality.

00:55:20.400 | And if they touch on sperm quality,

00:55:22.280 | maybe we can also just mention that.

00:55:24.400 | But for instance,

00:55:26.020 | does cannabis,

00:55:30.260 | either by edible or by smoking cannabis,

00:55:33.740 | impact egg quality in either direction?

00:55:36.240 | Alcohol would be the next.

00:55:38.760 | And then I'm going to assume,

00:55:41.100 | and I have to do this strictly because of what I understand

00:55:44.200 | about drugs of abuse,

00:55:45.880 | like cocaine and amphetamine, methamphetamine,

00:55:48.220 | that none of those can be good for systems of the body

00:55:51.020 | because they provide,

00:55:51.860 | they create so much stress for the body.

00:55:54.100 | But let's just say alcohol and cannabis.

00:55:56.100 | I read a statistic when researching the episode on cannabis

00:56:00.660 | that shocked me, which is that 15%,

00:56:03.580 | one five percent,

00:56:05.780 | not 1.5, 15% of American women,

00:56:10.060 | at least in this one study, survey,

00:56:12.220 | reported having consumed or smoked cannabis

00:56:16.180 | during known pregnancy.

00:56:18.100 | Which is wild. - Wild.

00:56:20.500 | - Unless of course, I'm just naive

00:56:23.540 | and THC is not harmful to the fetus,

00:56:26.380 | but I have a hard time believing that.

00:56:28.760 | So what gives?

00:56:30.820 | I mean, and there I actually just threw in

00:56:33.300 | fetal development.

00:56:34.180 | So is cannabis, is alcohol bad for egg quality?

00:56:39.180 | - So there are different things

00:56:40.340 | and they're the same thing in one.

00:56:41.340 | So let's answer them each individually.

00:56:42.820 | So we'll go with the one that everybody knows

00:56:44.460 | and has accepted now

00:56:45.780 | that they wouldn't have accepted 40 years ago, right?

00:56:47.640 | Smoking cigarettes.

00:56:48.540 | So that's obviously bad.

00:56:50.440 | Decreases the number of eggs you have in the vault.

00:56:52.740 | Smoking cigarettes actually gets into your vault,

00:56:54.540 | decreases the number that you have.

00:56:55.800 | You have a higher chance of going into menopause earlier

00:56:58.440 | and it increases the risk of having abnormal chromosomes,

00:57:02.560 | which is what we really think about

00:57:04.200 | when we think about egg quality, right?

00:57:05.780 | Impacting those myotic spindles inside the eggs,

00:57:09.000 | which hold the chromosomes in their perfect position.

00:57:11.860 | They are associated, they get wear and tear

00:57:15.100 | from things that cause inflammation or are toxic.

00:57:18.200 | So cigarette smoke, we know decreases egg quality,

00:57:21.280 | egg quantity, increases miscarriage,

00:57:23.780 | and then of course has fetal impacts.

00:57:25.600 | - Could I just ask you,

00:57:26.440 | because when we talk about there's nicotine,

00:57:29.800 | which itself is not carcinogenic,

00:57:31.320 | and then there's the smoking process,

00:57:32.720 | which brings in a bunch of other things.

00:57:34.520 | The question I know is burning in everybody's mind

00:57:37.480 | is vaping, right?

00:57:39.000 | Because vaping is, I'm very bullish on this.

00:57:42.580 | I mean, it's very clear that the chemicals

00:57:44.020 | associated with vaping are just,

00:57:45.200 | oh, so bad for everybody's health,

00:57:47.720 | but it's distinctly different from saying

00:57:49.720 | that nicotine is bad for one's health.

00:57:52.840 | And it can be, but without doing too much of a deep dive,

00:57:57.000 | are there any data that show

00:57:58.320 | that vaping is bad for egg quality?

00:58:00.320 | - Of course there's not as much data

00:58:01.840 | because it just hasn't been around as long.

00:58:04.520 | But yes, vaping definitely has chemicals

00:58:06.560 | that looks like it's associated

00:58:08.160 | with poor success rates and IVF cycles.

00:58:11.600 | And that's really kind of one of the most finite measures

00:58:14.280 | of egg quality we can see,

00:58:15.640 | because we're really testing the egg at a level in a lab

00:58:19.540 | versus just, are you getting pregnant naturally?

00:58:21.920 | - And sorry to interject again,

00:58:23.140 | but anytime a conversation like this comes up,

00:58:25.040 | especially between two people in the health science space,

00:58:28.620 | there are these shouts, 'cause I hear them, literally,

00:58:31.640 | where people say, well, listen, I vaped every day

00:58:35.800 | and I've had three healthy babies.

00:58:37.140 | And I think that my response is always,

00:58:39.040 | okay, there's going to be a distribution of responses.

00:58:41.140 | And then of course,

00:58:41.980 | how much healthier could your babies have been

00:58:45.120 | had you not vaped during pregnancy

00:58:46.800 | or vaped prior to pregnancy?

00:58:48.160 | Or, I mean, I think these are the key issues

00:58:50.200 | that like you can't rewind the clock, as far as I know,

00:58:53.600 | right, in the absence of a time machine,

00:58:54.960 | you can't rewind the clock.

00:58:55.900 | So, I mean, basically everything you're saying

00:58:58.500 | is that smoking cigarettes or vaping nicotine

00:59:02.300 | just can't be good for egg quality.

00:59:04.200 | - We know that.

00:59:05.040 | We know that it's not good for getting pregnant.

00:59:07.480 | We know that it's not good for sperm.

00:59:09.360 | And therefore, we also know it's going to impact

00:59:12.760 | pregnancy rates, you know, things like cannabis, right,

00:59:15.760 | decreases sperm production, decreases sperm motility,

00:59:19.240 | changes sperm morphology, the shape of it,

00:59:21.360 | changes the DNA, increases the fragmentation of the DNA.

00:59:25.200 | If your partner uses cannabis and you get pregnant,

00:59:29.040 | you have a higher chance of miscarriage

00:59:31.020 | because of the sperm association with the cannabis.

00:59:34.120 | - Edible cannabis as well as smoke cannabis.

00:59:35.480 | - I don't know, right,

00:59:36.320 | because you can't study something that's illegal.

00:59:38.280 | So a lot of this data is just more new

00:59:41.180 | and a lot of it's going to be observational.

00:59:43.200 | - And in states like Colorado and California,

00:59:45.040 | where, you know, canvas is essentially legal,

00:59:47.760 | I'm assuming that there are more data, but okay.

00:59:52.020 | So smoking and or vaping nicotine,

00:59:57.020 | cannabis, either edible or smoked,

01:00:01.680 | very likely detrimental to egg quality and sperm quality,

01:00:06.240 | which is not to say that one can't conceive.

01:00:09.080 | It just means that the quality of your baby,

01:00:11.920 | your child will not be as high as the quality of that baby

01:00:15.720 | if you didn't do that, is that right?

01:00:17.660 | - Yes.

01:00:18.500 | - And I'm not trying to demonize anyone

01:00:19.660 | that did do this during pregnancy.

01:00:21.480 | A lot of people didn't know,

01:00:22.760 | but this is really about people trying to make choices

01:00:25.580 | in anticipation of future pregnancy.

01:00:27.540 | - Yeah, and when you're trying to set yourself up

01:00:29.780 | for success, because we know infertility

01:00:32.480 | is becoming more common.

01:00:33.580 | We don't always know who is going to have it.

01:00:36.120 | And when you find yourself in that position specifically,

01:00:40.000 | you now want to optimize everything you can.

01:00:42.360 | So if there's something that is going to make

01:00:44.520 | the sperm quality worse and the egg quality worse

01:00:47.320 | and your success with treatment lower

01:00:49.560 | and your miscarriage rate higher,

01:00:51.840 | we're going to recommend that you not do it.

01:00:53.960 | If you're trying to get pregnant naturally,

01:00:55.720 | all these things correlate over, but of course,

01:00:58.220 | there's always going to be outliers and exceptions.

01:01:00.880 | I'm going to sit here and tell you

01:01:02.240 | that the odds of getting pregnant at age 43

01:01:04.580 | are less than 3% per month.

01:01:06.540 | And every single person is going to be like,

01:01:08.060 | but my Aunt Barbara, or I know this person who did,

01:01:10.940 | because 3% is not zero.

01:01:12.980 | - And you're talking about natural pregnancy there

01:01:14.840 | by intercourse?

01:01:16.220 | - Having old fashioned way, yes.

01:01:18.380 | Right, but yes, so people will get pregnant.

01:01:20.480 | People will have healthy children who do have exposures

01:01:23.900 | to nicotine, to cannabis, even to alcohol.

01:01:26.380 | Even though we know that alcohol

01:01:27.580 | can cause fetal alcohol syndrome,

01:01:29.560 | 0% of alcohol should be the acceptable level in pregnancy.

01:01:35.120 | And then does alcohol impact fertility?

01:01:37.440 | Such a complicated question.

01:01:39.300 | And this is probably due to the amount you consume

01:01:42.600 | and the frequency of which you consume it.

01:01:44.760 | Alcohol is a toxin that your liver must filter out

01:01:47.920 | and we know it causes inflammation.

01:01:50.000 | Anybody who's had a fun night with alcohol

01:01:51.800 | knows they can wake up the next day and they feel different.

01:01:55.220 | Their body is processing that alcohol.

01:01:57.960 | And that inflammation, especially if it's chronic,

01:02:01.200 | chronic exposure, we know chronic inflammation

01:02:04.640 | is one of the things that we see

01:02:06.520 | impacting egg quality and sperm quality.

01:02:08.920 | So certainly if you enjoy alcohol,

01:02:11.520 | it should be something that is done in moderation,

01:02:14.000 | one or two drinks a week at the most,

01:02:16.920 | and you should not do it at all

01:02:18.480 | once you find out you're pregnant.

01:02:20.240 | - I'd like to take a quick break

01:02:21.440 | and thank our sponsor, Inside Tracker.

01:02:24.120 | Inside Tracker is a personalized nutrition platform

01:02:26.400 | that analyzes data from your blood and DNA

01:02:29.040 | to help you better understand your body

01:02:30.520 | and help you reach your health goals.

01:02:32.360 | I've long been a believer in getting regular blood work done

01:02:35.160 | for the simple reason that many of the factors

01:02:37.320 | that impact your immediate and long-term health

01:02:39.320 | can only be assessed with a quality blood test.

01:02:41.920 | The problem with a lot of blood and DNA tests out there,

01:02:43.880 | however, is that they'll give you information

01:02:46.340 | about certain lipid markers or hormone markers,

01:02:49.500 | but no information about what to do with all of that data.

01:02:52.560 | Inside Tracker makes it very easy

01:02:53.920 | to look at your levels of hormones,

01:02:55.400 | metabolic factors, lipids, et cetera,

01:02:57.600 | and then to assess what sorts of behavioral, nutritional,

01:03:00.660 | supplementation, or perhaps other interventions

01:03:02.600 | you might want to use in order to bring those numbers

01:03:05.000 | into the ranges that are optimal for your health.

01:03:07.280 | Inside Tracker's ultimate plan now includes

01:03:09.320 | three new hormone markers that are critical to measure

01:03:11.860 | during a woman's reproductive and menopausal years.

01:03:14.380 | These are estradiol, progesterone,

01:03:16.280 | and thyroid stimulating hormone.

01:03:18.180 | If you'd like to try Inside Tracker,

01:03:19.580 | you can go to insidetracker.com/huberman

01:03:22.480 | to get 20% off any of Inside Tracker's plans.

01:03:25.160 | Again, that's insidetracker.com/huberman to get 20% off.

01:03:30.040 | When we were talking about birth control,

01:03:31.600 | I unfortunately moved us forward

01:03:34.120 | and forgot to ask about IUDs.

01:03:37.520 | So my understanding is that the copper IUD works

01:03:39.920 | by creating a sort of, not actually electric,

01:03:43.000 | but a kind of a electric fence that kills sperm.

01:03:48.000 | Sperm don't like copper. - I love that analogy.

01:03:49.760 | Yeah, I love that one. - Sperm don't like copper.

01:03:50.860 | Copper likes to kill sperm.

01:03:54.440 | There's some interesting history.

01:03:56.300 | I've been reading a lot on the history of medicine

01:03:57.860 | of people who, you know, for whatever reason,

01:04:00.900 | were forced into or chose to be in the sex trade,

01:04:03.480 | prostitutes using, inserting copper coins

01:04:06.920 | into their vaginal tract to try and kill sperm,

01:04:09.720 | but to varying degrees of success.

01:04:12.040 | Obviously, there's a whole socioeconomic landscape

01:04:14.980 | around that, so I think it's obvious what I'm referring to,

01:04:18.320 | but very interesting, but that's just one form of IUD.

01:04:21.880 | Right, there are some other IUDs,

01:04:23.960 | and then there's, of course, the ring.

01:04:25.740 | We didn't talk about that.

01:04:26.600 | So maybe we just touch on a few of those

01:04:28.480 | within the context of whether or not it alters egg quality

01:04:32.340 | and/or future fertility when one takes the ring out,

01:04:35.740 | takes the IUD out.

01:04:36.880 | - This is a great question

01:04:37.760 | because a lot of people don't know this,

01:04:39.520 | and I'll roll through a few of the top birth control methods

01:04:42.100 | and just thinking through.

01:04:43.480 | Copper IUD, as you already said, no hormonal involvement.

01:04:46.300 | It causes inflammation and a toxic environment

01:04:48.660 | inside the uterus, isolated,

01:04:50.940 | does cause sometimes heavier periods,

01:04:53.120 | but they should still be regular.

01:04:54.880 | If they are irregular, that's a sign of a hormonal issue

01:04:57.720 | because you still ovulate with the copper IUD.

01:05:00.000 | - Is it literally a copper wire woven

01:05:01.680 | into the tissue of the uterus?

01:05:03.080 | - Well, the IUD is a little T,

01:05:04.960 | and the arms have copper wires wrapped around them.

01:05:08.660 | - And those are, they grow into the uterine lining?

01:05:11.640 | - They don't grow into the uterine lining.

01:05:13.000 | The IUD just sits in there,

01:05:14.360 | and just the presence of that copper

01:05:16.640 | causes that inflammatory reaction

01:05:18.480 | in that toxic environment.

01:05:19.720 | - And is it toxic to the environment

01:05:21.560 | in ways that are detrimental to the woman or just to sperm?

01:05:25.120 | - Both.

01:05:25.960 | I mean, implantation is not going to occur likely, right?

01:05:29.680 | I mean, nothing is 100% successful,

01:05:32.480 | but it's much harder for an embryo to implant

01:05:34.480 | within that highly inflammatory environment.

01:05:36.640 | - To me, amazing that people figured this out before-

01:05:39.000 | - Oh, it's fascinating. - The advent of laboratories.

01:05:41.720 | - Right?

01:05:42.540 | Let's just put some copper in some uteruses

01:05:44.280 | and see what happens.

01:05:45.780 | - You know, it really speaks to the urgency

01:05:48.840 | that must have existed to preventing pregnancy

01:05:50.840 | and just how costly, biologically and financially,

01:05:54.440 | pregnancy is.

01:05:55.280 | - And pregnancy is not health neutral,

01:05:56.440 | so it is something that somebody needs to be

01:05:59.880 | of right health, or it can be a deadly circumstance.

01:06:03.720 | When we get back to other IUDs,

01:06:05.240 | so IUDs that more people are more familiar with

01:06:07.720 | are the progesterone-based IUDs.

01:06:10.200 | This is going to be your Mirena, Kylina, Lyletta.

01:06:12.880 | They have a bunch of different names

01:06:14.120 | based on the amount of progesterone

01:06:16.900 | and how long they last for.

01:06:19.520 | These work mostly by thinning out the uterine lining.

01:06:22.760 | As we already said, progesterone compacts the uterine lining

01:06:26.120 | to prepare it for implantation in a normal cycle.

01:06:29.640 | But if you have constant exposure to progesterone,

01:06:33.120 | what is going to happen is it's going to prevent

01:06:35.680 | the uterine lining from growing,

01:06:37.280 | and it gets it very, very thin.

01:06:39.800 | Not all IUDs, in fact, most of them don't prevent ovulation.

01:06:43.760 | Only in about 50% of people

01:06:45.400 | do they actually prevent ovulation.

01:06:47.700 | So their main mechanism of action

01:06:49.560 | is this endometrial effect.

01:06:52.360 | When you remove the IUD,

01:06:54.680 | especially if you're already ovulating, no problem.

01:06:58.240 | The problem we do see in some people with progesterone IUDs

01:07:01.660 | that maybe isn't talked about as much

01:07:03.600 | is that this prolonged progesterone exposure,

01:07:05.880 | because people are putting IUDs in for five to seven years

01:07:09.640 | and not having a period for that length of time

01:07:12.200 | because the endometrium has become so atrophic

01:07:15.280 | or nonexistent that you're no longer bleeding

01:07:18.820 | despite the fact that you may be ovulating.

01:07:22.020 | It can take a while for that lining to grow back.

01:07:24.780 | And so it's not uncommon to have an IUD in place,

01:07:28.700 | and if you have no period, you're gonna say,

01:07:30.440 | "This is great, I don't have a period, wonderful."

01:07:33.580 | You get it removed, and now your period hasn't come back.

01:07:37.540 | And that leads people to sometimes be concerned

01:07:39.780 | that the IUD is causing them not to ovulate

01:07:42.060 | or they have this infertility caused by the IUD,

01:07:46.480 | but really what it is is that the lining's become so, so thin

01:07:49.280 | that it can take many months

01:07:50.700 | of that unopposed estrogen exposure in the follicular phase

01:07:54.460 | to get it thick enough to finally bleed

01:07:57.280 | when you're ovulating.

01:07:58.740 | So I do tell people if they have a progesterone IUD

01:08:01.140 | to get it removed three to six months

01:08:03.280 | before they wanna get pregnant,

01:08:05.340 | use some other form of contraception,

01:08:07.540 | but give their body time to make sure

01:08:09.920 | they have that regular period pattern back.

01:08:12.600 | Important distinction, if you're still ovulating

01:08:16.200 | and having a period on an IUD,

01:08:18.360 | then this is gonna be less of a concern

01:08:19.940 | because if you're growing enough of a lining

01:08:22.080 | to then shed it, we're less worried about it.

01:08:25.080 | But if you are amenorrheic

01:08:26.840 | or have absence of your periods with an IUD,

01:08:29.740 | we need to think about removing it for a period of time

01:08:32.920 | before you get pregnant

01:08:34.160 | so that your body can grow that lining again.

01:08:37.320 | When it comes to some of the other things that you mentioned,

01:08:39.880 | one you didn't ask that I wanna mention

01:08:41.680 | is the Depo-Provera shot.

01:08:43.640 | The Depo-Provera shot is a high dose of progesterone,

01:08:46.560 | high enough to actually prevent ovulation.

01:08:49.280 | So in that circumstance, you are not ovulating

01:08:52.240 | and therefore if you don't ovulate,

01:08:54.540 | you're not going to get pregnant.

01:08:56.360 | Depo-Provera is proven to prevent ovulation

01:08:59.280 | for three months.

01:09:00.200 | So when you take it, you need to get it every three months

01:09:03.880 | to have a proven contraceptive benefit.

01:09:06.460 | However, it can last in your system for 18 months

01:09:09.940 | and prevent ovulation for up to 18 months.

01:09:13.780 | So I will see people who liked that option

01:09:16.580 | for contraception and now they haven't had a period

01:09:19.100 | in a long time but their last Depo shot was six months ago

01:09:23.300 | and they're all frustrated by the fact when I tell them,

01:09:26.460 | well, you still may not have another period for a year plus

01:09:29.180 | because this high level of progesterone

01:09:31.860 | that you've already injected into your system

01:09:34.340 | can last a substantial amount of time.

01:09:37.300 | So that is a contraceptive option that I tell people

01:09:39.680 | to discontinue a year and a half to two years

01:09:42.440 | before they want to get pregnant,

01:09:43.780 | which sometimes people don't know that yet.

01:09:46.920 | And so that's something that can be a contraceptive option

01:09:49.360 | for if you're very remote from wanting to have a child.

01:09:52.560 | But in people who are in their childbearing years

01:09:54.480 | contemplating family building soon,

01:09:57.400 | that is not my favorite option.

01:09:59.500 | - So you haven't mentioned, because I haven't asked,

01:10:03.880 | any negative consequences of birth control of any kind.

01:10:08.580 | And I'm not encouraging you to, if you don't believe in them,

01:10:10.800 | I know that this is a very controversial topic,

01:10:14.160 | but one of the more popular studies discussed

01:10:18.200 | on social media is one that I've spent some time

01:10:20.520 | with the paper and a few of the papers that stemmed from it.

01:10:24.280 | Not a huge study, but describing that how women rate

01:10:29.280 | the faces of men as either more,

01:10:32.700 | essentially what happens is there seems to be,

01:10:34.600 | at least in this study,

01:10:36.480 | there was a statistically significant bias

01:10:41.480 | for women to select particular male faces as attractive.

01:10:45.960 | And those male faces tended to be of the more, you know,

01:10:49.640 | square jaw, AKA masculine features, right?

01:10:52.100 | In air quotes, right?

01:10:53.200 | This is what the study found.

01:10:56.000 | But that when women were on oral contraception,

01:10:58.840 | presumably estrogen progestin type oral contraception,

01:11:02.140 | that that effect was smeared.

01:11:06.940 | They had not a statistically significant tendency

01:11:10.660 | to choose the quote unquote more masculine faces.

01:11:14.160 | I have to be very careful with my language here

01:11:15.560 | because, you know, it's easy to get description

01:11:17.320 | of a study like this wrong.

01:11:18.440 | And that has led a lot of people to think

01:11:20.440 | that birth control is going to throw off

01:11:22.500 | their partner choice.

01:11:23.640 | Now, of course, it is a small study.

01:11:28.000 | Studies like it are not always so well controlled.

01:11:32.300 | But is there any evidence that birth control,

01:11:35.800 | oral estrogen progestin based birth control,

01:11:38.820 | just to keep it specific, can increase rates of cancers,

01:11:41.840 | can decrease rates of cancers,

01:11:43.720 | can lead to any sorts of disruptions

01:11:46.640 | in bodily function or health?

01:11:50.260 | That's really like a rock solid result.

01:11:52.620 | That's been seen by multiple studies, clinical trials,

01:11:55.620 | or are we still just in the dark about a lot of this stuff?

01:12:00.180 | Okay, so nothing is without risk.

01:12:02.300 | Getting pregnant is not without risk.

01:12:03.820 | Taking the birth control pill is not without risk.

01:12:06.420 | We do see that there's been a lot of not informed consent

01:12:11.420 | in people who are taking the birth control pill,

01:12:13.820 | meaning maybe they weren't educated

01:12:15.940 | about what all of their options were,

01:12:18.420 | the positives and the negatives about each one of them.

01:12:21.460 | If we're gonna reference the convo to the pill,

01:12:23.860 | estrogen progesterone pill,

01:12:25.380 | important to understand that neither the estrogen

01:12:27.380 | nor the progesterone are the same estrogen progesterone

01:12:30.000 | that your ovaries make, right?

01:12:31.780 | It's ethanol estradiol,

01:12:33.180 | which your brain interprets as an estrogen,

01:12:35.740 | but other parts of your body may not.

01:12:37.860 | And then it's various types of progestins,

01:12:40.820 | some of which have even androgenic

01:12:42.740 | or male hormone-like properties, and some of which do not.

01:12:46.460 | So there's a ton of variation,

01:12:48.300 | even the amount of ethanol estradiol that each pill has,

01:12:51.660 | with your low low and your low pills having less,

01:12:55.420 | and even with the modern day average pill

01:12:57.660 | having a lot less estrogen than it used to.

01:13:01.320 | When you're on the birth control pill,

01:13:03.400 | your ovaries aren't making estradiol.

01:13:06.680 | And that estradiol is important

01:13:09.440 | in growing the uterine lining,

01:13:11.680 | but also for the genital structures.

01:13:14.120 | And so we think about vaginal health and vulvar health.

01:13:17.220 | We certainly see that especially with continuous use.

01:13:20.600 | So if we distinguish you take the pill for 21 days

01:13:24.800 | and you have a seven day break where you might bleed

01:13:27.080 | or you take sugar pills, and then you take them again,

01:13:29.740 | a lot of people now are taking continuously

01:13:32.480 | where you have exposure to these compounds every single day.

01:13:36.620 | - So in like the wheel, the little pouch with the wheel

01:13:41.620 | of different colored pills,

01:13:43.460 | may have seen these on the counter shop

01:13:46.160 | in previous relationships.

01:13:47.960 | And then there's the ones that sometimes people

01:13:49.880 | just opt not to take, because those are the,

01:13:51.880 | not the placebo, they're the sugar pills.

01:13:54.040 | There's no need to take estrogen during that phase.

01:13:56.480 | And then, and then they repeat, is that-

01:13:58.040 | - Exactly.

01:13:58.880 | - Okay, but some people are taking estrogen-

01:14:00.360 | - Continuously, it's very common right now.

01:14:02.560 | So people, and they're not wrong.

01:14:04.540 | They say, oh, well, why have a period

01:14:07.160 | in these little breaks?

01:14:08.320 | It's not really a reflection of my hormone status,

01:14:10.360 | which is accurate.

01:14:11.440 | And so they're taking them continuously.

01:14:13.640 | You also have less pill failure pregnancies.

01:14:16.180 | So if you're using the pill for contraception,

01:14:18.120 | that can be a great strategy.

01:14:19.800 | But the longer you take them,

01:14:20.760 | we do see some vaginal and vulvar changes, right?

01:14:24.080 | And so atrophic vaginitis, people who notice

01:14:27.360 | increased sensitivity, decreased elasticity,

01:14:30.400 | increase discomfort with intercourse,

01:14:33.400 | increase in yeast infections, that can sometimes be seen

01:14:36.440 | because that environment is different.

01:14:39.040 | Now, that's just one thing that can come from the pill.

01:14:43.040 | We also see the pill be lifesaving for other people.

01:14:46.320 | They have terrible PMS, or premenstrual dysphoric syndrome,

01:14:51.080 | where their mental health, when they change

01:14:53.160 | from high to low estrogen, it's always the change

01:14:56.360 | in estrogen that interferes, can cause some people

01:14:59.360 | to really have mental health issues that are so severe

01:15:02.740 | that having that stable hormone level is helpful.

01:15:06.060 | And so the pill can be extremely beneficial

01:15:08.160 | for some people when it comes to mental health.

01:15:10.360 | It can be beneficial for people who have issues

01:15:13.680 | with very heavy periods and anemia.

01:15:15.640 | Instead of getting blood transfusions,

01:15:17.520 | taking the birth control pill might prevent the lining

01:15:20.200 | of the uterus from growing so much that they bleed so much.

01:15:23.040 | Same thing with fibroids, people with PCOS.

01:15:26.520 | PCOS is polycystic ovarian syndrome.

01:15:29.280 | If we wanna put it very simply,

01:15:31.160 | you have a lot of eggs in your vault,

01:15:32.480 | so you release a lot of eggs every month.

01:15:34.640 | And what this does is the FSH signal gets diluted,

01:15:38.120 | and so you're not responding to the normal signal

01:15:41.080 | and you don't ovulate.

01:15:42.600 | And because the ovary is a hormone-making factory,

01:15:45.120 | it gets really bored when it can't make estrogen

01:15:48.080 | 'cause that egg's not growing,

01:15:49.400 | so it starts to make testosterone.

01:15:51.240 | So you start to see this androgen-dominant environment

01:15:53.920 | associated with lack of ovulation

01:15:56.280 | and having a lot of follicles inside the ovary

01:15:59.600 | that are not really responding.

01:16:00.960 | - And the androgenization of other tissues,

01:16:05.720 | like body hair, deepening of voice?

01:16:07.720 | - Yeah, body hair.

01:16:09.040 | Typically, the level of testosterone made in PCOS

01:16:12.000 | isn't truly deepening voice.

01:16:14.440 | It can if there is an ovarian tumor making testosterone

01:16:18.200 | or certain other conditions.

01:16:19.300 | But typically with PCOS, you see increase in body hair,

01:16:22.320 | increase in acne, and you can see some even male pattern

01:16:25.960 | balding, some temporal balding of women, so some hair loss.

01:16:29.700 | - Temporal balding, so like the widow's peaking?

01:16:31.740 | - Yeah, the widow peaking and then thinning out

01:16:33.680 | in these two areas.

01:16:35.400 | And then we see an increase in body composition

01:16:38.920 | towards the male level.

01:16:39.840 | So if we think about a male body holding your fat

01:16:43.320 | in your abdominal region,

01:16:45.280 | and if we think about the traditional female body

01:16:47.600 | holding more fat in the hips and thighs area,

01:16:50.560 | we see that when this hormone shifts in PCOS,

01:16:53.260 | you tend to get more abdominal fat distribution,

01:16:55.860 | which then leads to further insulin resistance

01:16:58.460 | and metabolic syndrome.

01:16:59.900 | But in PCOS, because you're not ovulating,

01:17:03.080 | and those ovaries, each little follicle

01:17:07.360 | makes a tiny amount of estrogen.

01:17:09.380 | We'll say each little follicle, when it's not responding,

01:17:11.720 | will make one to two picograms of estrogen.

01:17:14.700 | But if you have 50 of them each month,

01:17:16.640 | you're having some constant estrogen exposure.

01:17:19.920 | So that lining of the uterus

01:17:21.240 | is being constantly stimulated to grow,

01:17:23.360 | and you're never getting the progesterone to stabilize

01:17:26.300 | or the progesterone withdrawal to bleed.

01:17:28.600 | So endometrial cancer is much higher

01:17:30.460 | in people with PCOS who don't ovulate,

01:17:32.280 | and the birth control pill can prevent that.

01:17:35.020 | Any unopposed estrogen situation,

01:17:37.480 | because the body is made to have

01:17:39.240 | both estrogen and progesterone.

01:17:41.840 | So we see an immense decrease in endometrial cancer,

01:17:44.840 | an immense drop in ovarian cancer.

01:17:46.880 | Ovarian cancer comes from the remodeling of the ovary.

01:17:49.760 | So every time you have a follicle grow, and it ruptures,

01:17:52.760 | and it makes the corpus luteum, and then it heals up,

01:17:55.800 | those are opportunities for those cancer cells

01:17:59.820 | to go away in that remodeling process

01:18:02.200 | and lead to ovarian cancer.

01:18:04.520 | And because you're not ovulating on the pill,

01:18:07.960 | your incidence of ovarian cancer drops dramatically.

01:18:11.440 | 10 years of pill use has dropped the chance

01:18:13.520 | you get ovarian cancer by more than 90%.

01:18:16.320 | And of course, ovarian cancer is super hard to diagnose

01:18:19.800 | because the innervation to the peritoneal system is poor,

01:18:23.800 | and you don't have any outward signs,

01:18:25.320 | often till late-stage disease.

01:18:27.660 | That being said, could you potentially have an increase

01:18:31.860 | in breast cancer in some people?

01:18:34.200 | - By taking the pill?

01:18:35.040 | - By taking the pill.

01:18:36.000 | That's a concern, especially in people

01:18:38.400 | who might be predisposed to this for some other reason.

01:18:40.920 | - So they might have BRCA mutations

01:18:42.400 | or something like that.

01:18:43.920 | - And then is there a situation where the pill

01:18:47.280 | certainly masks what's going on with your menstrual cycle?

01:18:50.760 | And I really think this is where women's health

01:18:54.040 | has a huge history in paternalism,

01:18:56.120 | meaning doctors will just tell people,

01:18:59.200 | this is what you're going to do.

01:19:00.640 | So your periods are irregular,

01:19:02.400 | here is the birth control pill.

01:19:04.200 | And they're not explaining why or the pros and cons to it.

01:19:07.000 | And what happens is people are not being taught

01:19:09.760 | how their bodies work, and now they are

01:19:11.520 | because of your podcast amongst others.

01:19:14.400 | And now they're able to know that my period's a vital sign

01:19:17.880 | and I don't know what it is because the pill

01:19:20.560 | is producing a different environment.

01:19:22.920 | The pill's also been associated with potentially development

01:19:25.880 | of things like leaky gut or IBS.

01:19:28.340 | And so there is a definite change in your environment

01:19:32.720 | when you're on the birth control pill.

01:19:34.060 | Increased risk of blood clots

01:19:35.640 | because of how it's processed in the liver,

01:19:37.920 | increasing your clotting factors.

01:19:39.480 | - Can I just interrupt there?

01:19:41.480 | I'm aware that a fairly high percentage of people

01:19:46.480 | have mutations in factor V Leiden, a clotting factor.

01:19:52.600 | Fewer people are, as we say, homozygous,

01:19:55.000 | have two deficient copies, mutant copies, I should say.

01:19:58.960 | But there are many people out there

01:19:59.960 | that have one mutant copy of factor V Leiden.

01:20:01.920 | And my understanding is that oral contraception in females

01:20:04.760 | can really exacerbate the factor V Leiden mutation.

01:20:08.600 | Do you suggest that people get their factor V Leiden

01:20:13.600 | genetics analyzed?

01:20:15.440 | I mean, it's pretty inexpensive to do, right?

01:20:17.160 | I think on a standard blood test,

01:20:18.440 | you can just ask for the factor V analysis.

01:20:21.700 | And it's not like a really in-depth thing.

01:20:23.840 | You don't have to fly to some-

01:20:24.680 | - Yeah, it's a blood test.

01:20:25.520 | - Yeah, you don't have to fly to another country,

01:20:27.880 | like you do for many things.

01:20:29.840 | - It's important to say that's not the norm, right?

01:20:31.560 | Like that's not the recommendation.

01:20:33.040 | When you're talking about putting somebody

01:20:34.140 | on the birth control pill,

01:20:35.640 | you want to make sure they don't have high blood pressure

01:20:37.480 | 'cause it can increase their blood pressure.

01:20:39.080 | You want to make sure they don't smoke cigarettes

01:20:40.720 | because the combination of the pill and cigarette smoking

01:20:43.640 | can increase the risk of a stroke.

01:20:45.560 | But the recommendation is not to screen them

01:20:47.360 | to see if they have any inherited clotting disorders.

01:20:50.160 | That said, if you ever have a blood clot

01:20:52.560 | on the birth control pill,

01:20:53.960 | 'cause you're traveling on a plane

01:20:55.240 | or you're just on the pill or you're living your life,

01:20:58.040 | you're now gonna get this extensive workup

01:21:00.180 | to find out if you do have that.

01:21:02.120 | It's by no means wrong, and specifically you should,

01:21:05.040 | if anybody in your family has ever had a DVT,

01:21:08.480 | so a deep vein thrombosis, so a blood clot in their leg,

01:21:11.440 | or a pulmonary embolism or a PE,

01:21:13.800 | so anybody in your family has had one of those,

01:21:16.200 | you should 100% get worked up for clotting disorders.

01:21:19.740 | And if you have something, like you carry Factor V,

01:21:22.680 | you should no longer take the birth control pill.

01:21:24.880 | And specifically the pill, because it's an oral pill

01:21:27.960 | and how it's metabolized in the liver

01:21:30.320 | is actually what is causing the change

01:21:33.840 | in those clotting factors

01:21:34.920 | because that's where they're made as well.

01:21:36.840 | So it doesn't mean you can't take any form of contraception,

01:21:39.960 | but we do wanna make sure

01:21:41.340 | that we counsel you appropriately.

01:21:44.040 | I never think it's wrong to be an advocate

01:21:46.160 | for your own health or to ask questions.

01:21:49.140 | It's important to know that screening,

01:21:51.640 | I mean, I'll get on my soapbox

01:21:52.880 | 'cause we'll talk about screening for ovarian reserve

01:21:55.680 | and it is 100% not recommended,

01:21:57.800 | even though I think it should be.

01:21:59.340 | - Yeah, my next question was gonna be

01:22:00.800 | about testing AMH levels,

01:22:03.100 | and we'll return to that for those that hear that

01:22:05.960 | and it sounds cryptic as well as getting an ultrasound,

01:22:08.500 | just seeing basically how many eggs

01:22:10.660 | are likely to be in the vault on both sides.

01:22:14.840 | - Okay, so we have to remember

01:22:16.380 | that screening recommendations come

01:22:18.280 | from at what point in the population

01:22:20.720 | does it make sense to spend the money to test for a disease

01:22:24.880 | based on the likelihood of finding it.

01:22:27.020 | So if we think about, right,

01:22:28.860 | that's what your pap smear guidelines

01:22:30.680 | and your colonoscopy and your mammograms,

01:22:33.320 | everything is all based on

01:22:34.820 | when are you going to find enough cases at some age

01:22:38.180 | to make it worthwhile testing,

01:22:40.500 | which is a crazy principle, especially in the US,

01:22:43.060 | because the government's not paying for our healthcare.

01:22:45.220 | So why should these guidelines be based

01:22:47.660 | on when is it cost effective to do testing?

01:22:50.600 | - Well, I'll put in a,

01:22:51.880 | this is gonna sound a little bit conspiratorial,

01:22:53.820 | but it's not.

01:22:54.660 | I mean, I think that given that

01:22:55.940 | for people who have insurance,

01:22:57.480 | private paid insurance or through their work,

01:23:00.520 | that there's a cost to doing these tests

01:23:02.260 | of any kind, colonoscopy, AMH, et cetera.

01:23:04.800 | And they must have figured out the optimal point

01:23:08.920 | on the graph with which they can reduce their payout

01:23:11.960 | to people who, for instance, get colon cancer

01:23:14.440 | if they didn't get the colonoscopy at 45,

01:23:17.060 | as opposed to 50, as opposed to 60, as opposed to 25.

01:23:20.020 | I mean, this is, I mean, the reality we know is that

01:23:23.060 | the more information you have,

01:23:24.100 | the better choices you can make.

01:23:25.540 | I mean, the only caveat to that would be that for some,

01:23:29.540 | not all, but for some people,

01:23:31.240 | sort of the hypochondriatic type,

01:23:33.780 | sometimes more information leads to more anxiety,

01:23:35.820 | which leads to more problems, but that's a rare instance.

01:23:38.020 | - I always think that in general, data is always good.

01:23:41.860 | - I agree.

01:23:42.700 | - Having the information at hand about your body

01:23:45.340 | and being able to make educated choices

01:23:47.660 | versus being in a position where you say,

01:23:50.300 | "I had no idea that I had Factor V Leiden,

01:23:53.700 | and I had this terrible blood clot,"

01:23:56.020 | because pulmonary embolisms can kill people.

01:23:58.300 | We all know that, right?

01:23:59.400 | So we talk about this rare thing, but it can happen.

01:24:03.260 | But this is really where it can be tough.

01:24:05.460 | It can be tough to find even a doctor who may,

01:24:10.040 | like we said, Factor V is a blood test

01:24:11.580 | and relatively inexpensive, so that one is not hard,

01:24:14.660 | but physicians live in a weird world

01:24:17.460 | where they have recommendations based on screening,

01:24:20.620 | based on the likelihood of finding disease that they follow,

01:24:23.900 | and when they go off of those,

01:24:25.680 | they start introducing themselves

01:24:27.280 | to why are you not following medical guidelines?

01:24:30.100 | But for an individual,

01:24:32.380 | this is really tough to advocate for yourself.

01:24:35.500 | And the one thing that I'll say too,

01:24:36.860 | this is why paying attention to your body is so important,

01:24:40.500 | right, understanding your stool habits

01:24:42.700 | and what's normal and what's not

01:24:44.220 | so that you can catch early signs of things

01:24:46.860 | and present for that colonoscopy earlier.

01:24:49.820 | The current screening guideline

01:24:51.820 | for should you get your ovarian reserve checked

01:24:53.820 | is that you should not.

01:24:55.380 | ACOG, the American College of OB/GYN,

01:24:57.920 | has an entire practice bulletin situation

01:25:01.820 | saying there's no utility in screening for AMH.

01:25:06.000 | Okay, I totally disagree, but-

01:25:08.200 | - I'm glad you disagree.

01:25:09.040 | I mean, to me, it just seems nuts, or ovaries, rather.

01:25:12.600 | I mean, the AMH is a blood draw.

01:25:16.640 | - AMH is a blood test. - It's a blood draw.

01:25:18.760 | One could opt to do the ultrasound as well,

01:25:23.600 | which is, of course, more invasive.

01:25:25.560 | But women who are seeing their OB/GYN

01:25:28.200 | are probably familiar with pelvic exams.

01:25:32.000 | - Yeah, I mean, it's a vaginal ultrasound,

01:25:33.820 | but it's not painful.

01:25:35.280 | - Not painful, but different than a blood draw,

01:25:37.920 | just for in full disclosure.

01:25:39.780 | So, and I've heard of women in their early 30s

01:25:44.780 | going in, getting their AMH levels checked,

01:25:47.960 | getting their ultrasound, and then going,

01:25:49.300 | "Oh my goodness, they're down to like,

01:25:51.540 | I don't want to throw out numbers

01:25:52.720 | 'cause this actually can get tricky."

01:25:54.600 | They'll say, "Oh, you have whatever, four follicles."

01:25:58.560 | And then someone in their early 40s will have 20 follicles.

01:26:02.720 | And then people start to,

01:26:03.560 | it sort of becomes a scorekeeping thing.

01:26:05.400 | And of course, follicle quality,

01:26:07.740 | there are a bunch of other things.

01:26:09.280 | And then you can tell us more about those.

01:26:10.600 | But let's say someone did not have insurance

01:26:13.760 | or insurance permission to get this paid for.

01:26:18.080 | What is the approximate cost

01:26:20.000 | of getting one's AMH levels analyzed?

01:26:22.880 | - $79.

01:26:24.200 | - $79 to find out essentially

01:26:26.760 | where your ovarian reserve is at.

01:26:28.860 | - So let's talk about this.

01:26:30.800 | I already said this is my soapbox.

01:26:31.760 | So ACOG says you shouldn't screen it

01:26:33.960 | because AMH does not predict your fecundability, right?

01:26:38.600 | Your body's ability to get pregnant in that month

01:26:40.800 | is independent of your AMH.

01:26:43.200 | And for the most part, that's true, right?

01:26:45.040 | Because let's say you have a person

01:26:46.760 | and they're both 30, you have two people.

01:26:48.800 | One has low ovarian reserves.

01:26:51.360 | They have five eggs coming out of the vault.

01:26:53.480 | And this one has normal ovarian reserve

01:26:55.560 | and they have 20 eggs coming out of the vault.

01:26:57.160 | - And we should probably clarify that the number,

01:26:59.040 | 'cause you said this earlier,

01:26:59.960 | but the number of eggs coming out of the vault

01:27:01.680 | is an indirect measure of how many eggs is in the vault.

01:27:04.080 | When that number is going down,

01:27:05.500 | it means the number of eggs in the vault

01:27:07.000 | is likely going down as well.

01:27:08.840 | Sort of like your body starts to take smaller withdrawals

01:27:11.260 | as you start to run out.

01:27:12.520 | - The vault wants to be at like equilibrium, right?

01:27:15.460 | It really wants to be in this middle ground.

01:27:17.040 | So when you have too many, it shoots out more every month.

01:27:20.320 | It's too crowded, it doesn't want that.

01:27:22.360 | And then when it starts to get low,

01:27:24.120 | it gets scared about being empty

01:27:25.600 | and sends out fewer per month.

01:27:27.460 | So what you see outside the vault,

01:27:29.280 | and that is called an antral follicle count or an AFC.

01:27:32.120 | It's an ultrasound-based measurement

01:27:33.640 | of how many eggs you have outside the vault

01:27:36.240 | at one point in time.

01:27:37.520 | - And on the ultrasound, if one looks,

01:27:39.620 | this is gonna show up as sort of what looked like

01:27:42.240 | little hollow spaces, like so not gray stuff,

01:27:44.560 | but hollow bodies. - Yeah, I say chocolate chips

01:27:46.800 | and the chocolate chip cookie.

01:27:47.720 | If we can imagine the ovary. - Beautiful image, yeah.

01:27:49.720 | - Yeah, like looks like a chocolate chip cookie,

01:27:51.240 | the chocolate chips, small little dark fluid filled follicles

01:27:54.920 | each one of those houses an egg.

01:27:56.280 | - Some bigger than others

01:27:57.160 | because they're more mature than others.

01:27:58.360 | - Based on when you check in the cycle.

01:27:59.880 | So if you're looking in that early follicular phase,

01:28:02.640 | when somebody is on their period,

01:28:04.480 | they all should be small because nothing's been stimulated.

01:28:06.960 | If I'm looking periovulatory,

01:28:08.520 | I'll see that dominant follicle that's about to ovulate

01:28:10.920 | and then everything else will be small.

01:28:12.560 | - And is there a graph that people can look at

01:28:15.280 | that we could link to that says, okay,

01:28:17.880 | the average with a distribution of standard error

01:28:21.680 | on either side for let's say a 28 year old woman

01:28:24.920 | or a 37 year old woman or a 45 year old woman

01:28:27.920 | of the number of follicles on the right and left side.

01:28:32.080 | And as I understand, asymmetries are common,

01:28:35.120 | tends to be like if someone goes in

01:28:36.780 | and you got six follicles on the left side

01:28:38.640 | and 12 on the other side,

01:28:40.760 | how do people gauge where they're at?

01:28:43.160 | - Fantastic points.

01:28:44.680 | One, because their doctor should tell them,

01:28:46.520 | but that doesn't always happen.

01:28:47.540 | But yes, we add these counts together

01:28:50.120 | to get your antral follicle count

01:28:51.320 | because there is often asymmetry.

01:28:53.620 | But what we should expect, let's say in somebody who's 30,

01:28:56.720 | is you should have in the 16 to 20 range

01:29:00.380 | of total follicles per month.

01:29:01.920 | - Right and left side combined.

01:29:03.560 | - Combined, okay.

01:29:04.560 | When you're 35, that number is closer to like 14 to 16.

01:29:09.020 | So starting to drop, it's still pretty good.

01:29:11.400 | When you're 40, it's eight to 10.

01:29:13.760 | When you're 44, two to four, right?

01:29:16.640 | So you start to have this immense drop

01:29:19.020 | that exponentially starts to increase really around age 37.

01:29:22.760 | So things start to kind of get into this severe zone

01:29:27.520 | really after age 37.

01:29:29.000 | - And we didn't really talk about ages 18 to 25,

01:29:33.200 | but there are people who get pregnant in that age bracket.

01:29:36.800 | Are, is the follicle count very, very high?

01:29:39.260 | Is there sort of a nonlinear drop off or?

01:29:42.160 | - Yeah, their follicle count will be higher.

01:29:43.480 | And I mean, I occasionally have patients who are very young,

01:29:45.540 | but have infertility or want to freeze their eggs.

01:29:48.080 | I also had patients in that age range

01:29:49.880 | who are in premature ovarian failure, right?

01:29:52.240 | Because there can be things that go wrong even early.

01:29:54.720 | - But we should probably highlight again,

01:29:56.160 | something that you said earlier, but gosh, I, you know,

01:29:58.400 | this like contradicts so much of what's out there,

01:30:01.720 | which is that even if you have low follicle count,

01:30:04.300 | if you collect eggs, you're not changing what's in the vault.

01:30:07.280 | You're not pulling from the vault.

01:30:08.580 | - You can't.

01:30:09.420 | - Right, those eggs are spent.

01:30:10.840 | You now have the opportunity to turn them

01:30:12.880 | into potential pregnancies.

01:30:13.840 | - Correct, I mean, side note, right?

01:30:15.440 | We haven't even dove into IVF,

01:30:17.280 | but that's the next wave of technology

01:30:19.720 | is what we call IVM and vitro maturation.

01:30:21.820 | People are trying to figure out how can you get eggs

01:30:24.120 | from the vault and get them to grow in the lab?

01:30:26.480 | Because that would open up possibilities for people

01:30:29.440 | who have fewer eggs to have a higher efficiency

01:30:33.280 | of this process, because one of the limiting factors

01:30:35.600 | when you're doing fertility and you're doing egg freezing

01:30:37.720 | or IVF is how many eggs can you get per month?

01:30:41.680 | And that's why some people have to do cycle after cycle,

01:30:44.520 | because they can only get five eggs or five eggs.

01:30:47.640 | But if we circle back to what we were saying

01:30:49.520 | when we got off on this beautiful tangent

01:30:51.280 | is that no matter if you have five or you have 20 eggs

01:30:53.640 | outside the vault, you're ovulating one.

01:30:56.040 | So you're trying to get pregnant naturally.

01:30:57.960 | That's what fecundability is,

01:30:59.320 | probability of getting pregnant per month, naturally.

01:31:02.200 | You have the same chance if you're the same age,

01:31:04.440 | regardless of if you have five eggs or you have 20 eggs.

01:31:07.520 | And that's why ACOG came in and said,

01:31:09.600 | well, AMH doesn't impact fecundability.

01:31:13.140 | It doesn't predict your ability to get pregnant

01:31:15.420 | or who's gonna have infertility

01:31:16.800 | and who's not gonna have infertility.

01:31:18.780 | So there's no utility and screening for it in people now.

01:31:23.780 | - For once, I'm speechless.

01:31:26.140 | I mean, that argument makes sense through the lens

01:31:29.160 | of just probabilities of pregnancy

01:31:31.560 | through natural conception,

01:31:35.980 | but it completely erases the very, very, very real situation

01:31:40.980 | where people are making choices about, for instance,

01:31:44.620 | whether or not to stay with a given partner,

01:31:46.020 | whether or not to leave a given partner,

01:31:47.140 | whether or not to accelerate the process

01:31:48.520 | of building a family. - She raised my head.

01:31:49.820 | Should I have a baby now?

01:31:51.240 | These life choices. - There's so many factors

01:31:52.360 | that this American college of whoever, whoever

01:31:54.500 | is like completely psychologically divorced from.

01:31:57.700 | - But they're crazy.

01:31:59.200 | And that's what I say.

01:32:00.480 | They argue in their statement

01:32:03.220 | that finding that you have, I'm like, I'm reeling it in.

01:32:07.260 | - I mean, I'm trying to think of an analogy

01:32:08.600 | that doesn't fail, but it's like if you can,

01:32:10.440 | it's like saying, okay, if you can walk now, great.

01:32:14.100 | There's no reason to test for this inevitable paralysis

01:32:17.960 | that's going to happen at different rates

01:32:19.520 | in different people.

01:32:20.540 | And there are things that you can do to offset it.

01:32:21.880 | In other words, you could like take a little bit

01:32:23.820 | of some tissue that will allow you to walk in the future,

01:32:26.780 | but we're not gonna do that

01:32:27.620 | because if you can walk now, you can walk now.

01:32:28.880 | - It's good now. - That's absurd.

01:32:30.580 | - And that's really what it is.

01:32:31.660 | And they say, well, finding out that you have low ovarian

01:32:33.880 | reserve at a young age is going to cause undue stress

01:32:37.420 | that is unwarranted because most people

01:32:39.880 | don't have infertility.

01:32:41.780 | And so they're purely putting it through the lens

01:32:44.380 | of your likelihood to get pregnant.

01:32:45.780 | - But it's actionable stress.

01:32:47.060 | - Exactly.

01:32:47.900 | - Like if it were just stress like, hey, guess what?

01:32:49.700 | And you know, I know people who have family members

01:32:51.720 | with Huntington's mutations and some opt to not know

01:32:55.000 | whether or not they themselves have the Huntington's

01:32:57.420 | mutation and it's a very personal choice, right?

01:33:00.140 | But here, whereas unfortunately there still isn't a cure

01:33:04.920 | for Huntington's, hopefully someday there will be,

01:33:06.580 | Malcolm would, but in the meantime,

01:33:08.860 | there is essentially a cure for this situation,

01:33:11.500 | which is the harvest and potential fertilization.

01:33:14.220 | - There's at least an opportunity.

01:33:15.980 | And this is what I say, and of course,

01:33:17.540 | you and I feel similarly.

01:33:19.140 | Education and data, like being the one to make the choice

01:33:21.980 | is an extremely important distinction

01:33:24.740 | versus having it happen to you.

01:33:26.700 | So if you're young and you find out

01:33:28.540 | that you have low ovarian reserve,

01:33:30.380 | is that going to make a difference?

01:33:32.020 | And it very well might.

01:33:33.340 | You might now freeze your eggs

01:33:34.940 | when you wouldn't have otherwise.

01:33:36.600 | You might now start to try to get pregnant

01:33:38.900 | if you're partnered when you otherwise were just waiting,

01:33:41.620 | but now you know.

01:33:42.460 | - It might change the conversation with your partner too,

01:33:43.900 | right, because a lot of people think they can just wait

01:33:46.060 | because of age, right?

01:33:46.900 | We're in our 20s, we're in our 30s.

01:33:47.740 | - No, I'm only 30, I can totally wait.

01:33:49.100 | But if you have a low ovarian reserve,

01:33:51.200 | then you may lose the opportunity for parenthood.

01:33:54.420 | And for a lot of people, this is a life goal.

01:33:56.700 | And this is what's wild to me.

01:33:58.740 | When on earth, besides reproduction,

01:34:01.060 | do we have life goals that we take the approach,

01:34:04.160 | I'll just wait and see if it's a problem later.

01:34:07.060 | Never, right?

01:34:08.180 | If you wanna become a doctor, you wanna become an athlete,

01:34:12.340 | you are constantly working towards that goal

01:34:15.440 | or understanding what it's going to take to get there.

01:34:18.700 | But why does the goal of parenthood,

01:34:21.180 | the attitude is completely,

01:34:23.140 | I'm not going to think about it until later,

01:34:25.780 | and then I'll deal with it if it becomes a problem.

01:34:28.540 | Because you can make choices.

01:34:30.900 | You could freeze your eggs,

01:34:32.060 | you could try to get pregnant sooner,

01:34:34.260 | you could evaluate for reasons of low ovarian reserve.

01:34:37.720 | Do you have a genetic mutation or an autoimmune disease?

01:34:40.380 | Why is it low?

01:34:41.780 | It's not just always a big unknown.

01:34:44.140 | There can be some actual things

01:34:46.500 | that potentially might be impactful

01:34:48.120 | for your health long term.

01:34:50.780 | So I think it's wild that this is the current conversation.

01:34:54.980 | And I will say, I know personally a lot of OBGYNs

01:34:58.420 | who 100% will draw an AMH blood task

01:35:02.340 | if you're at your annual and you ask.

01:35:04.720 | And I recommend all of my OB friends,

01:35:07.060 | 'cause I see people at a different stage, right?

01:35:09.860 | When they see me, they're struggling to get pregnant

01:35:12.300 | or they wanna freeze their eggs.

01:35:13.860 | But when we talk about this, I say, hey,

01:35:16.620 | just like you say, are you trying to get pregnant now?

01:35:19.660 | And if somebody says no, and your follow-up question is,

01:35:22.660 | well, do you wanna be on birth control?

01:35:24.640 | The same question should be,

01:35:26.080 | well, do you wanna be pregnant at some point?

01:35:29.400 | And if so, should you consider freezing your eggs

01:35:33.160 | or getting this blood test checked?

01:35:34.900 | And very often people will make a different decision

01:35:38.180 | with that information.

01:35:40.220 | - I'm so glad that you're highlighting this

01:35:41.580 | because my understanding is,

01:35:42.560 | at least in the state of California,

01:35:43.880 | I don't know about other states

01:35:45.180 | or if it even varies by state,

01:35:47.060 | that the opportunity to harvest eggs and freeze them,

01:35:54.340 | there's a hard cutoff at age, I think it is 42.

01:35:58.860 | Prior to age 42, they'll do it.

01:36:01.580 | After 42, they'll do it if and only if

01:36:04.440 | you're willing to do in vitro fertilization

01:36:06.400 | to actually fertilize and then they'll freeze embryos.

01:36:08.700 | But they're far more reluctant to collect eggs after age 42.

01:36:12.140 | - Yeah, yes and no.

01:36:13.020 | So when you think about egg freeze and an IVF

01:36:16.660 | are really the same process, right?

01:36:18.440 | When you're going through the exact same thing,

01:36:20.260 | you're taking the eggs out of the body

01:36:21.660 | and then you're either just freezing them as an egg

01:36:24.340 | or you're fertilizing them in the lab

01:36:27.100 | and that's IVF and making an embryo right away.

01:36:30.020 | Egg freezing has changed dynamically over the past 10 years.

01:36:34.140 | Whereas 10 years ago, survival rate of eggs in the lab

01:36:37.080 | was 40%, really terrible.

01:36:39.900 | And so we really didn't offer it to many people.

01:36:42.340 | It wasn't something that was talked about

01:36:44.220 | and now it feels trendy almost,

01:36:46.480 | but it's really just the tech has gotten so much better.

01:36:48.700 | - And cheaper.

01:36:49.540 | - Yeah, 90% of eggs now survive the freeze thaw.

01:36:52.540 | So 90% is not a low number by any means.

01:36:56.780 | Embryos are much stronger, right?

01:36:59.060 | An egg is a single cell.

01:37:00.540 | It's a single cell.

01:37:01.940 | An embryo, when we freeze an embryo that's day five or six

01:37:04.940 | is 300 plus cells.

01:37:06.300 | So it's so much stronger

01:37:07.980 | and those embryos survive the freeze thaw 99% of the time.

01:37:11.540 | So yes, there's a 9% difference.

01:37:14.420 | That being said, making embryos is a lot more expensive.

01:37:18.160 | Eggs is cheaper.

01:37:19.340 | You could do two rounds of eggs

01:37:21.020 | and have just as many eggs or have more eggs

01:37:24.320 | than if you'd made them into embryos right away.

01:37:26.660 | So I never recommend that somebody commits to a sperm source

01:37:30.420 | that they don't wanna have a child with

01:37:32.660 | unless that's the sperm source they wanna have a child.

01:37:35.660 | And this has changed because when embryo survival

01:37:39.140 | was so much greater than egg survival,

01:37:41.940 | especially if you had few eggs or you were older,

01:37:44.460 | making embryos was the only option.

01:37:48.060 | What we do know is that egg quality decreases immensely

01:37:51.340 | as we get older.

01:37:52.180 | And we've touched on this,

01:37:53.020 | but we haven't really mentioned it.

01:37:55.100 | So not only do you have fewer eggs as you get older,

01:37:59.040 | the chromosomes inside start to lose their positioning.

01:38:02.780 | And so we think about egg quality,

01:38:04.100 | we think about genetic normalcy,

01:38:05.960 | and we know that the rates of aneuploidy

01:38:08.180 | or abnormal chromosomes increases proportionally to your age.

01:38:12.980 | - Which for people that aren't aware

01:38:14.620 | are going to predispose, not always,

01:38:17.780 | to miscarriages if they're implanted

01:38:20.140 | or potentially even the formation of a fetus

01:38:24.200 | that carries, for instance, trisomies,

01:38:25.980 | so chromosomal repeats, or lack of certain chromosomes.

01:38:30.420 | These could be deadly,

01:38:31.420 | or they could be capable of carrying to term,

01:38:35.100 | but have undetectable to mild

01:38:36.620 | to severe developmental abnormalities, correct?

01:38:39.500 | - Correct, and this is why you have a lower probability

01:38:43.060 | of pregnancy per month as you get older.

01:38:45.060 | So if we look at your natural fecundability,

01:38:47.340 | it's not because you have fewer eggs,

01:38:49.620 | because we already said your egg count per month

01:38:52.140 | doesn't impact your probability of getting pregnant.

01:38:54.900 | It's because the normalcy of those chromosomes

01:38:57.580 | has changed so dramatically

01:38:59.340 | that the odds that your body's randomly choosing

01:39:01.740 | the good one to ovulate becomes so low,

01:39:05.100 | and that's why those natural fertility rates are so low,

01:39:07.940 | because most genetically abnormal eggs

01:39:10.520 | do not fertilize or implant.

01:39:12.460 | But if they do, they have a significantly higher

01:39:15.300 | chance of miscarriage, it's 40% at age 40, right?

01:39:18.380 | So you have a much lower chance

01:39:20.500 | of seeing the positive pregnancy test,

01:39:22.540 | but then your chance of losing that pregnancy

01:39:24.460 | is significantly higher as well.

01:39:26.740 | So when we are counseling somebody about egg freezing,

01:39:29.780 | what we know is that not every egg

01:39:32.740 | is going to fertilize with sperm,

01:39:35.140 | going to make an embryo, going to be genetically normal,

01:39:38.760 | or even implant when it is genetically normal.

01:39:41.800 | There is huge loss in human reproduction,

01:39:44.700 | meaning the more eggs you have at a younger age,

01:39:47.460 | the better the ROI on this process is gonna be.

01:39:50.460 | It doesn't mean you don't do it when people get older,

01:39:53.180 | but every clinic does have a cutoff,

01:39:55.820 | and every clinic's gonna be a little bit different.

01:39:58.460 | A lot of different reasons why.

01:40:00.200 | We actually probably have an older cutoff,

01:40:01.660 | so we will let somebody go through IVF

01:40:04.100 | or freeze their eggs up to age 45,

01:40:06.380 | and it's a lot about informed consent

01:40:08.660 | and having the approach that you're smart enough,

01:40:12.420 | that if I give you the odds,

01:40:13.660 | and I walk you through how many eggs you are

01:40:15.860 | and the likelihood of them making into embryos,

01:40:18.420 | you can say, yeah, but four eggs or 10 eggs

01:40:22.220 | is way more than zero based on my circumstance,

01:40:25.740 | and that is worth it to me

01:40:27.760 | because it gives me the opportunity

01:40:29.660 | to potentially have a child

01:40:31.080 | when otherwise my opportunity is going to be zero.

01:40:34.700 | So a lot of this is rooted in paternalism

01:40:38.180 | that people can't, as a patient, understand these odds,

01:40:41.820 | and they have unrealistic expectations.

01:40:45.060 | I think there's a huge shift in reproductive medicine

01:40:47.060 | to really counseling patients

01:40:48.580 | and giving them autonomy in some of these decisions,

01:40:52.100 | but there does become a point

01:40:53.420 | where the likelihood of finding a normal egg

01:40:56.820 | is so, so low that the money

01:40:58.620 | or the expense of the process doesn't make sense,

01:41:01.540 | and people should utilize egg donation

01:41:04.700 | or other opportunities for conception.

01:41:07.300 | This drop in both the number of eggs and the egg quality,

01:41:11.240 | they really start to become so profound at age 37 and on,

01:41:15.240 | and that's when we really start to see

01:41:16.460 | both these things are overlapping at the same time.

01:41:19.460 | So if you're waiting till age 35, 36 for your first kid,

01:41:24.460 | but you want two or three,

01:41:27.560 | we've got to really look forward about

01:41:29.560 | is that strategy make sense?

01:41:32.580 | Well, what is your AMH?

01:41:34.420 | One, are you gonna run out of eggs before then?

01:41:36.820 | Two, what other issues could be going on?

01:41:40.220 | Is the sperm fine? Are the tubes open?

01:41:42.340 | Because we are seeing that when people start families later,

01:41:46.500 | when people have more chronic illness

01:41:48.320 | and autoimmune disease and obesity,

01:41:50.480 | that it's much harder to get pregnant.

01:41:52.480 | And so the birth rates are for the first time

01:41:55.260 | in a long time across the border dropping,

01:41:57.820 | and infertility is rising

01:42:00.200 | because of all of these factors combined.

01:42:02.920 | - So based on everything you just said,

01:42:05.200 | and yes, I'm gonna say it a fifth time

01:42:07.580 | because the misconception about this

01:42:09.100 | is one of the primary reasons

01:42:10.820 | why people avoid harvesting eggs.

01:42:13.540 | It's not the only reason,

01:42:14.700 | but when you harvest eggs, freeze them.

01:42:17.600 | Now it sounds like the viability of those eggs

01:42:19.460 | is quite strong compared to a few years ago.

01:42:22.100 | So that's great, 90% recovery when they thaw them

01:42:26.380 | is not going to diminish the number of eggs in the vault,

01:42:30.420 | such a critical point.

01:42:32.200 | And post age 37, there's a,

01:42:37.520 | sounds like a non-linear drop-off in egg quality for most,

01:42:40.480 | and these are averages.

01:42:41.600 | - Of course, always gonna be exceptions.

01:42:43.080 | - So the people that got pregnant with healthy kids

01:42:44.920 | in their late 30s and 40s, yes, we hear you.

01:42:48.460 | Congratulations, we're happy.

01:42:51.480 | But this speaks to the logic anyway,

01:42:56.480 | we're not putting any emotion or circumstances on this,

01:42:58.920 | but the logic of somebody in their,

01:43:01.360 | let's say late 20s, early 30s,

01:43:02.760 | getting their AMH levels through a roughly $80 blood draw.

01:43:07.440 | And then perhaps based on their life goals and circumstances,

01:43:13.260 | doing either one or several rounds

01:43:15.300 | of egg collection and freezing,

01:43:17.500 | especially since it sounds like you don't need

01:43:19.540 | to fertilize those eggs.

01:43:20.740 | So if one doesn't have a partner

01:43:22.460 | is concerned about what they're going to do,

01:43:24.740 | who's going to be, who's going to provide the sperm,

01:43:28.380 | 'cause of course some people choose

01:43:30.380 | to raise kids on their own,

01:43:32.100 | but parenting is a whole other issue,

01:43:33.960 | but they could do that later.

01:43:36.860 | So that raises the questions of what are the health risks,

01:43:41.860 | if any pain levels, if any,

01:43:45.900 | and that includes psychological pain of egg harvest.

01:43:50.180 | I mean, so going back to what you said earlier,

01:43:51.840 | this is going to be injecting synthetic mimics

01:43:54.540 | of FSH and LH, follicle stimulating hormone

01:43:58.200 | and luteinizing hormone, maybe some growth hormone.

01:44:00.520 | I hear nowadays, there's also the practice of injecting,

01:44:03.580 | these are essentially platelet rich plasma, PRP,

01:44:08.760 | platelet rich plasma, excuse me, PRP,

01:44:11.720 | perhaps even into the ovarian vault,

01:44:13.480 | we can get back to that.

01:44:14.640 | So there's a bunch of stuff that's being done to someone.

01:44:17.260 | There's low stim where people are getting

01:44:19.400 | like low doses of these drugs.

01:44:21.180 | There's high stim where it's like a full blast.

01:44:23.900 | Maybe you could walk us through that procedure

01:44:25.360 | and just sort of general contour,

01:44:26.660 | 'cause it would require a lot of time

01:44:28.280 | to go through it all in detail,

01:44:29.560 | but is this a horrible thing to go through?

01:44:31.360 | Is it mild to go through?

01:44:32.960 | Is it like a walk in the park?

01:44:34.420 | - Let's walk through it all.

01:44:36.680 | So I love this, and this is my bread and butter,

01:44:39.400 | and this is what I do every day.

01:44:41.120 | Studies tell us that if you are not ready to have a family

01:44:43.960 | by age 32 to 33, that that is the optimal time

01:44:47.200 | for the average person to intervene and freeze their eggs.

01:44:49.660 | It's not up for debate.

01:44:50.640 | It's when you have both the intersection

01:44:52.760 | of still a good egg quality and good egg quantity on average.

01:44:57.500 | And so that is younger than a lot of people

01:45:00.220 | are thinking about having families.

01:45:02.180 | And the reason why is when we really think

01:45:04.180 | about what happens to the egg afterward,

01:45:06.860 | that's what's really critically important.

01:45:08.820 | So I'm gonna answer the question about what you go through,

01:45:10.860 | but just thinking, we already said you freeze your eggs,

01:45:13.460 | 90% of them are gonna survive the freeze-thaw.

01:45:16.100 | About 75% will be fertilized by sperm,

01:45:19.020 | and about 50% of those will even make it

01:45:21.420 | to an implantation stage embryo or a blastocyst.

01:45:23.900 | - And we're assuming healthy sperm.

01:45:25.060 | So sperm, no DNA, excessive DNA fragmentations.

01:45:29.380 | - You've already hit the nail on the head.

01:45:30.380 | One of the biggest issues with egg freezing

01:45:32.900 | is I don't know the future.

01:45:35.540 | I don't know if this sperm is going to be great or not.

01:45:39.560 | I don't know-

01:45:40.400 | - It could be from a pot smoker.

01:45:41.220 | Just kidding, pot smokers.

01:45:42.060 | - Not kidding, pot smokers or not.

01:45:44.080 | But we don't know, right?

01:45:45.020 | So we have this future yet undetermined sperm source.

01:45:47.020 | So I am going to assume you're gonna fall average

01:45:49.720 | on these data points that we're gonna walk through.

01:45:52.020 | But the reality is you buffer the risk by having more eggs

01:45:55.300 | frozen, and that's why people are going through

01:45:57.300 | multiple rounds or cycles, because we don't know.

01:46:00.200 | We don't know how that fertilization will be.

01:46:02.420 | If you have 20 eggs, and 18 survive the freeze-thaw,

01:46:05.780 | and 14 fertilize, and seven make it to the blastocyst stage.

01:46:09.940 | If you're age 30, we would anticipate around 60 to 70%

01:46:14.940 | of them are gonna be genetically normal.

01:46:16.740 | And you're young, so that's already kind of a big hit

01:46:19.020 | at that age.

01:46:20.020 | So let's say of the seven, four of them

01:46:23.040 | are genetically normal.

01:46:24.900 | When I go to transfer them, I have at best a 65% chance

01:46:28.380 | of live birth per embryo, which is really good

01:46:31.660 | when you put in the lens of fecundability,

01:46:33.380 | and peak success tends to be closer to 20%.

01:46:36.100 | - And you're gonna implant one embryo at a time?

01:46:37.820 | - 100%, we're gonna implant one embryo at a time now.

01:46:39.860 | - Does anyone ask for two?

01:46:41.100 | - People ask for two, doctors will do two.

01:46:43.620 | It is, it lowers live birth rates.

01:46:46.420 | If we're looking at giving each embryo the healthiest

01:46:50.460 | opportunity at becoming a baby, number one,

01:46:54.160 | embryos with IVF have a slightly higher chance

01:46:56.160 | of monozygotic twinning, right, so twinning,

01:46:59.180 | fraternal twinning comes if you ovulate two eggs,

01:47:02.100 | they both get fertilized, so each baby is completely

01:47:05.400 | different genetically, own egg, own sperm.

01:47:07.980 | Monozygotic is from an embryo split.

01:47:10.660 | Because of the IVF process, likely putting the embryo

01:47:15.100 | in the catheter, maybe having that outer surface touched,

01:47:20.100 | predisposes it to splitting after you put it into the body.

01:47:22.980 | - So more identical twins, monozygotic.

01:47:25.220 | - Yeah, we have a two to 3% chance of monozygotic twins

01:47:27.540 | with IVF, and the natural chance is .03%.

01:47:30.540 | So significantly higher, even though ultimately

01:47:34.040 | not a probable outcome, I'm gonna have a couple patients

01:47:37.300 | a year who are going to have monozygotic twins.

01:47:40.500 | And if I put two embryos in, I've now one,

01:47:43.640 | taken this from a potential twin pregnancy

01:47:46.900 | to a triplet or even a quad if they both split.

01:47:50.460 | - So hence, presumably, like the Octomom cases

01:47:53.280 | and things like that.

01:47:54.120 | - Well, that one, they just literally put eight embryos

01:47:55.860 | inside, but that's a whole, I mean,

01:47:57.380 | that's medical malpractice, right?

01:47:59.140 | But really, most of the time, when we're talking

01:48:00.740 | about embryos, we're talking about people with infertility

01:48:03.820 | or people who've spent a significant amount of money,

01:48:06.060 | a huge portion of fertility is embryo quality, right?

01:48:09.700 | The competency of the embryo, the genetics of the embryo,

01:48:12.140 | it's expensive to go through egg freezing and IVF,

01:48:15.060 | yet the uterine environment is another component.

01:48:18.140 | It doesn't make sense to waste multiple embryos

01:48:20.800 | in the same uterine environment.

01:48:22.120 | Statistically, it doesn't make sense.

01:48:23.980 | It also doesn't make sense to make your embryos

01:48:25.740 | compete against each other.

01:48:26.920 | - So will people put one embryo into,

01:48:29.620 | let's just say DNA mom, right, and one into surrogate mom?

01:48:34.620 | And try and get two siblings simultaneously?

01:48:38.120 | - I've definitely done that and had patients do that.

01:48:41.020 | It's not common because surrogacy using a gestational carrier

01:48:44.760 | is so expensive and there's such limited supply,

01:48:48.180 | it's very hard to find somebody who wants to go through

01:48:51.560 | the act of carrying a child for somebody else,

01:48:54.640 | but that definitely is a strategy that some people utilize,

01:48:57.580 | especially if they're older or they're concerned

01:48:59.980 | that they might have a lower chance of implantation,

01:49:02.700 | but they wanna give themselves a try.

01:49:04.980 | But if we look at one embryo, 65% chance of success.

01:49:09.740 | Cumulative probability after the second is 88%, okay?

01:49:14.260 | Almost everybody's pregnant after two,

01:49:16.980 | and these are euploid genetically normal embryos, okay?

01:49:21.260 | And then if you go to the third,

01:49:23.360 | so cumulatively after three euploid embryo transfers,

01:49:26.580 | each one being a single embryo,

01:49:28.100 | 95% of people have a baby in their arms,

01:49:31.480 | meaning the incidence of recurrent implantation failure

01:49:35.360 | is actually pretty low, 5%.

01:49:37.780 | But how many normal embryos do you need

01:49:41.340 | for what family size if you're freezing your eggs?

01:49:43.980 | Because you got 20 eggs at age 30 in the example I gave

01:49:47.220 | and you just made four normal embryos, right?

01:49:50.020 | So that's really unlikely to make three or four kids.

01:49:53.880 | It would, it has a really good chance of making one,

01:49:57.060 | gives you the opportunity for a second,

01:49:59.260 | but that's also presuming that everything happened perfectly,

01:50:02.220 | that the sperm is not pot smoking sperm,

01:50:05.220 | but you know what I mean, not bad quality sperm,

01:50:06.900 | there's not other environmental issues

01:50:09.000 | when it comes to your own health

01:50:10.780 | when you're trying to get pregnant

01:50:12.060 | or other diseases you may have.

01:50:14.320 | So we really need a higher number of eggs,

01:50:17.100 | specifically when we don't know what the equation

01:50:20.040 | will truly look like for one individual person

01:50:22.780 | when they go through the process.

01:50:24.380 | And one of the only added benefits of embryos,

01:50:28.440 | especially if you are partnered,

01:50:30.940 | if you're with somebody who you do wanna have children with,

01:50:33.180 | you just don't wanna have them yet,

01:50:35.200 | is that I know the downstream, I know the number,

01:50:38.360 | I know how many embryos I have,

01:50:40.740 | and if it's not enough to give you a high chance

01:50:44.020 | of what you want your family to be,

01:50:45.840 | you can intervene now, right?

01:50:47.840 | Because by definition with egg freezing,

01:50:50.260 | we're not wanting to be pregnant for years.

01:50:53.540 | So if you're doing this with a partner

01:50:55.380 | and you're making embryos,

01:50:56.740 | and now I say we only got one genetically normal embryo,

01:51:00.700 | you have the opportunity to choose

01:51:03.300 | to either go through more cycles

01:51:05.620 | and store more embryos for later

01:51:08.320 | to maybe try to get pregnant sooner

01:51:10.660 | because there's some underlying issue with your fertility.

01:51:13.280 | You can make a choice

01:51:15.020 | because you're falling off the curve there.

01:51:17.140 | - Could I ask you a question?

01:51:18.200 | So you mentioned age about 32 to 33.

01:51:21.340 | In an ideal circumstance with the finances there, et cetera,

01:51:24.900 | one would harvest eggs,

01:51:26.460 | unless they're already starting a family

01:51:28.460 | through natural means.

01:51:30.300 | What about for sperm?

01:51:31.620 | I mean, we've all heard the studies

01:51:33.420 | that with increased age of the sperm,

01:51:37.240 | that there's a higher,

01:51:38.620 | although still statistically pretty small,

01:51:40.540 | incidence of things like spectrum conditions.

01:51:44.180 | So do you recommend to younger males,

01:51:49.180 | men in their late 20s, early 30s, to free sperm?

01:51:54.200 | - I mean, it's never gonna be wrong to save your gametes

01:51:56.360 | because we don't have crystal balls for the future, right?

01:51:58.660 | So your gametes are your eggs and your sperm.

01:52:00.920 | That increase in, we'll just say, negative outcome

01:52:04.540 | from advanced paternal age

01:52:06.260 | really starts to be seen at age 50.

01:52:08.620 | So most men are not looking at

01:52:10.620 | primarily starting their family after that age.

01:52:14.160 | However, what I run into all the time is

01:52:17.100 | maybe you're working on a second family

01:52:19.960 | or maybe life has gone down a different pathway

01:52:22.420 | and now you're with a partner who potentially is younger

01:52:25.260 | and wants to conceive and you now have older sperm.

01:52:28.180 | Having sperm in the bank,

01:52:29.180 | it's so cheap and easy to free sperm.

01:52:31.620 | Eggs, I haven't even answered your primary question.

01:52:33.720 | - And the process of collecting sperm,

01:52:35.800 | while not entirely without its issues, is far simpler.

01:52:40.120 | - It's embarrassing at best, but it's much simpler.

01:52:42.980 | - Yeah, it's much simpler.

01:52:43.820 | It generally doesn't require hormone injections,

01:52:46.560 | although maybe for rare instances

01:52:48.200 | where people are hypogonadal or something.

01:52:50.300 | - If you're gonna freeze your sperm, you're right.

01:52:52.540 | Typically, you're going to get some blood work done

01:52:54.680 | because most places that store sperm per FDA guidelines

01:52:58.240 | have to make sure that if you carried an infectious disease,

01:53:00.700 | it's stored in a special tank.

01:53:01.900 | So you'll have to get blood work done,

01:53:03.500 | then you'll have to abstain for your two to three days,

01:53:05.780 | collect into a cup, you're done.

01:53:07.980 | - Which, by the way, guys, you can do at home

01:53:09.420 | and bring it in.

01:53:10.260 | Sperm are so stable.

01:53:11.340 | If you've ever done this, you just bring it in.

01:53:12.780 | It's pretty-

01:53:13.600 | - Just carry it in a little bag.

01:53:14.440 | - A little bit of, I think I'm not gonna feign

01:53:17.100 | that my friend did this and told me,

01:53:18.900 | but it's kind of outrageously easy

01:53:22.260 | in the sense that you just bring it in

01:53:24.380 | and they'll take it out in the lobby and be like,

01:53:26.100 | is that your name?

01:53:26.940 | Like very different than the egg collection procedure.

01:53:29.520 | - So here's what I'll say about sperm

01:53:31.200 | and what I wish more men knew/more men did.

01:53:34.920 | If you're going to get a vasectomy

01:53:36.360 | because you are choosing that you don't want to have kids,

01:53:39.480 | and we see many men who do this,

01:53:41.500 | they say they don't want to have kids,

01:53:43.120 | they want to go get a vasectomy,

01:53:44.880 | yet later on in life, you don't have a crystal ball

01:53:47.480 | about life is dynamic and things can change.

01:53:50.180 | If you're going to get a vasectomy, go free sperm first.

01:53:52.260 | - Why are so many men getting vasectomies?

01:53:54.580 | - I don't have the answer to that.

01:53:56.320 | - I hadn't heard this.

01:53:57.440 | - Yeah, a lot of men are getting vasectomies,

01:53:59.800 | even I think to just take control

01:54:01.840 | over not having a child out there when they don't want to, so.

01:54:05.820 | - Maybe this explains the drop in birth rates.

01:54:08.240 | I'm just kidding, it's multifactorial.

01:54:10.240 | - But so many people, even if you're in your family,

01:54:12.640 | let's say you have two kids and y'all decided

01:54:14.880 | you're going to get the vasectomy

01:54:16.300 | so that you don't have any more children,

01:54:18.400 | things happen, terrible things happen and life changes.

01:54:23.220 | There might be a circumstance where you potentially

01:54:27.620 | would have another kid if something really bad happened

01:54:30.460 | or you just changed your mind.

01:54:32.260 | Freezing sperm is so easy and so much easier

01:54:35.820 | than if you don't, not all vasectomy reversals work,

01:54:39.180 | especially the longer that it's been reversed,

01:54:41.320 | the lower the likelihood that it's actually going to work.

01:54:44.060 | And very often if it does, you don't get sperm

01:54:46.340 | in sufficient levels for a timed intercourse

01:54:48.460 | and you're seeing me in the office.

01:54:50.180 | - And freezing sperm is cheap.

01:54:52.140 | I mean, it's relatively cheap.

01:54:53.320 | - It's like $400, right?

01:54:55.180 | So it's much, much cheaper all in

01:54:57.700 | than the entire egg freezing process.

01:55:00.020 | So to answer the original question,

01:55:01.700 | when you go through egg freezing,

01:55:03.420 | most people do fantastic.

01:55:06.140 | And we'll just use egg freezing and IVF interchangeably here

01:55:09.300 | because what you as a person is going through

01:55:12.020 | to harvest your eggs or to take them out of your body

01:55:14.720 | is exactly the same, right?

01:55:16.460 | The distinction between egg freezing and IVF

01:55:18.940 | is all about what happens on the lab end of it

01:55:21.220 | after they've come out of your body.

01:55:23.220 | So if we have this group of eggs that comes out of the vault,

01:55:25.980 | your body doesn't want to allow them all to grow,

01:55:28.700 | even if it's a low number, right?

01:55:30.140 | That's the check and balance to not have so many kids.

01:55:33.260 | So we need to override that process.

01:55:35.300 | And what we tend to do with this

01:55:37.100 | is to use a combination of hormonal medications.

01:55:40.460 | And very often I describe it to patients

01:55:42.700 | as suppressing your body and then stimulating it.

01:55:45.780 | So if I can temporarily stop the production of FSH

01:55:50.140 | and you have a group of eggs come out of the vault,

01:55:52.460 | and we can imagine that FSH is their food,

01:55:55.220 | and there is no food

01:55:56.340 | because you're taking the birth control pill for three weeks.

01:56:00.060 | These eggs are going to synchronize,

01:56:01.960 | be very small, be very hungry.

01:56:04.140 | For lack of a better word,

01:56:05.100 | their FSH receptors are gonna open all up.

01:56:07.220 | It's like a nest of baby birds that are all now starving

01:56:10.100 | instead of the hungry bird gets the worm.

01:56:12.500 | So now we go with the suppression period for a few weeks.

01:56:16.860 | We can come in and give gonadotropins,

01:56:19.660 | which is FSH and LH.

01:56:21.660 | FSH is now synthetically made in a lab.

01:56:24.020 | It's very easy.

01:56:25.300 | It's a synthetic compound that mimics the structure

01:56:27.180 | of the brain FSH.

01:56:29.120 | We actually can't synthetically make LH, very interesting.

01:56:32.780 | We don't have a way to make it yet.

01:56:34.540 | And so we use the purified urine of menopausal women

01:56:39.020 | because when you're in menopause,

01:56:41.040 | your FSH and LH levels are naturally so high

01:56:45.180 | because they're trying to get that egg to make some estrogen.

01:56:48.420 | - So here are some that,

01:56:51.100 | we've covered male hormone health before,

01:56:53.800 | and there's been a discussion of HCG,

01:56:55.740 | human chorionic gonadotropin,

01:56:58.060 | which is essentially mimics LH.

01:57:00.060 | - In the receptor, it does, yes.

01:57:01.580 | - All right, so is pregnant human chorionic gonadotropin,

01:57:06.480 | is it purified from post-menopausal women's urine?

01:57:10.160 | - No. - Or is it synthetic?

01:57:12.060 | - HCG is synthetic.

01:57:13.320 | - And so why can't-

01:57:14.540 | - Well, I'm talking about, it's called Minipure.

01:57:16.260 | - Minipure. - Minipure is a combination

01:57:17.900 | of FSH and LH.

01:57:19.700 | The reason why we give HCG to men

01:57:22.700 | to try to stimulate the spermatogenesis process,

01:57:25.420 | which of course, if we could just give LH, we'd give LH,

01:57:28.060 | it's the same reason why we give HCG for a trigger.

01:57:30.740 | If we are going to go through fertility treatments

01:57:33.060 | and we're trying to mimic that LH surge,

01:57:35.200 | which naturally would cause ovulation,

01:57:37.420 | we actually are giving HCG because it does mimic LH

01:57:41.740 | when it comes to the receptor action of it.

01:57:43.960 | But when it comes to really, especially in getting

01:57:48.120 | follicular development and the relationship

01:57:50.520 | between LH and FSH, meaning LH is really providing

01:57:55.160 | some of the hormone substrate that we need

01:57:57.340 | to be able to make estrogen.

01:57:59.320 | And so you really need some LH in a lot of people,

01:58:03.580 | depending on your protocol or if you're older

01:58:05.800 | and you're naturally making less.

01:58:07.520 | The example or the offshoot would be like the PCOS patient

01:58:12.580 | who has some naturally high LH.

01:58:14.580 | Sometimes they don't actually need LH in their protocol.

01:58:18.200 | - But who are these postmenopausal women

01:58:20.080 | that are supplying their urine?

01:58:21.320 | They're paid? - I don't know, right?

01:58:22.960 | - Yeah, I swear, I imagine them on some island someplace.

01:58:25.380 | Yeah, interesting.

01:58:26.660 | - Go to the menopause.

01:58:27.500 | - Getting paid to urinate.

01:58:28.680 | - And it's called Menopure,

01:58:29.700 | like it's purified menopausal urine, right?

01:58:32.500 | It's wild. - I did not know that.

01:58:33.340 | - Most people don't know that.

01:58:34.640 | - They know now.

01:58:35.480 | - Now they know.

01:58:36.300 | And so we use FSH and LH, we'll just say,

01:58:40.060 | in lack of better terms,

01:58:40.980 | those are the two primary compounds that we're giving

01:58:43.920 | over the course of, on average, a 12-day period

01:58:47.360 | to get the follicles to grow and the eggs to mature.

01:58:51.500 | So you can measure egg maturity by blood levels of estradiol

01:58:55.740 | and by transvaginal ultrasounds.

01:58:57.200 | So when you're going through egg freezing or IVF,

01:58:59.940 | you're taking these hormone shots of FSH and LH,

01:59:04.060 | and they are getting those follicles to start to grow,

01:59:07.260 | the eggs are starting to mature,

01:59:09.300 | we are monitoring them along the way,

01:59:11.420 | trying to determine the time period where we think

01:59:14.180 | most of the eggs will be in the mature range.

01:59:17.980 | These eggs have gotten to maturity.

01:59:20.220 | You then are going to take a trigger shot,

01:59:22.480 | which allows that final stage of meiosis

01:59:25.100 | so those chromosomes can separate, right?

01:59:27.140 | We think about the egg,

01:59:28.620 | we remember that normal female genetics, it's 46XX,

01:59:33.020 | and I always think about, in the egg,

01:59:35.100 | that these chromosomes are lined up.

01:59:36.740 | Your eggs are frozen inside your body.

01:59:40.200 | When you're born, your eggs are in metaphase of meiosis.

01:59:42.900 | So that's when metaphase chromosomes meet in the middle

01:59:46.140 | and they're held apart by these meiotic spindles.

01:59:48.480 | And this is why eggs are so stinkin' fragile,

01:59:51.140 | because they're held like this,

01:59:52.500 | and those meiotic spindles just absorb

01:59:54.340 | the wear and tear of your life,

01:59:56.740 | but when you use that trigger shot,

01:59:58.860 | that LH surge naturally or that HCG in a cycle,

02:00:02.780 | that's when you're gonna get that final separation

02:00:05.300 | into half those chromosomes into the egg.

02:00:08.420 | - So for people listening, think about like a zipper.

02:00:12.020 | - Oh, I love that.

02:00:12.860 | - And you're pulling apart of a zipper

02:00:14.460 | that then you now have the chromosomes,

02:00:17.900 | just one, you now have halved the chromosomes, because why?

02:00:21.300 | Because in successful fertilization,

02:00:23.140 | the other chromosomes are gonna come from sperm.

02:00:25.620 | - The sperm, and that's why this process has more error

02:00:29.580 | the older you are,

02:00:30.660 | and the longer your chromosomes have been sitting there,

02:00:33.440 | because those spindles are going to break down,

02:00:36.000 | and we're gonna have that increase in aneuploidy,

02:00:38.260 | like we already said, purely because of this impact.

02:00:41.860 | - Can I ask a question about that specifically?

02:00:43.660 | I think now would be the right time to ask,

02:00:45.040 | which is that my understanding is that a lot of the dynamics

02:00:47.760 | of pulling apart of this zipper-like thing,

02:00:49.420 | these chromosomes, and then is related to mitochondrial DNA,

02:00:53.940 | because there are a lot of mechanics.

02:00:54.840 | We're literally talking about an egg splitting itself

02:00:58.140 | in half. - Yeah, the mitochondria

02:00:58.980 | is its powerhouse.

02:00:59.800 | - Yeah, and the mitochondria.

02:01:01.140 | And so mitochondrial health is a big topic these days,

02:01:03.900 | and so we will be sure to touch on nutrition,

02:01:06.040 | supplementation, and prescription drugs

02:01:07.520 | that impact mitochondrial health.

02:01:09.060 | But I've heard of a new procedure called three-parent IVF,

02:01:13.420 | where they're taking basically the DNA

02:01:16.400 | from the intended mom, the DNA from intended dad,

02:01:21.400 | and then putting it into a surrogate, like a donor egg,

02:01:28.180 | that is where the DNA has been sucked out,

02:01:31.420 | and then because it has healthier, younger mitochondrial DNA.

02:01:36.420 | So you're essentially, let's say you've got a couple

02:01:40.260 | in there, like let's say late 30s, early 40s,

02:01:42.740 | and they're not getting successful embryos

02:01:44.740 | or implantations or whatever, things aren't working.

02:01:47.280 | They'll take the DNA from mom and dad,

02:01:48.840 | and they'll merge it with a third parent encapsulation.

02:01:53.840 | There are clinics that do this.

02:01:55.060 | I know that a lot of this was actually being done

02:01:57.140 | in Eastern Europe until recently.

02:01:59.980 | Mexico offers, there are places in Mexico that do this.

02:02:03.300 | In England, it's been used to solve

02:02:06.540 | mitochondrial dysfunction, but in the US,

02:02:08.820 | this is still not legal, is that right?

02:02:11.180 | - Yes, so the purpose of what you're talking about,

02:02:13.660 | essentially, when we think about utilizing

02:02:16.500 | a donor mitochondrial or a donor egg,

02:02:20.740 | the point of that technology existed

02:02:23.700 | to help cure mitochondrial diseases,

02:02:26.660 | which are 100% fatal.

02:02:28.780 | And so you would have this subset of people who would,

02:02:31.980 | because if you're the mom, you always pass on

02:02:35.060 | your mitochondria to all of the offspring.

02:02:39.560 | So if there's disease inherent in your mitochondria,

02:02:41.940 | everybody's going to get it.

02:02:43.460 | And these are very severe diseases.

02:02:46.020 | So the idea of this was first to say,

02:02:48.620 | hey, can we overcome this mitochondria disease

02:02:51.740 | and give people the opportunity?

02:02:54.220 | Which it has done that, right?

02:02:55.980 | Now--

02:02:56.820 | - So it works when done properly.

02:02:58.300 | - When done properly, especially for that purpose.

02:03:00.540 | Now that purpose is distinct because

02:03:03.800 | those people aren't infertile, right?

02:03:07.300 | There's something else going on

02:03:08.660 | within their mitochondrial disease.

02:03:10.780 | Utilizing that technology to overcome

02:03:13.380 | age-related changes in the eggs

02:03:15.260 | has not been successful yet.

02:03:17.500 | Are we hopeful that it can?

02:03:18.980 | Will people charge you money for it in certain places?

02:03:21.760 | Yes, but you're hitting on a really important topic,

02:03:25.340 | is that the political environment of embryo research

02:03:30.340 | in the United States makes it extremely hard for us

02:03:34.580 | to be the pioneers of new technology in this space.

02:03:38.560 | And that is because a lot of views about an embryo

02:03:43.180 | or when does life begin that happens here in the US,

02:03:46.840 | that results in limiting the availability

02:03:49.180 | and the possibility of doing research

02:03:52.420 | in a meaningful way on human embryos.

02:03:54.900 | - Right, 'cause it would require

02:03:55.820 | the destruction of a lot of,

02:03:57.740 | and it would also, and I looked into this a little bit

02:04:01.500 | from an academic perspective to be clear,

02:04:04.620 | it would also require that the abortions

02:04:09.140 | be performed differently because suction abortions

02:04:10.940 | destroy embryos in ways that extraction abortions don't.

02:04:14.020 | So this is a very controversial topic.

02:04:15.660 | I mean, it's something that maybe we'll return to

02:04:18.300 | in an episode about stem cells in the future.

02:04:20.380 | - Yeah, it's fascinating because,

02:04:22.380 | especially if you look at IVF, a whole separate issue

02:04:25.420 | is that there's millions of embryos

02:04:27.160 | that people are no longer using

02:04:29.580 | because they have had success,

02:04:32.620 | they had extra embryos in the bank,

02:04:34.260 | they got divorced, a variety of reasons.

02:04:37.160 | And a lot of people would like to donate their embryos

02:04:40.820 | to science, feel like, hey,

02:04:43.180 | I don't wanna have this embryo implanted,

02:04:46.580 | I don't wanna carry this child,

02:04:48.440 | but potentially could something good

02:04:49.940 | or could it help advance the field?

02:04:52.540 | But that's not really a tangible option.

02:04:54.980 | When people do that, what is actually happening

02:04:57.100 | is their embryos are being utilized to train embryologists,

02:05:01.060 | which is valid, right?

02:05:02.500 | To teach them how to thaw and freeze and biopsy

02:05:05.860 | and do different things, so it's still useful,

02:05:08.100 | but it's not in a meaningful way like we'd really love

02:05:11.440 | to be able to utilize to advance the science,

02:05:14.140 | especially for these embryos that have been created,

02:05:17.260 | yet people no longer need them for family growth.

02:05:21.460 | - So what happens to all the embryos that people don't use?

02:05:23.940 | - It's a fantastic question, right now they sit in storage.

02:05:26.620 | This is-- - Forever?

02:05:27.460 | - Well, this is a new problem, okay?

02:05:28.740 | IVF is only 40-ish years old, embryo freezing alone, right?

02:05:32.860 | The first IVF, we haven't even gone through

02:05:34.900 | the whole process, but the first IVF baby,

02:05:37.620 | there's no FSHLH to stimulate more of the eggs

02:05:41.260 | outside the vault to grow,

02:05:42.260 | so they followed the single follicle

02:05:44.460 | and they didn't have the procedure,

02:05:46.300 | which we do now, which is a minimally invasive procedure

02:05:49.040 | to extract eggs.

02:05:50.060 | We go vaginally with a needle attached to the ultrasound

02:05:54.160 | and we enter into each follicle and we drain it.

02:05:57.420 | The very first IVF, you followed one follicle

02:05:59.940 | and you went in abdominally with a surgery

02:06:02.620 | to put that needle into the follicle and drain it out

02:06:05.420 | and give that just one egg a chance.

02:06:07.380 | And then of course, there was no embryo freezing originally,

02:06:10.320 | so the field is still rather young to understand

02:06:14.400 | some of this and as technology rapidly improves,

02:06:18.480 | we see things like better success rates

02:06:20.900 | with freezing and thawing embryos,

02:06:23.140 | better process of getting more embryos to grow,

02:06:26.100 | but now we have a lot of embryos in storage

02:06:28.760 | that may or may not be used.

02:06:31.080 | I personally tell people, you should keep your embryos,

02:06:35.580 | you should pay the storage fee until no matter what,

02:06:40.200 | the worst thing on planet Earth happens to you,

02:06:42.880 | you're done having children.

02:06:44.460 | Because sadly, I live in a spectrum with my field

02:06:47.220 | where I see a lot of sadness

02:06:48.740 | and people who maybe have lost a child,

02:06:50.880 | something else has happened and they have maybe a sibling

02:06:54.180 | who they feel like they really wanna give this sibling child

02:06:56.840 | the chance to be a sibling again

02:06:59.580 | and often you're much older when you're experiencing this

02:07:03.180 | and if you had had embryos frozen that you could have used

02:07:06.140 | but you got rid of them, you're gonna be really upset

02:07:09.100 | if you find yourself in that circumstance.

02:07:11.560 | So I always say you should save them until you know

02:07:13.880 | that you are not going to need them

02:07:16.020 | and then what do you do with them?

02:07:18.200 | Most people just discard them,

02:07:20.020 | some people will donate them to labs

02:07:21.740 | which is called for research

02:07:23.620 | but mostly it's for embryologist training.

02:07:26.760 | - To get better at doing IVF.

02:07:27.600 | - To get better, which is also important.

02:07:30.060 | But embryo donation's a new thing.

02:07:31.780 | So being able to, just like we have people who donate sperm

02:07:35.700 | and donate eggs, embryo donation is the next evolution

02:07:40.500 | of an opportunity to allow more people to become parents.

02:07:44.540 | It's a little bit of the wild west,

02:07:46.780 | people finding people in Facebook groups and connecting,

02:07:51.680 | it's this whole other dynamic when it comes to

02:07:54.360 | what we call third party reproduction

02:07:57.260 | or what do you do with known donors and things like that

02:08:01.800 | but it's a very interesting concept.

02:08:04.160 | So this problem is emerging

02:08:06.860 | as the technology is getting better.

02:08:08.980 | I'm realizing now, remembering rather,

02:08:13.460 | that when I was in college and graduate school

02:08:16.220 | you would see these ads in the student paper

02:08:19.020 | for egg donors and sperm donors.

02:08:21.660 | Sperm are generated throughout the lifespan

02:08:25.020 | so that's a kind of less controversial issue

02:08:27.340 | but this has now not allowed most places

02:08:30.180 | to advertise for egg donors on college campuses.

02:08:32.900 | That's my understanding.

02:08:34.760 | The egg donors were often paid whatever they were paid.

02:08:39.440 | I'm not going to say it was reasonable amounts or not

02:08:41.400 | 'cause I don't recall what they were paid

02:08:43.440 | and everyone's circumstances are different.

02:08:45.280 | But the argument that most people use against this is,

02:08:49.840 | oh well these people are giving up eggs

02:08:51.840 | that they could otherwise use

02:08:53.000 | but we now know that's not true.

02:08:55.040 | So do you have any knowledge as to what was the rationale

02:09:00.040 | for limiting the recruitment of egg donors?

02:09:04.360 | Anyway, I'm not arguing for or against.

02:09:06.860 | I just, it's no longer supported based on what you said

02:09:11.000 | by the argument that they're losing eggs

02:09:14.840 | they would otherwise be able to keep.

02:09:17.000 | - Some of it's about proper informed consent,

02:09:19.560 | especially at an age where the financial incentive

02:09:24.560 | can be very persuasive without understanding.

02:09:27.980 | - That makes sense.

02:09:28.820 | - Not that it harms your fertility later

02:09:30.760 | but that you're going to have genetic children out there

02:09:34.080 | and you might potentially, and we are seeing this now,

02:09:39.080 | we don't know if you individually will have infertility

02:09:42.400 | for a variety of reasons

02:09:43.540 | 'cause you're not trying to have a family until much later.

02:09:46.160 | - But the same concern doesn't seem to exist

02:09:48.040 | for men who are donating sperm.

02:09:49.360 | - I mean, it should.

02:09:50.280 | There's this whole donor conceived community

02:09:52.160 | where people are really talking about

02:09:54.080 | putting new restrictions on,

02:09:55.640 | will you sperm donation for example.

02:09:57.760 | There are sperm donors who have hundreds of children,

02:10:01.680 | hundreds, right?

02:10:02.720 | There are these sibling pods because it's been so unlimited

02:10:06.420 | and sperm banks are a business that work to make money

02:10:09.900 | and they make money by selling more sperm.

02:10:12.740 | But that's not healthy.

02:10:14.260 | One, for a population you need genetic diversity

02:10:17.000 | but also it's not healthy necessarily for one person

02:10:20.440 | to have all these half siblings

02:10:23.000 | and to just not know when you're going to run into somebody

02:10:26.080 | who could potentially be your sibling.

02:10:28.440 | Is it this guy at the bar that you like?

02:10:30.400 | Do you have to worry about that if your donor conceived?

02:10:33.200 | So we're starting to see sperm banks

02:10:35.160 | finally start to reel back

02:10:36.560 | and put limitations on how many families.

02:10:39.800 | Total children's tough, right?

02:10:40.960 | Because one family might have a child

02:10:43.400 | and you want them to be able to have sibling children

02:10:45.960 | but at least for how many families

02:10:47.520 | that that donor can contribute to.

02:10:50.440 | And we're seeing sperm donors deal with the fact

02:10:53.340 | that now there's no anonymous donation.

02:10:56.260 | We can act like anonymous donation exists,

02:10:58.860 | meaning it is not identified at the time

02:11:01.580 | that somebody is utilizing the sperm.

02:11:04.160 | But with direct to consumer testing for genetics,

02:11:07.440 | like 23andMe and Ancestry,

02:11:10.160 | people are being connected with their sperm donors,

02:11:13.380 | with their egg donors, with their sibling pods

02:11:16.500 | and we have to believe that technology

02:11:18.360 | is only going to improve over time.

02:11:20.040 | So what people do for money,

02:11:23.260 | especially when they're young,

02:11:24.880 | I think without understanding the potential ramifications

02:11:28.180 | and I don't wanna act like sperm donation

02:11:30.560 | or egg donation are bad,

02:11:31.720 | they give people the opportunity to become parents

02:11:35.400 | that otherwise might not be able to

02:11:37.160 | and that is a lovely and a beautiful gift

02:11:40.080 | but you need to understand what that might mean

02:11:43.340 | and how that might impact your own potential children

02:11:46.480 | later too to know that they have

02:11:49.080 | genetic half-siblings out there.

02:11:51.280 | Egg donation, people do get compensated

02:11:54.680 | much better than sperm donation.

02:11:57.180 | There's certain characteristics that are hard to find

02:11:59.700 | that get compensated even more so

02:12:03.280 | and certain ethnicities, doctorate degrees

02:12:07.000 | and things like that where somebody can really pay

02:12:08.760 | for their education by donating their eggs.

02:12:12.420 | It's a dilemma because what you'd love to say

02:12:17.400 | is like free some eggs for you too.

02:12:20.400 | If you're gonna do that, you're at the perfect age

02:12:22.640 | to freeze your own eggs and there's been strategies

02:12:26.200 | to try to mitigate this

02:12:29.040 | and I don't wanna get off too much on a tangent

02:12:30.900 | but it's a really fine line that you walk

02:12:34.160 | with what people understand.

02:12:35.220 | So there is a company and I won't name them

02:12:37.780 | but they are promoting that young women donate their eggs

02:12:40.560 | and they will freeze half of them for you

02:12:43.940 | and half of them will go and become donor eggs.

02:12:47.680 | - Interesting business model

02:12:48.960 | that I could see the potential ethical concerns.

02:12:51.080 | - So I think ethically, this sounds good

02:12:53.160 | 'cause you get to freeze some eggs

02:12:55.040 | but I think more people will donate eggs

02:12:58.320 | than otherwise would have

02:12:59.560 | for some of the reasons we previously stated

02:13:01.920 | and I also think you would get more money

02:13:04.680 | by simply donating your eggs and then turning around

02:13:08.600 | and paying for a round of freezing your own eggs.

02:13:11.720 | You would get paid more and you'd have more eggs

02:13:14.160 | because one of the issues is do you now falsely believe

02:13:17.720 | that you have enough eggs in the bank

02:13:19.160 | because you did this split but you don't really have enough

02:13:22.400 | because we already walked through the math at 20 eggs,

02:13:25.240 | doesn't really result in such a high probability

02:13:27.900 | of having a multi-child family.

02:13:30.440 | So there's a lot of ethical debate

02:13:34.240 | in gamete and embryo donation.

02:13:36.060 | It definitely is the wild west

02:13:37.760 | and there's uncharted territory, even in embryo donation.

02:13:42.360 | There's places who are very unethical about it,

02:13:44.800 | who will only allow people to have embryos

02:13:49.480 | if they are heterosexual, been married for three years,

02:13:52.360 | make a certain income, submit to a home study,

02:13:55.500 | yet they let the people have no say

02:13:57.480 | over the embryos that are transferred,

02:13:59.320 | be it how many, what stage, what quality

02:14:03.280 | and they're taking people's money

02:14:04.720 | and putting terrible embryos inside of them

02:14:08.280 | and really wasting their resources

02:14:10.960 | which could have been used in another way.

02:14:13.040 | - Yeah, the dangers of profitization of biology.

02:14:15.800 | - Right, and tech, I mean, tech entering spaces is amazing

02:14:18.920 | but also technology starts to advance before studies, right?

02:14:23.300 | Tech is gonna become, has more finance backing

02:14:27.200 | than we see scientific studies get.

02:14:29.560 | - I feel like one of the major questions out there

02:14:34.240 | is whether or not IVF babies, we'll just call them that,

02:14:39.100 | have a higher incidence of things like spectrum conditions

02:14:44.100 | or other developmental trajectories, let's call them.

02:14:47.720 | And I'm not trying to be politically correct here

02:14:49.540 | but I think nowadays the word disorder

02:14:52.900 | has to be really carefully examined

02:14:54.760 | when considering any neurologic and psychiatric situation.

02:14:59.760 | We've had discussions about this on this podcast before

02:15:04.240 | but a lot of people are wondering, just to be direct,

02:15:07.180 | a lot of people are wondering, do more IVF babies

02:15:09.520 | have autism than non-IVF babies?

02:15:14.020 | - This is a good question and it's changed over time

02:15:18.440 | in a couple different ways

02:15:19.520 | and I think this is important to understand.

02:15:20.980 | So if we just think about the hormonal environment

02:15:23.840 | with natural conception and you have a peak estrogen,

02:15:28.080 | let's say you have 200 something,

02:15:30.280 | you have progesterone being made,

02:15:31.980 | the placenta is implanting,

02:15:33.720 | then what is the main difference with IVF babies?

02:15:38.580 | And a lot of it has been tied back

02:15:40.460 | to the uterine environment,

02:15:43.020 | especially in what we call fresh embryo transfers

02:15:45.940 | which is really not a common practice anymore.

02:15:48.460 | So in a fresh embryo transfer,

02:15:50.100 | I'm gonna take the eggs out of your body,

02:15:51.720 | fertilize them in the lab and grow out embryos

02:15:53.940 | and then I'm going to put the best embryo

02:15:56.980 | back in your body five days later

02:15:59.040 | at the natural time of implantation.

02:16:01.220 | And if we rewind the clock, that's how IVF was done.

02:16:03.700 | Right, when you couldn't freeze embryos very well

02:16:06.020 | and they didn't survive.

02:16:07.340 | And you'd put lots of embryos inside

02:16:09.820 | because they wouldn't survive

02:16:11.140 | and that's the early days of IVF

02:16:13.080 | when you saw a lot of multiples,

02:16:15.400 | a lot of high order multiples

02:16:17.040 | and of course multiples have their own distinct issues

02:16:20.820 | that put them at higher risk for developmental disorders

02:16:24.820 | and issues with development and birth risk in general.

02:16:27.420 | Right?

02:16:28.260 | - They're common, to be fair,

02:16:29.240 | they're commonly referred to as disorders.

02:16:31.240 | I just think around autism in particular,

02:16:33.840 | there is a camp, a growing camp out there

02:16:36.140 | that one referred to differently.

02:16:39.000 | We've covered this.

02:16:40.760 | Anytime this comes up, I bring up both

02:16:42.760 | just to highlight the fact that yes,

02:16:44.480 | we are aware and sensitive to that emerging issue.

02:16:47.300 | Right now, unfortunately, for sake of conversation,

02:16:49.440 | there's no new nomenclature.

02:16:51.000 | So we could easily get caught down

02:16:53.920 | in the attempt to try and smooth over everything

02:16:58.060 | with everybody and as a consequence, confuse everybody.

02:17:00.640 | So I think we'll go for clarity forward

02:17:02.360 | with the understanding that the nomenclature is changing.

02:17:04.200 | Can't even say alcoholism anymore

02:17:06.080 | because it's alcohol use disorder

02:17:07.780 | and I don't have a problem with that

02:17:09.000 | but a lot of people wonder

02:17:10.560 | if those are two different things.

02:17:11.940 | - Which is confusing and we want to simplify science

02:17:14.040 | for people. - Right, exactly.

02:17:14.880 | So feel free.

02:17:15.880 | - Okay, so when we first were doing IVF,

02:17:18.360 | we're putting embryos back

02:17:19.360 | in an extremely unnatural environment.

02:17:22.040 | If you have 20 eggs growing

02:17:24.040 | and each egg makes 200 picograms of estrogen,

02:17:26.720 | suddenly now you have these extremely high

02:17:29.480 | super physiologic estrogen levels,

02:17:32.200 | higher progesterone levels

02:17:33.440 | because there's more corpus luteums

02:17:35.320 | and this environment is not the normal

02:17:38.520 | for how the placenta would invade

02:17:40.140 | into that maternal blood circulator

02:17:43.160 | and a lot of these issues that are commonly associated

02:17:46.600 | became so because of placental issues.

02:17:48.960 | So a lot of things like growth restriction,

02:17:51.200 | small for gestational age, preterm birth,

02:17:54.080 | which further puts you at risk

02:17:56.100 | for other developmental disorders,

02:17:58.500 | were associated with these fresh transfers.

02:18:00.920 | The field has changed.

02:18:01.760 | We do a lot of frozen embryo transfers

02:18:03.440 | and a lot of it for this reason,

02:18:04.680 | we see huge improvement in neonatal outcomes

02:18:07.740 | when you bleed off that high hormonal uterine environment

02:18:12.000 | and then regrow the lining of the uterus

02:18:14.380 | in a hormonal level that's more natural

02:18:17.320 | and then transfer the embryo

02:18:19.120 | and we see completely different fetal outcomes.

02:18:23.300 | So that's fantastic

02:18:25.320 | as far as looking at the change over the field

02:18:27.240 | but of course, if you take all IVF babies over all time,

02:18:30.480 | it's a little murky

02:18:31.380 | because you have modern practice and old practice.

02:18:34.280 | We also know that infertility people,

02:18:39.140 | if you get diagnosed with infertility,

02:18:41.240 | so you're under age 35

02:18:43.120 | and you try to get pregnant with regular periods

02:18:45.440 | for one year and have not had success

02:18:48.300 | or you're 35 and older and you've tried for six months

02:18:50.740 | and you've not had success,

02:18:51.800 | you meet the medical definition for infertility.

02:18:55.140 | When that happens, you now statistically,

02:18:59.080 | regardless if you get pregnant naturally in the next month

02:19:02.180 | or you do IVF,

02:19:03.680 | you have a 1% higher chance of birth defects

02:19:06.560 | and you have a slightly higher chance

02:19:09.160 | of developmental disorders.

02:19:10.860 | So is it more population-based versus procedure-based

02:19:14.840 | and there's probably something to that

02:19:16.580 | to underlying a lot of potentially what goes in

02:19:19.360 | or what can cause infertility

02:19:21.520 | when it comes to quality of eggs or sperm

02:19:25.120 | or uterine environment

02:19:26.640 | or things that we're still learning about.

02:19:29.560 | When it comes to autism specifically,

02:19:31.480 | the number one strongest association we have

02:19:33.620 | is advanced paternal age.

02:19:35.040 | So when you look at the people

02:19:37.440 | and the male sperm comes from an ejaculation after age 50,

02:19:42.440 | that one does have the highest significance

02:19:44.820 | associated with autism

02:19:46.440 | and also with some other very interesting

02:19:48.400 | autosomal dominant disorders.

02:19:50.360 | So we don't wanna take advanced paternal age likely,

02:19:53.840 | although it does get so much less attention

02:19:56.000 | than what we call advanced maternal age

02:19:59.040 | or being over age 35 in a woman.

02:20:01.680 | And that is purely because of the differences

02:20:04.340 | in the sperm and the egg environment

02:20:07.000 | and how their quality is impactful.

02:20:09.000 | - Thank you for that answer.

02:20:10.000 | I think it's really important for people to hear that

02:20:13.880 | because the lore out there is that IVF,

02:20:17.920 | higher incidence of autism and IVF babies,

02:20:20.480 | but it sounds like a good percentage of those.

02:20:24.060 | Could be because of age related factors

02:20:26.400 | as well as technology related factors

02:20:29.700 | and that the technology is getting better all the time

02:20:33.660 | if I understood correctly.

02:20:35.660 | We didn't complete the discussion of IVF

02:20:38.660 | and I want to do that,

02:20:39.480 | talk about ICSI and a few other things.

02:20:40.980 | I know that's definitely your wheelhouse.

02:20:42.900 | Before we do that,

02:20:44.080 | can we inject a little sub conversation around this

02:20:48.180 | because I neglected to bring this up earlier

02:20:50.700 | and I know there's a lot of curiosity about this

02:20:52.600 | and then we'll finish off IVF.

02:20:55.660 | Can we do that? - Let's do it.

02:20:56.560 | - Sort of a pause in the IVF.

02:20:58.080 | So the eggs are out, they're frozen,

02:21:00.280 | sperm's out, it's frozen,

02:21:01.660 | or maybe they're going to put live sperm on,

02:21:03.780 | a non-frozen, excuse me,

02:21:05.580 | sperm directly onto those unfrozen eggs.

02:21:07.860 | We'll pause there,

02:21:08.860 | intermission for those potential embryos.

02:21:11.560 | And talk about something that you've been very open about,

02:21:18.000 | which is, and a lot of people are not,

02:21:20.900 | frankly, in your profession.

02:21:22.780 | So I really appreciate this,

02:21:23.820 | which is nutrition and supplementation

02:21:25.620 | to optimize the health of egg quality

02:21:28.900 | and not just for people who want to get pregnant,

02:21:32.260 | but for people who believe that fertility

02:21:36.200 | is a proxy for overall health.

02:21:38.200 | So, I mean,

02:21:39.040 | are there things that people should eat and not eat,

02:21:41.340 | things that people should supplement and not supplement

02:21:43.740 | in order to optimize their fertility?

02:21:47.500 | - I mean, this is definitely an interest of mine, right?

02:21:49.280 | All my fellowship research cycles around

02:21:51.240 | fecundability and natural fertility.

02:21:53.400 | And I think we really do a disservice

02:21:55.320 | by how medicine really is categorized by organ systems,

02:21:59.560 | because we act like things in one place

02:22:01.980 | don't impact the other.

02:22:03.240 | - As if. - Right?

02:22:04.200 | But you have a body and your body,

02:22:06.540 | and especially your hormones,

02:22:07.960 | change and fluctuate and they're meant to.

02:22:10.280 | They are meant to be a dynamic system,

02:22:13.080 | but the world and the environment

02:22:15.360 | of which you are subjecting your body to

02:22:19.160 | has proven changes on both hormonal function

02:22:23.200 | and also when it comes to egg and sperm quality.

02:22:26.360 | And so if you are somebody

02:22:27.400 | who just wants to live your healthiest life

02:22:29.480 | and have your most regular periods

02:22:32.480 | and have your hormones as well balanced as they can be,

02:22:35.780 | for a lack of a better word,

02:22:37.480 | we'll just say that that means

02:22:38.360 | that they're functioning normally,

02:22:40.100 | then paying attention to the things that you do

02:22:41.940 | are really important.

02:22:43.020 | And so I know this is a big one for you.

02:22:45.000 | Sleep is probably the number one thing that people don't do

02:22:47.400 | that does impact their reproductive hormone system

02:22:49.720 | and therefore can impact egg and sperm quality

02:22:52.680 | because sleep is when you have cellular repair

02:22:54.960 | and when you can drop your inflammation levels.

02:22:57.280 | We know that inflammation is just toxic to eggs and sperm.

02:23:02.280 | It is.

02:23:03.240 | The inflammatory environment is not ideal for conception.

02:23:07.960 | And then for a female, you have to deal with the fact

02:23:11.020 | that you have your egg quality,

02:23:12.760 | but you also have how inflammation

02:23:15.340 | or what you're exposed to impacts your uterine environment.

02:23:18.260 | So you have a two-fold situation here.

02:23:21.940 | So none of this should be shocking news

02:23:24.660 | when it comes to nutrition,

02:23:26.340 | but it is not talked about enough, you're right.

02:23:29.260 | Decreasing inflammation by the foods that we put in our body

02:23:32.640 | is consistently shown with an improvement in fecundability,

02:23:37.360 | an improvement in ovulation,

02:23:39.340 | and an improvement in success with IVF,

02:23:41.840 | and a decrease in miscarriage, right?

02:23:44.340 | Huge studies have looked at these.

02:23:46.680 | Now, the big caveat is that nutrition studies are super hard

02:23:51.160 | because people who consume flax, for example,

02:23:55.320 | tend to have other good health behaviors

02:23:58.140 | that sometimes make it hard to identify what flax did

02:24:01.600 | versus their general health

02:24:03.120 | versus somebody who eats fast food every day.

02:24:07.100 | So nutrition studies tend to be observational,

02:24:09.460 | and fertility studies are really hard too

02:24:11.600 | because what endpoint are you using?

02:24:14.840 | Is it getting pregnant?

02:24:15.760 | Is it live birth?

02:24:16.800 | Are you looking at IVF?

02:24:18.120 | Are you looking at natural fertility?

02:24:19.800 | And we have a lot of different overlap

02:24:22.160 | that makes both of these a little bit difficult.

02:24:24.840 | And so they're all cohort-based or population-based studies

02:24:28.420 | where you analyze how people perform

02:24:31.060 | when it comes to fertility treatments

02:24:32.680 | or getting pregnant naturally

02:24:34.500 | based on their exposures to certain things.

02:24:37.200 | Diets high in fruits and vegetables are good for you, right?

02:24:40.880 | Fiber, antioxidants.

02:24:42.320 | Fruit is not bad.

02:24:43.460 | Fruit got this really bad reputation.

02:24:45.400 | - Really? I love fruit.

02:24:46.240 | - I love fruit too, but people think that it has sugar

02:24:48.360 | and that it's bad for you.

02:24:49.560 | - Well, it has fructose, but, you know.

02:24:51.040 | - No, it's not, that type of sugar is not bad for you.

02:24:53.560 | If we can just agree on the fact

02:24:55.400 | that fruit has a lot of nutritional benefit,

02:24:57.780 | especially when it comes to vitamins and antioxidants,

02:25:00.360 | that can be extremely beneficial in decreasing inflammation.

02:25:03.520 | Grains, so whole grains, especially,

02:25:06.600 | that your body provide a lot of great fiber.

02:25:08.800 | So, of course, if you have celiac

02:25:11.200 | or you're gluten intolerant, you're a different category,

02:25:13.920 | but there was so much focus on keto

02:25:15.840 | and people eliminating grains as a food group overall.

02:25:19.240 | And even though that might be utilized

02:25:20.800 | in a dietary strategy to lose weight

02:25:23.240 | and losing weight can improve fertility,

02:25:26.160 | likely because of inflammation being the primary driver,

02:25:30.840 | because we know that even in studies

02:25:32.880 | where I take donor eggs and I transfer that embryo

02:25:36.700 | into somebody who's overweight,

02:25:38.940 | they have lower odds of success

02:25:40.460 | than if they were a normal BMI.

02:25:43.080 | So we can't act like that causation

02:25:46.100 | is just on egg quality from obesity, right?

02:25:48.260 | There's also some inflammation, some inflammatory changes

02:25:51.860 | that impact the body's ability or desire

02:25:55.860 | to allow an embryo to implant.

02:25:57.960 | So fruits, veggies, whole grains are all good.

02:26:02.760 | Interestingly, dairy, dairy tends to be okay in most studies,

02:26:07.380 | but what we do see is that if you're gonna have dairy,

02:26:10.900 | have the real thing, the processed dairy, the skim milk,

02:26:15.680 | that actually decreases your fertility.

02:26:18.440 | And likely because the processing

02:26:20.780 | to make it still look like milk when you take out the fat

02:26:23.780 | is adding in things that are unnatural,

02:26:26.400 | potentially impacting your fertility.

02:26:28.400 | - I don't drink milk anymore,

02:26:29.440 | but when I was a teenager, I drank half and half.

02:26:31.600 | I'm not recommending anyone do that.

02:26:32.860 | Remember I was a skiing teenager.

02:26:34.220 | - You were trying to bulk up.

02:26:35.340 | - Well, no, I just could afford to.

02:26:36.560 | I wasn't trying, at that age, I wasn't trying to at all,

02:26:38.980 | but it was just delicious.

02:26:41.780 | But so cheeses,

02:26:44.020 | full fat milk, half and half, yogurt, okay.

02:26:50.040 | - Yeah, but don't choose the skim one.

02:26:51.500 | Choose the actual one that comes with some of the milk fat.

02:26:55.580 | Fat is not bad for you.

02:26:56.740 | There's also this, right?

02:26:58.560 | Hopefully we're getting away from it,

02:26:59.540 | but there's been such a low fat craze

02:27:01.340 | or this real attention that fat is so bad.

02:27:04.460 | But fat comes in so many important forms,

02:27:08.360 | avocados and oils and nuts, dairy, meat.

02:27:13.220 | Fat and cholesterol are the backbone for all hormones, right?

02:27:17.020 | So you need that in order for your body

02:27:20.040 | to make the estrogen and progesterone that it needs

02:27:22.820 | to allow this whole process to happen.

02:27:25.260 | And so there's this idea that those are bad for you.

02:27:28.220 | That's just really not.

02:27:29.060 | So healthy fats, whole grains, fruits, veggies.

02:27:31.860 | - And what about proteins and meats?

02:27:33.040 | Because I think within those categories,

02:27:35.340 | I'm a big fan of sustainably raised meats if possible.

02:27:39.980 | Some people choose not to eat meat, but fish, eggs.

02:27:42.480 | - Love it all.

02:27:44.300 | Okay, so let's just go through the meats

02:27:45.820 | and the myth and the facts.

02:27:47.700 | So we'll do tofu.

02:27:49.540 | So there's this big issue that tofu has soy

02:27:51.820 | and that too much soy can be bad

02:27:53.800 | because soy can be a phytoestrogen.

02:27:56.120 | Tofu does not negatively impact fertility, even in men.

02:27:59.420 | In fact, it can improve it

02:28:00.840 | because it does have some antioxidant-like properties,

02:28:03.560 | lots of iron.

02:28:04.660 | When it comes to fish, fish are fantastic sources

02:28:08.700 | of healthy fats and omega-3 fatty acids,

02:28:11.220 | which are very crucial in the reproductive process.

02:28:15.200 | We do worry about if you're pregnant,

02:28:17.280 | having too much fish and overexposure to mercury

02:28:20.320 | and how that can impact fetal brain development.

02:28:22.920 | So the general recommendation is three servings per week.

02:28:26.480 | That doesn't-

02:28:27.320 | - Let me guess, a serving is like four to six ounces

02:28:28.900 | as opposed to like a real human that eats, you know.

02:28:31.300 | - A real human.

02:28:32.140 | - Yeah, that eats six to eight ounces of fish, right.

02:28:36.680 | - And I think it's important to say,

02:28:38.320 | even though people will tell you that

02:28:39.900 | when you're trying to get pregnant

02:28:41.300 | with the idea of we don't know

02:28:42.520 | when you're going to be pregnant,

02:28:44.680 | if you're going through things like egg freezing or IVF

02:28:47.300 | and you know when you're going to be pregnant,

02:28:49.560 | I wouldn't feel like you have to restrict yourself

02:28:51.660 | on the consumption of seafood during those time periods

02:28:55.320 | when you know you're not pregnant yet.

02:28:56.620 | Because really the concern is about that mercury

02:28:59.400 | and what it could potentially do to a fetal brain.

02:29:01.680 | - And raw seafood, correct?

02:29:02.840 | No sushi, no sashimi.

02:29:04.180 | - Well, when you're pregnant, correct.

02:29:05.300 | And that's mostly because of the risk of infectious disease

02:29:08.220 | that can cause severe brain development and other issues.

02:29:11.400 | - What do they do in Japan?

02:29:12.680 | - I don't know.

02:29:13.520 | I don't live there.

02:29:14.340 | - They probably laugh at this.

02:29:15.180 | - They probably do laugh at us.

02:29:16.460 | They probably do laugh at us a lot.

02:29:17.940 | - Someone who's been pregnant in Japan.

02:29:21.280 | - Yeah, reach out, tell us.

02:29:22.120 | - Yeah, or conceived in Japan.

02:29:23.680 | Tell us, don't tell us the story of the conception.

02:29:25.900 | But tell us, did you have sashimi?

02:29:28.460 | - Overall, meat is a really broad category

02:29:33.600 | and studies study it differently.

02:29:35.200 | Like, is it all meat?

02:29:36.280 | Are you distinguishing now red meat and chicken?

02:29:40.440 | Are you putting it all together?

02:29:42.600 | I mean, obviously I think we can all come to the agreement

02:29:44.800 | that processed meats are not good

02:29:46.480 | for a variety of different reasons.

02:29:48.760 | In addition to being carcinogenic,

02:29:50.760 | those toxins do negatively impact fertility.

02:29:54.080 | Now--

02:29:54.920 | - So deli meat, no bueno.

02:29:56.080 | - So yeah, but in specifically those things like the bacon

02:29:59.260 | and the things that are really highly processed hot dogs.

02:30:03.560 | Sorry, the 4th of July hot dog picnic.

02:30:06.120 | But those things really do not provide

02:30:08.780 | nutritional advantages and only harm.

02:30:12.280 | Especially then when we have red meat.

02:30:14.440 | For the most part, red meat when isolated individually

02:30:18.080 | in most circumstances in moderation tends to be fine.

02:30:22.880 | I usually tell my patients,

02:30:24.800 | I want them to eat a plant-forward diet.

02:30:27.560 | That doesn't mean no meat.

02:30:28.760 | But I say, look at your meat servings.

02:30:31.060 | I don't want it red meat every single day.

02:30:33.520 | Because there was a study looking at IVF

02:30:35.840 | and looking at embryos and the more servings,

02:30:38.840 | a lot of nutritional studies based things on quartile.

02:30:41.360 | So who eats the lowest and the second most

02:30:43.800 | and the third most and the top most.

02:30:45.780 | And people who ate in that top quartile of red meat

02:30:49.380 | had lower progression of embryos through the culture.

02:30:52.340 | So less embryos, that developed.

02:30:55.500 | Less normal embryos and lower success rates.

02:30:59.100 | - Do we know anything about how that meat was arriving?

02:31:02.220 | - No, unfortunately we don't.

02:31:03.060 | - Are we talking about like hoagie sandwiches

02:31:04.860 | or are we talking about like grass-fed steaks?

02:31:06.580 | - Right, these studies are not wonderful,

02:31:08.700 | but that doesn't mean that they don't hold merit

02:31:10.940 | in helping us guide counseling.

02:31:12.700 | But no, that one was how many servings of red meat

02:31:16.180 | do you eat in a week, right?

02:31:17.580 | So we don't really know.

02:31:19.100 | Does the really ethically sourced, the grass-fed,

02:31:22.780 | this environment which we feel like is much less toxic

02:31:27.020 | than potentially let's say like a cattle factory

02:31:29.300 | where the cows are injected with all sorts of things,

02:31:31.420 | is there a difference in how those impact your reproduction?

02:31:35.420 | Probably, right?

02:31:36.300 | If this cow is getting injected with a lot of hormones,

02:31:38.300 | why are we thinking that it's not impacting the meat

02:31:41.400 | that you're then ingesting into your body?

02:31:43.700 | - No, I think our audience

02:31:44.860 | will certainly subscribe to that idea.

02:31:48.820 | I think most of them will.

02:31:49.760 | I mean, the notion that like the pollutants

02:31:52.420 | you breathe in the air somehow are not the air

02:31:55.160 | that you breathe into your lungs

02:31:56.220 | is just like completely naive.

02:31:57.940 | - Wild.

02:31:58.760 | - And the idea-

02:31:59.600 | - But people feel that way and they hold strongly

02:32:01.140 | to this idea that it can't be this thing that I love

02:32:05.300 | that is causing this problem, right?

02:32:07.940 | The denial of the association between

02:32:11.420 | what we put in and on our body

02:32:13.880 | and how it impacts our body's function

02:32:16.520 | is really strong in some people.

02:32:18.160 | And I think it's really just lack of education and awareness

02:32:22.960 | because the medical community for so long

02:32:25.760 | did not address these factors, right?

02:32:27.940 | Your doctor never talks to you about nutrition.

02:32:31.000 | And so it just became this idea that it must not matter,

02:32:35.080 | otherwise your doctor would talk to you about it.

02:32:37.940 | I think sugar is the last thing I just didn't mention,

02:32:39.700 | but added sugar and artificial sugars are bad for you.

02:32:44.700 | - Artificial sugars.

02:32:46.020 | - Artificial sugars too.

02:32:47.460 | - Including stevia, sort of plant-based,

02:32:50.060 | low calorie sweeteners.

02:32:51.100 | - Stevia itself hasn't been studied

02:32:52.660 | as much as the other ones,

02:32:54.040 | things like sweet and low and all of those.

02:32:57.760 | But what we do know is that they interfere,

02:33:00.520 | they cause inflammation inside the body.

02:33:02.280 | And then they also can cause a stress reaction

02:33:05.680 | and they can cause higher rates of miscarriage

02:33:09.640 | when you intake more sugar and artificial sugar.

02:33:12.720 | So that's a lot to wrap your head around.

02:33:15.640 | And I say the same thing to every patient.

02:33:17.740 | One cake, one this, one hot dog.

02:33:21.500 | I mean, those things individually

02:33:22.800 | are not gonna make a difference, right?

02:33:24.360 | It's the choices that you make every single day

02:33:27.500 | that are going to set you up

02:33:28.960 | to be your healthy self or not.

02:33:30.460 | And so you should make choices

02:33:32.600 | in line with how you wanna treat yourself.

02:33:34.620 | You want to be in your best health,

02:33:36.720 | you want your hormones functioning the best.

02:33:38.740 | And if that added helps you get pregnant when you want to,

02:33:42.920 | helps you have a better chance of success with IVF,

02:33:45.500 | oh my gosh, what a fantastic benefit.

02:33:48.460 | But that doesn't mean you can't enjoy

02:33:50.040 | some of these bad things here and there,

02:33:53.540 | as long as you've set yourself up on the day-to-day

02:33:56.480 | where you're giving your body lots of nutritious food

02:33:59.580 | that it needs to make hormones.

02:34:02.040 | Similarly, being very underweight and calorie restricting,

02:34:05.740 | we all know is really terrible for your reproductive system

02:34:08.640 | and can cause the brain to totally shut down ovulation

02:34:11.420 | because it senses that you can't have a pregnancy.

02:34:15.580 | - Do people miscarry, excuse me,

02:34:18.200 | by virtue of being underweight?

02:34:19.800 | Does the body, like I learned some years ago,

02:34:24.640 | I think this is still true,

02:34:25.660 | that one of the signals for the onset of puberty in females

02:34:28.480 | is that leptin hormone is secreted from body fat

02:34:32.920 | that then signals to the brain, to the hypothalamus,

02:34:35.720 | like, okay, there's enough reserves to create environment.

02:34:39.840 | It's a signal about environmental-

02:34:42.000 | - Yeah, there's enough extra fat to have a baby.

02:34:43.520 | - Yeah, and there's presumably enough food around

02:34:45.400 | to sustain that baby, right.

02:34:47.500 | Are miscarriages and lack of body fat correlated?

02:34:52.140 | - On both ends of the spectrum, yes, right?

02:34:54.000 | So lack of body fat and being overweight,

02:34:57.200 | we see decrease in getting pregnant per month

02:35:01.160 | and we see increase in losing pregnancies.

02:35:04.240 | So certainly there is a healthy medium

02:35:07.520 | where your body has what it needs.

02:35:09.880 | And that makes sense because if you have,

02:35:12.440 | I like to even say hypothalamic dysfunction.

02:35:14.680 | So maybe your brain's not totally shut off

02:35:16.840 | where it's sending out no hormones and you're not ovulating

02:35:19.880 | 'cause you're not getting pregnant in that circumstance.

02:35:22.040 | But certainly ovulation disorders are on a spectrum

02:35:24.840 | where you go from a perfectly synchronized cycle

02:35:27.520 | to one that prolongs it, gets shorter together,

02:35:30.320 | then prolongs, and then you have nothing.

02:35:32.320 | There's this spectrum of dysfunction,

02:35:34.200 | which is representing your hormones

02:35:36.320 | not being necessarily perfect.

02:35:39.400 | And that can have impacts on the placenta

02:35:41.520 | trying to grow into that uterus.

02:35:44.120 | I mean, the placenta is fascinating, right?

02:35:46.160 | An entire talk just on the placenta.

02:35:48.080 | But it does this incredible job

02:35:50.120 | where your body has to not reject it,

02:35:51.840 | yet allow it to eat away at the side of your uterus

02:35:54.600 | and grow into your blood vessels.

02:35:56.680 | But that requires a very specific hormonal environment

02:35:59.480 | for it to be done and to be done right.

02:36:02.320 | I think in the same breath of all of this,

02:36:03.760 | what you're also asking is yeah, okay,

02:36:06.240 | so that's eating healthy.

02:36:07.240 | None of that's really new news for most people.

02:36:09.220 | A lot of those things I just said.

02:36:10.760 | - Well, I think some, but I do want to thank you

02:36:12.480 | 'cause I think rarely, if ever,

02:36:14.440 | do we hear somebody, a physician,

02:36:17.080 | be really direct about like, hey, listen, some red meat,

02:36:19.800 | yes, not excessive amounts of red meat,

02:36:21.680 | ideally from sustainable sources,

02:36:25.600 | whole fat milk products, grains, fruits, vegetables.

02:36:28.400 | I mean, those kind of straight,

02:36:30.080 | what to you seem like straightforward directives

02:36:32.040 | are actually pretty rare in the landscape

02:36:34.480 | of public health discussion

02:36:35.960 | because more often than not,

02:36:37.880 | people talk about nutrition

02:36:39.000 | in these kind of elimination diet type things

02:36:40.980 | like eliminate all the grains or eliminate all the meat

02:36:43.840 | or eliminate all the milk fats,

02:36:47.060 | when in reality, I think people forget

02:36:48.800 | that like most people out there are omnivores

02:36:51.720 | and they can make better choices about not deli meat,

02:36:54.380 | you know, less bacon, if any bacon, right?

02:36:56.300 | - Have some veggies with your lunch, right?

02:36:57.800 | Like you can make better choices on the day-to-day.

02:36:59.840 | I think that is a great point.

02:37:01.900 | I think there's a place for supplements.

02:37:03.520 | I think the big disclaimer

02:37:04.680 | that everybody's going to say with supplements

02:37:06.240 | is that they are not regulated

02:37:08.980 | like the way medications are, right?

02:37:11.760 | And I will say supplements and herbs are different things,

02:37:16.200 | right, a supplement, but many companies are adding herbs

02:37:19.960 | to their supplements

02:37:20.940 | and that can get into really murky territory,

02:37:23.760 | especially when it comes to how some of these herbs

02:37:26.300 | do have estrogen and progestin-like properties

02:37:28.800 | and can impact reproduction and hormones.

02:37:31.480 | - And perhaps even androgenic properties too.

02:37:33.200 | - Yes, yes.

02:37:34.040 | So we can't act like everything's created equal.

02:37:37.040 | So I always tell people,

02:37:38.140 | if I recommend you take a supplement or your doctor does,

02:37:41.360 | your due diligence is to look at what is also included

02:37:44.440 | and make sure it doesn't have these extra added things

02:37:48.040 | that they're unaware of

02:37:49.280 | because sometimes they can have negative impact

02:37:52.360 | at one stage of your life or another,

02:37:53.880 | depending on where you are.

02:37:55.640 | Certainly, a prenatal vitamin, which has folic acid,

02:37:58.580 | we all know that folic acid is really important

02:38:01.600 | to prevent neural tube defects,

02:38:02.960 | but it's also important in cell division

02:38:04.920 | and how the ovary is growing follicles and growing eggs.

02:38:08.800 | - So should people, women,

02:38:11.480 | but also men be taking a vitamin with folic acid

02:38:14.560 | even when they're not trying to conceive?

02:38:17.200 | - There's no harm in having it,

02:38:19.560 | but very often pregnancies occur

02:38:22.420 | when you're not trying to conceive.

02:38:24.360 | And that is a store that needs to be built up

02:38:27.040 | three months ahead of time.

02:38:28.160 | So we really need you to be taking that

02:38:31.120 | ahead of getting pregnant.

02:38:32.640 | So not just, let's get pregnant right now,

02:38:34.980 | I'm going to start this prenatal vitamin.

02:38:37.260 | So I recommend anybody who's in their reproductive years,

02:38:40.380 | take a prenatal vitamin.

02:38:42.040 | We also know that many, many people

02:38:44.480 | are vitamin D deficient and vitamin D

02:38:47.440 | does impact reproduction.

02:38:49.840 | And so I usually say a thousand international units

02:38:53.100 | of vitamin D is not going to be harmful in anybody.

02:38:55.940 | It's going to be helpful for most people.

02:38:58.160 | Some people definitely need higher levels.

02:39:01.400 | So we screen everybody with a vitamin D

02:39:03.320 | to see who needs to have extra.

02:39:05.720 | But a blanket statement that extra vitamin D

02:39:08.900 | is going to be helpful.

02:39:10.440 | Omega-3 fatty acids, also extremely important

02:39:13.700 | in one, being anti-inflammatory,

02:39:16.060 | but two, brain development of a fetus.

02:39:18.920 | So most prenatals now actually do have

02:39:21.600 | those omega-3 fatty acids in them,

02:39:23.840 | but if they don't, I recommend a patient take those.

02:39:26.920 | - Just a brief question/insertion there.

02:39:30.600 | There's a laboratory up at

02:39:31.740 | the University of California, Santa Barbara

02:39:33.280 | that's published some really interesting data

02:39:34.680 | showing that essentially brain weight,

02:39:38.080 | which is just about one indirect measure of brain health,

02:39:41.280 | but brain weight at birth seems to be correlated,

02:39:45.200 | at least in some positive way,

02:39:46.620 | with the amount of essential fatty acids

02:39:49.240 | that mom consumed during pregnancy.

02:39:51.400 | Does that sound, does that hold?

02:39:52.940 | - Yeah, I mean, that does hold.

02:39:54.480 | And there's, I mean, like there's my studies

02:39:57.820 | about that mice are smarter when they have diets,

02:40:00.340 | you know, with omega-3 fatty acids

02:40:02.700 | when they are in utero, right?

02:40:04.880 | So the exposure and the time period is really important.

02:40:07.160 | And omega-3s have a lot of health benefits

02:40:09.000 | when it comes to their antioxidant properties,

02:40:11.300 | especially in like an endometriosis,

02:40:14.580 | diseases that are very highly inflammatory,

02:40:17.640 | they can be very beneficial.

02:40:19.920 | - We're definitely going to talk about your work

02:40:21.120 | about after a baby has arrived

02:40:22.800 | and impact of essential fatty acids,

02:40:24.360 | but what would you say is the dosage cut off?

02:40:27.000 | On this podcast before I've sort of thrown out numbers

02:40:29.560 | like one to two grams per day of the EPA form

02:40:34.560 | of essential fatty acids,

02:40:36.040 | and then we could have a whole discussion

02:40:37.280 | about omega-3 omega-6 ratios,

02:40:38.840 | but do you think there's a upper limit?

02:40:41.400 | Is it truly that, you know,

02:40:43.440 | let's say up to four grams per day of EPA,

02:40:46.680 | is, would that be advantageous?

02:40:48.380 | Is it better than one gram?

02:40:49.560 | - I tell people a gram.

02:40:50.840 | - A gram, okay, that's in alignment

02:40:52.320 | with pretty much what we've talked about before.

02:40:54.640 | - So that's what I recommend, you know,

02:40:55.880 | when I give my handout to my patients

02:40:57.720 | and they're trying to get pregnant,

02:40:58.840 | it's going to have a prenatal, a thousand I use of vitamin D,

02:41:02.200 | a gram of omega-3s and then CoQ10.

02:41:04.940 | So CoQ10, which, you know, essentially in general

02:41:09.940 | is trying to help the mitochondria.

02:41:11.760 | That's the whole idea here

02:41:13.040 | that it is helping provide support across the body

02:41:16.720 | in a lot of different ways, right?

02:41:17.820 | Like CoQ10 is used in a lot of different areas of the body,

02:41:20.760 | but when it comes to reproduction,

02:41:22.400 | when it comes to meiosis and cell division

02:41:25.200 | and ovulation and egg quality and even sperm quality,

02:41:28.920 | there's a place for CoQ10 showing benefit without harm,

02:41:33.800 | right, and so no, like I said earlier,

02:41:36.280 | nothing's without any harm or any risk of harm,

02:41:38.060 | but very, very little.

02:41:39.020 | So I usually recommend if you're trying to get pregnant

02:41:41.440 | and you take CoQ10, a dose of 200 milligrams

02:41:45.100 | three times a day.

02:41:46.120 | So there's kind of a higher dose

02:41:47.380 | than sometimes people are on.

02:41:49.040 | Often prenatals now have just like 200 total in it.

02:41:53.080 | And so-

02:41:53.920 | - The expensive ingredients

02:41:55.060 | are usually the lower concentrations in blends.

02:41:58.500 | - They're going to use just enough

02:41:59.560 | so they can put it on the label.

02:42:00.760 | - Right, which includes CoQ10.

02:42:03.020 | Does the form of CoQ10 matter?

02:42:04.500 | 'Cause you'll find them in gel capsules.

02:42:06.060 | You'll also find them in powdered capsules.

02:42:09.260 | - I always say, I mean,

02:42:10.420 | there might be for the individual person.

02:42:12.440 | I mean, absorption of medication

02:42:14.360 | is really dependent a lot on gut health and other factors.

02:42:17.460 | But the number one issue with supplementation

02:42:18.900 | is that people don't stick to it.

02:42:20.640 | So I always say,

02:42:21.520 | whichever one you're going to consistently take

02:42:23.700 | is going to be the better form.

02:42:25.340 | - Right.

02:42:26.480 | A question about L-carnitine.

02:42:28.020 | - Yeah.

02:42:29.140 | - I'm researching a little bit for this episode and others.

02:42:32.700 | Oral L-carnitine has been associated with some improvements

02:42:36.220 | in forward motility and sperm, maybe egg quality.

02:42:39.020 | But we know that a very small percentage

02:42:40.680 | of the oral L-carnitine that one ingests

02:42:42.460 | is actually utilized.

02:42:44.420 | So some people actually purchase and use

02:42:46.620 | injectable L-carnitine, which is kind of painful

02:42:48.440 | 'cause it's an alcohol-based suspension.

02:42:50.240 | So not comfortable.

02:42:52.160 | It's gotta be done intramuscularly.

02:42:53.460 | But my read of the data is kind of impressive.

02:42:56.980 | I wouldn't say super impressive.

02:42:58.420 | Are you ever injecting patients

02:43:00.920 | or having them inject themselves with L-carnitine?

02:43:03.620 | This would be both female or male patients or both,

02:43:08.540 | or using oral L-carnitine?

02:43:10.020 | Or do the data just not impress you enough to motivate that?

02:43:12.700 | - We use a gram of L-carnitine with a gram of vitamin C

02:43:15.620 | for our male patients who have any abnormal sperm parameter.

02:43:19.900 | And so that is kind of what we consider

02:43:21.460 | the sperm enhancement protocol.

02:43:23.340 | And so- - And just that?

02:43:25.040 | - That with a multivitamin. - Got it.

02:43:25.880 | - So those two with a multivitamin and CoQ10.

02:43:28.460 | So that's kind of like the male protocol.

02:43:30.640 | Of course, there's different specifics

02:43:32.580 | for one individual person.

02:43:34.260 | I don't tend to recommend it for most females.

02:43:37.420 | That being said, those who have endometriosis

02:43:40.060 | fall into a unique category where inflammation is so high

02:43:44.280 | that usually it's a different environment

02:43:46.900 | where we recommend L-carnitine, N-acetylcysteine,

02:43:50.000 | vitamin C and E.

02:43:51.720 | They kind of fall into a different category

02:43:53.160 | 'cause they have a known inflammatory disease.

02:43:55.000 | But if we're just talking about the person at whole

02:43:57.580 | who maybe wants to take some supplements

02:43:59.600 | for their reproductive health

02:44:01.420 | that have very little side effects

02:44:03.900 | and for the most part can potentially be helpful,

02:44:06.620 | it's gonna be CoQ10, L-carnitine, vitamin C can be helpful,

02:44:10.860 | especially for the male.

02:44:12.380 | For the female partner,

02:44:14.260 | we're gonna be looking at that extra vitamin D

02:44:16.860 | in addition to the prenatal with folic acid.

02:44:18.940 | - And what about women with PCOS?

02:44:20.740 | I get so many questions about PCOS.

02:44:21.980 | - Inositol, yeah, yeah. - Inositol.

02:44:23.760 | So, and there are we talking myoinositol

02:44:26.980 | or the, what is it, the D-Chiro?

02:44:29.180 | Do I have that right?

02:44:30.020 | - You do have that right.

02:44:30.840 | Myoinositol is the main driver of inositol

02:44:33.100 | and how it can be helpful.

02:44:34.640 | If you, most blends are gonna have a combination

02:44:37.680 | of both of them but a much higher ratio

02:44:40.160 | of myoinositol to D-Chiro.

02:44:42.720 | And so myoinositol is probably the one

02:44:44.640 | that really is doing the work in PCOS.

02:44:47.920 | What is it doing?

02:44:48.840 | It is definitely helping the body

02:44:50.620 | when it comes to insulin and sugar,

02:44:53.000 | helping the body be more sensitive to insulin

02:44:56.340 | or less resistant to it.

02:44:58.480 | Essentially helping you respond to what you eat

02:45:02.820 | in a better way.

02:45:04.520 | And it also looks like it does potentially decrease

02:45:07.220 | some of that inflammation pathway in PCOS.

02:45:11.000 | In PCOS, this insulin resistance correlates

02:45:14.980 | with this testosterone production from the ovary.

02:45:17.920 | Meaning even metformin alone

02:45:19.860 | can decrease testosterone levels

02:45:21.840 | based on some of the change that it has in the ovary.

02:45:24.680 | - Take note, men.

02:45:26.000 | I have so many guys taking metformin or berberine

02:45:28.800 | thinking, "Oh, this is great.

02:45:29.840 | I'm gonna lower my blood sugar,

02:45:30.820 | mimic fasting and live longer."

02:45:32.280 | And then these are also the same people

02:45:34.220 | who are writing to me, go,

02:45:35.360 | "How come when I take metformin,

02:45:36.680 | I either have headaches

02:45:37.920 | 'cause I'm essentially hypoglycemic,

02:45:40.680 | but also their testosterone levels are getting crushed."

02:45:44.240 | Not in every case, but it happens.

02:45:47.280 | - And I think those are things

02:45:48.120 | people just don't think about.

02:45:49.440 | They read that a supplement might be beneficial

02:45:51.520 | for this one thing that doesn't apply to them

02:45:54.040 | and they start taking it.

02:45:55.720 | Also the evidence on metformin extending life,

02:45:57.600 | we had Peter T. on here talk about this,

02:45:59.420 | the evidence for that is like, "Oh, so poor."

02:46:03.040 | It's just not really that convincing.

02:46:04.620 | It may change, but then now all the excitement

02:46:06.760 | is about rapamycin.

02:46:07.720 | And so extending your life while plummeting your testosterone

02:46:11.260 | you know what I mean?

02:46:12.600 | Actually that strategy has been tried

02:46:13.900 | in the longevity community.

02:46:14.960 | There was this whole castration idea.

02:46:16.640 | - Oh, I don't like this.

02:46:17.820 | - Oh yeah, this was like the Heaven's Gate cult

02:46:19.520 | where they castrated themselves.

02:46:20.880 | - Did they live longer?

02:46:21.800 | - Well, they ended up committing mass suicide.

02:46:23.720 | - Oh no.

02:46:24.560 | - So they ended the experiment early.

02:46:26.760 | Yeah, so in any event, going back to supplements,

02:46:33.040 | sorry, I couldn't help myself.

02:46:34.620 | Supplements that women can potentially take

02:46:38.200 | just to increase their fertility

02:46:40.440 | even if they don't want to get pregnant

02:46:41.800 | as just kind of creating a milieu of health.

02:46:44.160 | You talked about the nutrition, you talked about CoQ10,

02:46:46.160 | maybe L-carnitine, vitamin C,

02:46:48.440 | the essential fatty acids getting at least one gram of EPA.

02:46:53.460 | So that might require taking two grams of fish oil

02:46:57.040 | to get the EPA.

02:46:59.320 | Myo-inositol, so how much are you talking about?

02:47:01.360 | I've seen some pretty high dosages thrown out there.

02:47:03.320 | - For myo-inositol, 2000 milligrams.

02:47:06.000 | - Okay, taken before sleep or does it matter?

02:47:08.440 | - That one doesn't matter, that one doesn't matter.

02:47:10.200 | - Thank you for covering the topic of supplements

02:47:12.360 | and supplementation.

02:47:14.080 | This is probably a good point

02:47:15.960 | to return back to those harvested eggs.

02:47:19.140 | So eggs are out and there's a collection of them frozen.

02:47:24.140 | Maybe, just maybe, lives, they're always alive, sorry.

02:47:29.060 | - I mean, they're not always alive.

02:47:31.440 | - The fresh sperm, they're not always alive.

02:47:32.680 | Some portion of the ejaculate is going to be dead sperm,

02:47:35.440 | right, some live, some for motile, some non-forward motile.

02:47:39.080 | The twitchers, I read, is the name.

02:47:41.520 | - I hate those twitchers.

02:47:42.360 | - Right, and so, okay, they're going to wash the sperm.

02:47:47.360 | Why, because, yeah, most of what people see as ejaculate

02:47:49.880 | or know, excuse me, as ejaculate,

02:47:51.840 | is not actually the sperm, right?

02:47:54.720 | Okay, so, but sperm are washed, they're in one compartment.

02:47:57.820 | You get the eggs out, you or your embryologist

02:48:03.120 | at your clinic is then going to, at some point,

02:48:05.500 | decide to combine them.

02:48:07.340 | So is it kind of, is it a sperm race

02:48:09.620 | or are you, maybe you could explain ICSI.

02:48:12.520 | And why would one want, why would one opt for ICSI?

02:48:15.600 | And is, are there any risks with ICSI?

02:48:17.360 | Because there, you're really, at some level,

02:48:20.560 | this is the only place where I kind of sit back and, okay,

02:48:22.600 | as somebody who, you know, is tight in neural development,

02:48:24.920 | like at some level, you're saying,

02:48:25.880 | hey, that sperm looks good.

02:48:27.360 | Whereas when you run a sperm race, nature is saying,

02:48:29.920 | hey, this sperm really did beat all the other sperm.

02:48:32.420 | - So let's segue first, because I think this is nice,

02:48:35.420 | because the question I get asked all the time

02:48:37.160 | when we talk about nutrition and supplements and all of that

02:48:41.760 | is to, now you're doing IVF or you're freezing your eggs.

02:48:45.140 | And what if, what behaviors are good or bad?

02:48:48.720 | Of course, all of those same ones are,

02:48:50.560 | but about how long do you need to do them?

02:48:52.400 | And this is why if you live healthy most of the days,

02:48:54.720 | it doesn't really matter 'cause that's how you're living.

02:48:56.920 | But we already know the sperm cycle is about 90 days.

02:48:59.620 | And the eggs, I like to say,

02:49:01.600 | even though they're in the vault, they become,

02:49:03.620 | they start lining up, getting ready to exit the vault

02:49:06.260 | and become more susceptible to the things you're doing

02:49:09.260 | in that 90 day window.

02:49:10.600 | And we know that to be true as well.

02:49:12.720 | So they start to be pre-selected

02:49:15.300 | for who's coming out the next month.

02:49:16.900 | They start to line up.

02:49:18.100 | And so making these changes

02:49:20.420 | as you start thinking about getting pregnant,

02:49:23.000 | doing fertility treatments, is still extremely beneficial.

02:49:26.580 | People will often say, well, I haven't been doing that.

02:49:29.580 | So why start now?

02:49:30.500 | It's not gonna make a difference.

02:49:31.700 | But truly, it can.

02:49:33.740 | - Or I'll drink up until the week.

02:49:35.300 | - Until the day of, right?

02:49:37.300 | I'll just get it in the entire time.

02:49:39.300 | - Like I'm gonna have my two glasses of wine,

02:49:41.140 | which actually equates to about six glasses of wine

02:49:43.440 | when you measure out by-

02:49:44.360 | - How much it actually is.

02:49:45.200 | - By the volume, right.

02:49:46.380 | Right up until the week before getting pregnant

02:49:48.960 | or something like that.

02:49:49.800 | - Yeah, but no.

02:49:50.800 | So people always ask, what should I be doing?

02:49:52.560 | It's these healthy behaviors,

02:49:53.660 | and you should be doing them this whole time.

02:49:56.160 | When we do IVF,

02:49:57.600 | and I'm gonna get to all the things you just asked,

02:49:59.100 | but earlier you said, well, how tolerable is it?

02:50:01.700 | The truth is, you're taking shots.

02:50:04.760 | These are subcutaneous shots during the egg growth process.

02:50:07.560 | - So next to the belly button?

02:50:08.400 | - Yeah, next to the belly button,

02:50:09.500 | like how a diabetic gives insulin, a very small needle.

02:50:12.480 | I mean, nobody loves shots,

02:50:13.980 | but they're not a big intramuscular shot.

02:50:16.620 | It's not like a flu shot or something like that.

02:50:18.840 | - Listen, I've been to Austin, the Texan mosquitoes-

02:50:21.180 | - They're way worse.

02:50:22.020 | - They hurt way worse than one of these needles.

02:50:24.360 | - Exactly.

02:50:25.200 | So you're gonna use those medications

02:50:27.180 | for about 12 to 14 days.

02:50:29.060 | You're going to have your follicles grow.

02:50:31.960 | You're going to feel that.

02:50:33.420 | So you're gonna have pelvic pressure.

02:50:34.820 | As your estrogen rises,

02:50:35.980 | you're also going to third space your fluid,

02:50:38.580 | which means your fluid, your water component of your blood

02:50:42.100 | is going to start to just eek out a little bit,

02:50:44.800 | and you're gonna get more bloated.

02:50:46.100 | You're gonna have more water, weight.

02:50:48.060 | You're going to feel puffier.

02:50:50.180 | And that is very common

02:50:51.380 | just because of getting the eggs to grow.

02:50:53.620 | You're gonna mentally be fine

02:50:55.280 | 'cause the female brain loves high estrogen,

02:50:57.460 | so you're doing fine.

02:50:58.920 | That's one of the main concerns is how emotional will I be?

02:51:02.140 | And during this phase of the process, people do great.

02:51:05.900 | When we take the eggs out of the body,

02:51:07.140 | it's about a 20-minute procedure.

02:51:09.140 | It is usually done under IV sedation,

02:51:11.820 | like propofol and fentanyl.

02:51:13.620 | And we are watching while we drain those follicles

02:51:16.460 | and get test tubes full of the eggs.

02:51:18.420 | - Do some people opt to not use any?

02:51:21.440 | I hear the word fentanyl,

02:51:22.500 | and I'm sure a lot of people are like,

02:51:23.460 | "Wait, fentanyl crisis."

02:51:24.980 | And obviously, fentanyl is a drug that has its uses,

02:51:29.260 | valid uses in the medical community.

02:51:32.500 | Does anyone just kind of opt for just-

02:51:34.980 | - I mean, we have an anesthesiologist

02:51:36.660 | who is really talking to the patients.

02:51:38.300 | I mean, propofol's the base of it.

02:51:39.600 | Certainly, there's some patients

02:51:40.600 | who may want to avoid narcotic usage,

02:51:42.700 | and they use different strategies.

02:51:44.500 | I mean, there was this huge, right?

02:51:46.220 | The Retrievals podcast came out from the New York Times

02:51:49.160 | doing a deep dive into a fertility clinic, Yale,

02:51:52.420 | where a nurse was siphoning off fentanyl.

02:51:55.140 | - For herself. - For herself,

02:51:56.540 | and replacing it with saline and giving patients saline.

02:51:59.880 | This clinic did not do anesthesia-based propofol,

02:52:04.340 | so they were supposed to just get fentanyl

02:52:06.500 | and have kind of a less pain environment,

02:52:09.140 | not a no pain environment, and not just a few,

02:52:13.060 | hundreds of women reported extreme pain,

02:52:15.380 | extreme pain through the procedure,

02:52:17.380 | really speaks largely to pain not being taken seriously

02:52:21.440 | when they went and found this out.

02:52:22.860 | - Whoa, what happened to, I can't help but ask,

02:52:24.540 | what happened to this technician?

02:52:26.900 | - Well, I mean-

02:52:27.740 | - Yeah, they're trying to find fentanyl behind bars.

02:52:30.900 | - Yeah, I mean, but it's huge as far as to,

02:52:33.860 | like, I mean, I can't imagine doing,

02:52:37.140 | I do this procedure like all the time, right?

02:52:39.620 | I've done thousands and thousands in my career,

02:52:41.820 | and I can't imagine having people be in pain during it.

02:52:45.380 | So it's, but it's important to know

02:52:46.740 | that some clinics don't use IV sedation

02:52:49.700 | or they don't use propofol, they don't put you to sleep.

02:52:52.180 | Understanding what your clinic is using

02:52:54.140 | is really, really important to set the expectations

02:52:57.500 | or to know, am I going to be awake

02:52:59.240 | or am I going to be asleep?

02:53:00.580 | - Can a patient ask you to what specific drugs

02:53:03.180 | are you going to give me to kill pain?

02:53:04.260 | - For sure, and I mean, some clinics only do one.

02:53:08.120 | Like, I am not going to do a retrieval under no sedation.

02:53:12.880 | Now, some clinics would allow that,

02:53:14.700 | some clinics, that's all that they do,

02:53:16.800 | but you, that's a huge piece of the puzzle

02:53:18.380 | that you need to know.

02:53:19.260 | If you're a patient, are you going to be feeling pain,

02:53:21.900 | not feeling pain, what's it going to be like?

02:53:24.660 | I'll say most clinics use propofol

02:53:27.240 | and put patients to sleep.

02:53:28.580 | And so you take a nice little nap for 15 to 20 minutes,

02:53:32.180 | the eggs are retrieved from the follicles

02:53:34.700 | under direct visualization, they're in test tubes,

02:53:38.180 | you wake up and you're going to feel crampy

02:53:41.380 | and you'll get a period 10-ish days later,

02:53:44.300 | but this is when you'll feel your worst

02:53:46.180 | and this is just the one thing I want to say

02:53:47.340 | about tolerability of it.

02:53:48.740 | - Can you get pregnant in that time?

02:53:50.320 | - Yeah, yeah, yeah.

02:53:51.160 | There's a case report of an egg donor

02:53:53.280 | who was donating her eggs and she had sex with her boyfriend

02:53:57.620 | and because not every egg is always retrieved

02:53:59.900 | from the follicles or some small ones,

02:54:02.100 | could ovulate too and she got pregnant with quintuplets.

02:54:05.740 | - Whoa.

02:54:06.920 | - Okay, so you have to really tell people

02:54:08.220 | not to have intercourse, one from an infectious standpoint

02:54:11.100 | 'cause we really are poking a pretty large gauge needle

02:54:14.220 | through the vaginal mucosa into the peritoneal cavity,

02:54:16.840 | so we don't want to introduce infection,

02:54:18.240 | but also for pregnancy in that time period

02:54:21.340 | and if you got pregnant, your risk of what we call

02:54:24.180 | ovarian hyperstimulation syndrome or OHSS is very profound.

02:54:29.620 | So what is normally happening is after the retrieval,

02:54:32.780 | your estrogen and progesterone are gonna drop,

02:54:34.740 | you're gonna feel a severe PMS for lack of a better word,

02:54:38.340 | so when you'll be more emotional,

02:54:39.740 | you're still pretty bloated until this all heals.

02:54:42.660 | If you get OHSS, which is very uncommon in modern practice,

02:54:47.660 | but when you did fresh embryo transfers

02:54:50.340 | or people who don't utilize some of the modern protocols,

02:54:53.300 | this means that HCG continues to encourage

02:54:58.120 | all those follicles to make estrogen and progesterone

02:55:00.620 | and if you are pregnant, you're just gonna have

02:55:03.140 | a constant yet exponential increase in HCG

02:55:06.900 | and so this is going to get worse and worse.

02:55:10.440 | So we really don't want people to get pregnant

02:55:12.660 | in that time period.

02:55:13.500 | - So when during that time period should they avoid sex?

02:55:16.540 | So is it in the few days before the extraction?

02:55:20.080 | - So typically, I usually say it's from like day five

02:55:23.260 | of your stimulation, okay, so usually the earliest

02:55:27.340 | egg retrievals are kind of around cycle day nine or 10

02:55:30.000 | if somebody goes fast until your next period comes.

02:55:34.260 | So that's usually about a three week time period

02:55:36.280 | where we want you to abstain from intercourse.

02:55:38.580 | So for the most part though, the more eggs you have,

02:55:43.080 | the more you're gonna feel both this hormonal

02:55:44.980 | and physical shift than the fewer eggs that you have.

02:55:47.700 | So if you have a low egg count and you need to do IVF

02:55:51.220 | or freeze your eggs and you might do multiple cycles

02:55:53.880 | or rounds, you're gonna tolerate it actually pretty fine

02:55:56.840 | because you're not gonna have these huge shifts.

02:55:58.500 | Physically, you're gonna feel fine

02:56:00.160 | and that's always a big concern.

02:56:02.960 | When you mentioned earlier about different stimulation

02:56:05.200 | types, people have this idea that things that are more

02:56:09.040 | natural are better, right, just like this human thought

02:56:12.960 | that natural is good and synthetic is bad.

02:56:17.440 | Naturally, you ovulate one egg a month.

02:56:20.140 | When we're trying to get eggs out of your body,

02:56:22.440 | the success is determined by how many eggs I can get

02:56:26.720 | and how young you are.

02:56:28.780 | So it doesn't make sense in most circumstances

02:56:32.660 | to do a minimal stimulation protocol,

02:56:35.360 | meaning purposefully understimulating somebody

02:56:38.520 | by saving them money and medication costs

02:56:41.440 | in order to purposely get fewer eggs

02:56:44.400 | because their odds of getting the ultimate success

02:56:47.400 | of what they want is going to be so much lower.

02:56:50.680 | - Is there, I don't want you to be in the position of,

02:56:53.680 | I don't wanna put you rather in the position of

02:56:56.360 | kind of like having to demonize your colleagues

02:56:59.240 | in your profession, but I could see how there's a pretty

02:57:01.360 | significant financial incentive for people

02:57:03.120 | who are really desperate to have children

02:57:05.040 | or who just simply might want to have children

02:57:06.640 | down the road to, they hear low stim is better.

02:57:10.280 | We're talking multiple low stim cycles.

02:57:12.080 | They might be even a fraction of the cost

02:57:14.880 | of a full stim cycle, but then there are many,

02:57:16.400 | many more low stim cycles. - You got it.

02:57:18.960 | You got it.

02:57:19.800 | You can make a lot more money by doing things

02:57:22.320 | that are not in the best interest of the patient.

02:57:24.600 | And I mean, that's not uncommon in my field,

02:57:26.920 | which is very sad, but it does mean that because

02:57:29.600 | reproduction and IVF are so foreign and unknown,

02:57:32.680 | so many people walk in blind, not knowing

02:57:36.440 | if what they're being told really makes sense

02:57:38.840 | for their situation.

02:57:40.960 | There are a couple situations where minimal stimulation

02:57:43.320 | makes sense.

02:57:44.160 | If you're only gonna make three eggs,

02:57:45.440 | you're only gonna make three eggs.

02:57:46.880 | I don't need all the drugs in the world

02:57:49.040 | to tell your body to make three eggs

02:57:50.680 | 'cause there's only three.

02:57:51.920 | And so that is a scenario where minimal stimulation

02:57:54.840 | does make sense.

02:57:56.040 | And then there's the scenario where,

02:57:58.640 | there's something called InvoCell.

02:58:00.000 | Has your research exposed you to this?

02:58:02.400 | - No.

02:58:03.240 | - InvoCell is a way to try to take IVF

02:58:06.520 | into making it more financially accessible

02:58:09.720 | for certain patient populations,

02:58:11.880 | mainly people who don't ovulate,

02:58:14.520 | like your very refractory PCOS patient

02:58:16.840 | who doesn't respond to medication,

02:58:18.800 | or who have tubal factor infertility, right?

02:58:20.960 | So your fallopian tubes are blocked

02:58:22.480 | because of chlamydia or endometriosis.

02:58:26.240 | And we just have a problem here

02:58:28.520 | that egg and sperm can't get together

02:58:30.120 | 'cause you're not ovulating or your tubes are blocked.

02:58:33.480 | And InvoCell, it's a device that is plastic.

02:58:37.720 | And you can fit up to 10 eggs in it.

02:58:41.600 | And there's a little middle chamber where the sperm can go.

02:58:44.280 | And so you go through this IVF process

02:58:46.200 | with the goal to only get eight to 10 eggs

02:58:48.360 | 'cause that's what fits in the device.

02:58:50.320 | And then you put the sperm in the middle of it.

02:58:52.440 | And then you put it inside your vagina

02:58:55.440 | and you hold it in place with a diaphragm.

02:58:57.760 | And the vagina is the right temperature to incubate.

02:59:01.160 | And so you incubate your embryos

02:59:04.000 | in this little InvoCell container inside your vagina.

02:59:08.360 | And then five days later, you come in and we take it out

02:59:10.640 | and we take the best embryo and we transfer it.

02:59:13.080 | And you can do a fresh transfer

02:59:15.140 | because you didn't make so many eggs

02:59:17.240 | so your hormones weren't so high.

02:59:19.480 | - Do people like this procedure?

02:59:20.720 | There's something that seems like staying in proximity

02:59:23.040 | to the sperm and egg, like you're taking it home.

02:59:25.600 | - Okay, so I love this procedure in some circumstances

02:59:28.800 | and I see it applied often in the wrong case

02:59:31.760 | and that can be frustrating, right?

02:59:32.960 | 'Cause it's still not cheap.

02:59:34.040 | Even if it's cheaper than IVF,

02:59:36.920 | it is still not inexpensive in any means.

02:59:40.240 | And so patient selection, like most things in this field

02:59:43.680 | are so important.

02:59:45.000 | So let's just say, if you've had no,

02:59:47.700 | like if the sperm's the problem,

02:59:50.000 | then it's probably not smart to just presume

02:59:53.800 | that the sperm and egg will be fine in there, right?

02:59:56.000 | Like that might be a case where you really do need help

02:59:58.340 | with assisted fertilization

03:00:00.200 | or if you have unexplained infertility.

03:00:02.200 | If we don't know why you haven't been able to get pregnant

03:00:04.880 | because everything looks good on paper,

03:00:06.900 | what if fertilization is the issue?

03:00:08.640 | And these are circumstances where you pull out an InvoCell

03:00:11.160 | and there's no embryos

03:00:12.440 | and you don't really know where it went wrong.

03:00:14.960 | Was it the fertilization step?

03:00:16.760 | Was it the growth step of the embryos in culture?

03:00:19.640 | So you do have less data.

03:00:21.420 | Notably, I like data.

03:00:23.060 | You can't do genetic testing

03:00:24.960 | and this isn't really a strategy

03:00:26.220 | that allows you to freeze embryos for future family growth.

03:00:29.620 | That being said, the young patient

03:00:32.100 | who's got great egg quality,

03:00:33.620 | who might have really bad PCOS or tubal disease,

03:00:36.600 | it can certainly allow them the opportunity

03:00:39.240 | for a child at a lower price point

03:00:41.840 | when they still have many reproductive years

03:00:43.960 | to finalize their family.

03:00:45.880 | It also is a lovely option

03:00:48.240 | for people who need donor sperm to conceive

03:00:50.480 | because the success rates with this

03:00:52.160 | are so much higher than an IUI,

03:00:54.400 | which is what a lot of people use,

03:00:56.460 | an intrauterine insemination

03:00:57.900 | or putting the sperm in the uterus.

03:00:59.820 | So now we're able to improve this outcome.

03:01:03.700 | So like our same-sex couples

03:01:05.280 | or our single parents by choice,

03:01:07.420 | if it's a single woman who's trying to become a parent,

03:01:10.440 | then they need to buy donor sperm

03:01:11.920 | and go through the process anyway.

03:01:13.740 | This often can improve that efficacy through the process,

03:01:18.040 | pending their age and other factors.

03:01:20.600 | There was a study that was just really neat.

03:01:22.860 | There was a lesbian couple,

03:01:23.860 | and one of them, the eggs came out of,

03:01:28.380 | and the other one incubated the embryos,

03:01:31.960 | and then the other one had the embryo transfer.

03:01:34.220 | So but it gave both partners

03:01:35.740 | a way to feel a little more involved in the process,

03:01:38.320 | which I just think is always a really cool way

03:01:40.940 | when you have these different options with reproduction.

03:01:43.100 | - Seems also that it's a more

03:01:46.100 | of a three-dimensional environment.

03:01:47.500 | Like I always imagined that the Petri dish approach

03:01:51.140 | is so two-dimensional compared to the body,

03:01:53.380 | and all these things that having done cell culture before

03:01:55.440 | and cultured neurons and things of that sort,

03:01:57.220 | like there's all these concerns

03:01:58.780 | about like the concentration of CO2 and the thing,

03:02:00.860 | or God forbid if there's a fluctuation

03:02:04.540 | and you have backup generators and things,

03:02:06.640 | but in the electrical flow to the incubators,

03:02:08.940 | that's disruptive.

03:02:09.780 | Whereas the natural environment of the body,

03:02:11.780 | even though it fluctuates in temperature,

03:02:13.700 | it's, I mean, this has evolved over tens of thousands,

03:02:16.300 | if not hundreds of thousands of years

03:02:18.220 | to be the process by which embryos are created.

03:02:20.700 | So here's where I sort of default in my mind anyway

03:02:24.980 | to the kind of like, oh, like it seems more natural.

03:02:26.980 | You're incubating in the quote-unquote

03:02:28.420 | more natural environment.

03:02:29.540 | - But at the same breath, why are you having infertility

03:02:34.200 | if you're an infertility patient, right?

03:02:36.620 | So if you need donor sperm,

03:02:39.260 | you maybe don't have infertility,

03:02:40.720 | or if you have tubal disease,

03:02:42.100 | you have a very defined reason why we don't think

03:02:45.660 | that there's this huge inflammatory issue in your body

03:02:49.640 | or something unknown.

03:02:51.500 | So again, I'll see it applied to people

03:02:54.020 | who really are bad candidates for it based on their age

03:02:56.940 | or based on their diagnosis.

03:02:59.220 | And so it's not always better, but for the right patient,

03:03:03.100 | I mean, I've had patients have babies that way

03:03:04.640 | who otherwise may not be able to.

03:03:06.500 | So it can really open up the door.

03:03:08.380 | So that's the most minimal of the minimal stimulation, right?

03:03:12.480 | Then we have minimal stimulation

03:03:13.720 | because you don't have many eggs.

03:03:15.200 | So we don't really need that.

03:03:16.820 | But for the vast majority of people

03:03:18.780 | who go through egg freezing or IVF,

03:03:20.760 | we are really trying to get as many eggs

03:03:22.420 | as you potentially have.

03:03:24.440 | Everybody has a different number, but whatever you have,

03:03:27.260 | whatever that antral follicle count is for you

03:03:29.700 | is what we're trying to get.

03:03:31.000 | And that's what these combination of medications

03:03:33.040 | is trying to do.

03:03:34.660 | When the eggs come into the lab, if you have egg freezing,

03:03:39.220 | very important to know

03:03:40.060 | is before we get into the ICSI discussion,

03:03:41.960 | the eggs are stripped of their outer cells,

03:03:43.980 | which is called the cumulus.

03:03:45.060 | That's what the sperm has to attach to

03:03:46.860 | in order to fertilize.

03:03:48.420 | In order to freeze the eggs,

03:03:49.700 | those cumulus cells are stripped off, the eggs are frozen.

03:03:52.020 | You have to do ICSI.

03:03:53.380 | So if we're gonna lead into this ICSI conversation,

03:03:56.580 | if you're freezing your eggs,

03:03:57.980 | you're having ICSI when you fertilize them.

03:04:00.820 | So I don't want somebody to ever not know that

03:04:04.500 | if that is what they are choosing.

03:04:06.460 | - And ICSI is, you can tell us?

03:04:08.100 | - Yes, ICSI stands for its ICSI,

03:04:10.700 | or intracytoplasmic sperm injection.

03:04:13.560 | It is taking a sperm that under the microscope

03:04:16.240 | looks normal in shape and moves well,

03:04:19.140 | and you're pulling it up into a little needle.

03:04:22.840 | And you're essentially using a little laser

03:04:26.320 | on the side of the egg or the zona pellucida of the egg,

03:04:29.000 | and you're injecting that one sperm

03:04:31.700 | into that egg cytoplasm.

03:04:33.180 | - And you're picking that sperm

03:04:34.620 | on the basis of shape, motility.

03:04:37.540 | You're picking what you think

03:04:38.740 | is the best sperm in the batch, obviously.

03:04:40.780 | - Yeah, you're picking,

03:04:41.620 | I mean, there's gonna be one sperm per egg,

03:04:42.820 | so there's multiple sperm that are chosen,

03:04:45.060 | but you're picking sperm

03:04:45.900 | that look like they have the highest potential.

03:04:47.660 | - My understanding is that there's a range

03:04:50.020 | from very low to potentially high,

03:04:51.900 | but hopefully not high, of DNA fragmentation

03:04:54.100 | in pretty much every cell of the body.

03:04:55.380 | Like the cell is always repairing its DNA.

03:04:58.160 | So when visually selecting a sperm for ICSI,

03:05:02.820 | it's based on morphology, shape, and motility.

03:05:05.220 | - Right, you can't see the DNA damage

03:05:07.180 | inside the head of the sperm or the DNA itself.

03:05:09.700 | - Are we soon to have a technology

03:05:10.960 | where you could actually get a dye

03:05:13.520 | that could label DNA fragmentation and select?

03:05:17.120 | Because I feel like when we talk about embryology,

03:05:19.500 | not to get too far down in the weeds,

03:05:20.800 | but the methods of selecting eggs and selecting sperm,

03:05:25.800 | I mean, these are the same methods

03:05:28.080 | that have been used in embryology since the 1930s.

03:05:30.620 | Like, oh, this one looks good, that one looks good.

03:05:32.560 | And the skilled embryologists can really develop

03:05:35.040 | a real talent over time of knowing what correlated

03:05:38.660 | with healthy pregnancy and an offspring.

03:05:41.220 | But I do like technology.

03:05:42.700 | You would think that by now, 2023,

03:05:44.840 | that someone would have some dye

03:05:46.080 | that you could drop on the sperm and go,

03:05:47.440 | well, that one has a lot of DNA fragmentation

03:05:49.940 | and that one doesn't. - I know, right?

03:05:51.040 | There should be better ways to choose which sperm.

03:05:53.640 | There's definitely, people are trying things.

03:05:56.120 | Nothing has proven to be helpful so far.

03:05:58.560 | There's definitely some interest in this

03:06:00.760 | because we're starting to get more insight

03:06:03.200 | as we have become better at embryo culture,

03:06:06.320 | getting embryos to grow, doing genetic testing on embryos

03:06:09.720 | to understand that that male genome kicks in at day three.

03:06:12.640 | And there's a subset of people

03:06:14.020 | who have beautiful fertilization and embryo growth,

03:06:17.680 | day zero to three, and that's all on the egg.

03:06:20.040 | And then as soon as that male genome kicks in,

03:06:22.360 | you have this huge drop-off in your embryo number.

03:06:25.880 | And even some of this is in the context

03:06:28.400 | of normal sperm parameters, right?

03:06:31.080 | So things aren't really normal though,

03:06:33.920 | or there's something underlying it.

03:06:35.920 | - Does that mean that every embryo failure

03:06:37.780 | on day three post-fertilization is sperm-based?

03:06:39.480 | - No, of course not, but it definitely means

03:06:42.060 | that none of the ones before that can be blamed on the sperm

03:06:45.440 | and ones after that, there's definitely still maternal

03:06:48.000 | and sperm contributions.

03:06:49.480 | - We don't want to create any couple disputes around this.

03:06:53.760 | - But it can be an insight

03:06:55.200 | when you're trying to look through somebody's IVF cycle

03:06:58.200 | about potentially modifiable factors, right?

03:07:01.520 | Can you improve sperm quality

03:07:04.640 | by some of these lifestyle measures?

03:07:06.580 | I mean, the debatable thing

03:07:07.760 | about a DNA sperm fragmentation, so what is that?

03:07:10.220 | It is not a normal semen analysis,

03:07:12.480 | but it is like that as far as it's a sperm sample

03:07:16.140 | that is then sent off to be evaluated,

03:07:18.360 | how much fragmentation or abnormal DNA

03:07:21.280 | is in the heads of those sperm.

03:07:23.420 | The studies have shown that people

03:07:25.220 | who have abnormal DNA sperm fragmentation should do ICSI.

03:07:28.700 | Okay, that's like the point of the study.

03:07:30.680 | Now, ICSI has become very commonplace.

03:07:34.080 | So ICSI, choosing the sperm to put into the egg

03:07:38.180 | originally didn't exist, right?

03:07:40.320 | So what's the alternative?

03:07:42.300 | Conventional fertilization.

03:07:43.800 | This is having your petri dish, your eggs are on it,

03:07:46.580 | you scorch your sperm, you cover it up,

03:07:48.580 | you put it in the incubator.

03:07:49.660 | - Guys, she didn't mean you squirt your sperm.

03:07:51.060 | She meant the embryologist.

03:07:52.940 | - The embryologist squirts the sperm on top.

03:07:55.200 | - Just to be clear, just to be clear.

03:07:56.040 | - And then pulls it out, and the next day sees

03:07:58.460 | by which eggs and sperm fertilized.

03:08:02.360 | Well, it's really devastating to pull out the dish

03:08:06.540 | and have no fertilization,

03:08:08.180 | and it definitely is a cause of infertility,

03:08:11.740 | and it can be very hard to know that

03:08:14.140 | because fertilization is not challenged

03:08:16.340 | on a cellular level until you challenge it.

03:08:19.380 | So ICSI used to be an add-on cost.

03:08:22.580 | It used to be a separate thing

03:08:24.900 | because it was harder to find embryologists who could do it.

03:08:27.260 | It's so standard that a lot of clinics do it

03:08:29.180 | the majority of the time,

03:08:31.020 | purely because you often don't know all the variables

03:08:33.780 | that are impacting fertilization,

03:08:35.780 | and you're trying to give somebody

03:08:37.340 | as many opportunities as possible.

03:08:39.940 | ICSI has, in a lot of those original IVF studies,

03:08:44.880 | got some of the bad reputation of being the problem

03:08:47.920 | with why you might see that 1% rise of birth defects.

03:08:51.180 | And so ICSI took the brunt from a lot of that.

03:08:54.420 | We really don't see that when we're growing out

03:08:57.780 | and we're doing, freezing the embryos,

03:08:59.900 | doing frozen transfers.

03:09:02.060 | And I mean, I do ICSI in almost every patient.

03:09:05.060 | I'm not gonna say in every one, but--

03:09:06.220 | - Higher probability of success, right?

03:09:07.860 | - Higher probability of success.

03:09:08.700 | So when you get to this point,

03:09:10.420 | and so few people have insurance coverage,

03:09:13.220 | so they're spending their money,

03:09:15.480 | they're getting second mortgages,

03:09:16.580 | they're taking out loans.

03:09:17.980 | If there's one decision that you say,

03:09:20.420 | well, I don't know, you could have zero eggs fertilized,

03:09:23.700 | or I could have the embryologist pick the best sperm

03:09:26.620 | and put them inside the egg,

03:09:27.860 | and we expect a 75% chance of fertilization,

03:09:31.160 | that makes sense for the majority of people.

03:09:33.580 | - Yeah, that makes sense to me.

03:09:35.520 | Because I'm obsessed with data

03:09:38.780 | and do blood work fairly regularly,

03:09:40.900 | not obsessively, but twice a year or so.

03:09:44.160 | Now, I didn't always do that.

03:09:45.340 | And I actually did one of these DNA fragmentation tests.

03:09:48.180 | They're pretty expensive.

03:09:49.580 | You know, they're in the--

03:09:50.420 | - They're far more than a semen analysis.

03:09:51.260 | - Yeah, they're in the low, they're sort of $1,200, $1,500

03:09:55.460 | or so, at least the one that I did.

03:09:57.380 | It was very informative.

03:09:58.340 | Like I was relieved to see

03:09:59.940 | not abnormal levels of DNA fragmentation.

03:10:02.620 | But I will say that based on everything you just said,

03:10:05.500 | it seems like it might be the lower cost option

03:10:07.800 | because the alternative is to go through repeated cycles

03:10:11.840 | of IVF and it's failing,

03:10:12.980 | and that's certainly much more expensive.

03:10:14.780 | - It is.

03:10:15.820 | And I mean, I will say that there is some current thought

03:10:19.220 | by my urology colleagues, right?

03:10:20.660 | So I'm not a urologist,

03:10:22.900 | but definitely when I have a male

03:10:24.580 | who needs a sperm extraction,

03:10:26.740 | maybe he's had a prior vasectomy,

03:10:28.260 | maybe he's got very low sperm counts,

03:10:30.020 | and we're going and we're doing

03:10:31.000 | a sperm extraction procedure,

03:10:32.900 | that potentially if you have a patient

03:10:35.820 | who has an abnormal DNA sperm fragmentation,

03:10:38.160 | and even with ICSI has this drop-off in embryo growth

03:10:41.600 | after day three,

03:10:43.060 | because the sperm are still being made the same way,

03:10:45.820 | right, are they still fragmented,

03:10:47.500 | that potentially the ejaculatory process

03:10:49.940 | could cause some of that fragmentation in certain men,

03:10:53.580 | and by going in and doing a sperm extraction

03:10:56.060 | and not subjecting those sperm

03:10:59.220 | to the rigors of ejaculation, for lack of a better word,

03:11:02.500 | could potentially lessen the fragmentation

03:11:06.060 | and improve outcomes.

03:11:07.020 | And I have some patients who,

03:11:09.260 | we've gone down that road and that has helped them,

03:11:11.540 | clear to say there's not a study,

03:11:12.720 | that's not the point of DNA sperm frag,

03:11:15.100 | is to try to distinguish if potentially ICSI

03:11:17.500 | could be a helpful technology,

03:11:19.260 | but a lot of doctors are offering or doing ICSI

03:11:23.060 | because we want you to fertilize your eggs.

03:11:26.540 | When they grow it in culture,

03:11:28.460 | as we talked about IVF changing,

03:11:30.540 | the metabolic needs of the embryo

03:11:32.260 | change throughout the process,

03:11:33.740 | and so embryo culture has become so much more successful,

03:11:36.640 | but even in those best case scenarios,

03:11:38.820 | we're looking at 50% progression.

03:11:40.540 | So you're gonna have loss throughout that culture process

03:11:43.940 | no matter what.

03:11:45.140 | - And you said 50% progression,

03:11:46.560 | so half of the fertilized embryos that make it past eight,

03:11:49.020 | let's say day seven,

03:11:50.460 | then they're screened for chromosomal abnormalities.

03:11:52.700 | So then, okay, then you've got,

03:11:54.220 | let's say two or three of those, maybe four,

03:11:56.100 | depending on how many eggs were harvested.

03:11:57.600 | - And your age.

03:11:58.440 | - And age, yes, thank you.

03:12:00.140 | And then you said of those that are implanted into,

03:12:04.260 | let's say a woman, you're 45 or younger,

03:12:06.900 | you're looking at about anywhere from 30 to 65%

03:12:10.620 | successful implantation and pregnancy,

03:12:12.340 | like healthy baby.

03:12:13.780 | - It's usually a 65% chance of live birth

03:12:15.720 | if it's a genetically tested embryo.

03:12:18.340 | That asterisk is the if,

03:12:19.540 | and that's why you're gonna see

03:12:20.380 | such varying IVF success rates,

03:12:22.480 | because if you don't do genetic testing of embryos,

03:12:25.300 | let's use the 40-year-old who makes four embryos,

03:12:29.100 | and I send them off for genetic testing.

03:12:31.060 | I anticipate she has one normal embryo.

03:12:33.860 | If I do genetic testing, which takes,

03:12:36.140 | it's called PGT, pre-implantation genetic testing,

03:12:39.140 | I am testing for aneuploidy as the traditional testing,

03:12:42.380 | meaning does it have the right number of chromosomes?

03:12:44.660 | You can also importantly test for single gene disorders

03:12:47.540 | like cystic fibrosis or Huntington's.

03:12:50.100 | But if we're just doing PGT for aneuploidy,

03:12:52.920 | I expect an age-related proportion of your eggs

03:12:55.260 | to be normal or abnormal.

03:12:56.580 | So at age 40, I expect 20 to 25% normal.

03:13:00.580 | So I can choose that one and put it in you

03:13:02.940 | and have a 65% chance that you have a baby.

03:13:05.800 | I could not do it.

03:13:07.420 | I still have the same four.

03:13:08.820 | That one is in there.

03:13:10.420 | But if I go and transfer them each independently,

03:13:12.960 | I'm now gonna have closer to a 20 to 30% chance of success.

03:13:16.580 | So it is not that I'm changing the embryo by testing it,

03:13:20.540 | but I'm allowing myself to have higher utility of success,

03:13:24.500 | higher efficiency,

03:13:25.860 | putting somebody through less failed transfers,

03:13:28.580 | which is extremely important and less miscarriages

03:13:31.700 | because those also take time.

03:13:33.820 | And one of the most important things

03:13:36.100 | is that you have the opportunity to understand

03:13:38.180 | how many potential normal embryos you have in batch cycles.

03:13:42.260 | So you could go into another cycle because I'm 40,

03:13:45.580 | I just met my person, I really wanna have two kids

03:13:48.280 | because my sibling is really important in my life,

03:13:51.140 | yet naturally by the age I would be for that second child,

03:13:54.700 | it's gonna be very hard to conceive.

03:13:57.060 | I can go through IVF and batch some embryos.

03:14:01.040 | So I could save two or three for that second baby

03:14:04.420 | that I'm not gonna transfer for a few years.

03:14:07.180 | And that's called embryo banking.

03:14:08.740 | And that is changing the ways

03:14:11.220 | that people can potentially grow their family at later ages.

03:14:14.640 | But you don't know that

03:14:15.760 | unless you know what's normal or not.

03:14:17.940 | And it also gives you the chance to go

03:14:20.580 | and intervene right now.

03:14:21.900 | Because right now, especially if you're older,

03:14:24.120 | I'm gonna have a higher chance of success

03:14:26.340 | than if I am four transfers down the road.

03:14:29.900 | And maybe there was one miscarriage in there too,

03:14:32.900 | we're suddenly now eight months down the road

03:14:34.980 | before I can go do another cycle and get more eggs.

03:14:38.340 | Versus if I found out

03:14:39.500 | that none of those were genetically normal,

03:14:42.020 | the average 40 year old might have zero to one

03:14:44.460 | if they have average ovarian reserve per cycle.

03:14:47.480 | So they're going to need multiple cycles.

03:14:49.600 | It's not that it's impossible,

03:14:51.040 | but it's just setting that road of expectation for them.

03:14:54.120 | But if I don't get any normal embryos,

03:14:55.880 | I can turn right around and go get more.

03:14:57.820 | So I am using what's left in that ovarian vault each month

03:15:01.460 | to try to get to that opportunity of a pregnancy for you

03:15:05.000 | in a much more efficient way

03:15:06.960 | by utilizing genetic testing of these embryos.

03:15:09.800 | - This is where we can put an ellipse in

03:15:11.520 | sort of like dot, dot, dot, healthy baby, right?

03:15:14.540 | And maybe in the future, if we're lucky,

03:15:17.660 | you'll come back and talk to us about healthy pregnancy

03:15:20.900 | and healthy baby onward.

03:15:24.820 | That would be a fun and important set of discussions.

03:15:28.120 | I would like to touch on the,

03:15:31.460 | I don't want to call it the issue,

03:15:32.300 | but the topic of menopause,

03:15:33.900 | which I assume is defined as the cessation of menses.

03:15:38.760 | But there I'm guessing,

03:15:40.220 | and I'm guessing it's a constellation of things that happen.

03:15:43.180 | And I have a very straightforward question,

03:15:45.620 | which is, is there an acceleration

03:15:47.540 | of the onset of menopause?

03:15:48.700 | Are we seeing that nowadays?

03:15:51.620 | Are there good data on that?

03:15:53.020 | Should people try to delay menopause?

03:15:55.940 | What are some of the things that you talk to patients about

03:15:59.880 | in terms of their considerations of ways

03:16:01.420 | to ease that transition,

03:16:02.620 | or maybe even offset that transition

03:16:04.700 | with hormone replacement therapy or other approaches?

03:16:08.420 | - These are great questions.

03:16:09.580 | And I do think this is going to be a huge interest

03:16:12.640 | in upcoming years,

03:16:14.980 | as we have learned more about the menopausal transition

03:16:17.980 | and the health risks really associated

03:16:20.400 | with being hypoestrogenic or having low estrogen.

03:16:24.160 | Menopause, if we define it as ovarian failure.

03:16:26.460 | So your ovaries now have no eggs or so few eggs

03:16:31.460 | that they are refractory to the brain sending out FSH.

03:16:35.320 | So your brain is sending out all the FSH and LH that it can.

03:16:38.700 | Your ovary is done and not making any estradiol

03:16:43.060 | or progesterone anymore.

03:16:45.060 | In this time period, what we know is one,

03:16:48.720 | are we seeing a population-based increase

03:16:51.320 | in earlier menopause?

03:16:52.260 | There's not been a study to say that.

03:16:54.040 | Observationally and clinically, I would say yes,

03:16:56.340 | because I see so many younger women

03:16:59.500 | having low ovarian reserve

03:17:01.020 | or having premature ovarian failure

03:17:03.220 | or premature ovarian insufficiency,

03:17:05.300 | which is the more politically correct way of saying it.

03:17:08.260 | But when we think about what this is,

03:17:09.940 | is there are modifiable factors, right?

03:17:12.020 | If running out of eggs is a variable,

03:17:14.100 | and we already said certain things like smoking cigarettes

03:17:17.040 | and exposure to toxins and likely chronic inflammation

03:17:20.940 | and untreated disease, we know that having diabetes,

03:17:24.540 | those things increase your risk

03:17:26.700 | of going into menopause earlier.

03:17:28.700 | So paying attention to the lifestyle that you have

03:17:33.700 | when you're not concerned about your fertility, right?

03:17:36.540 | When you're in your younger years,

03:17:38.620 | and maybe you're not worried about getting pregnant yet,

03:17:40.780 | or you're not worried about menopause,

03:17:42.940 | but those choices that you're making in those time periods,

03:17:46.540 | at least for women, your eggs are gonna hold onto them.

03:17:49.420 | So they have an influence later.

03:17:52.620 | Similarly, trying to live a lower inflammatory life

03:17:56.700 | and getting sleep and avoiding toxins, of which you can,

03:18:00.740 | is some of the best that you can do

03:18:03.220 | to try to naturally prolong

03:18:05.700 | when you'll go through menopause with a huge caveat

03:18:08.460 | that everybody is truly born with a different number,

03:18:11.220 | and you do not control that, you don't.

03:18:13.940 | And so you might have been born with a lower number,

03:18:16.540 | and you can't change that trajectory.

03:18:18.900 | And you might have cancer and be exposed to chemotherapy,

03:18:21.860 | which also will deplete your ovarian reserve.

03:18:25.040 | But so do things like endometriosis,

03:18:27.780 | especially if it's not being treated in any fashion.

03:18:32.180 | So that's where we think the birth control pill

03:18:35.340 | or progestin exposure or surgery,

03:18:38.100 | ways to go and decrease the inflammation.

03:18:40.340 | It's that inflammation associated with endometriosis

03:18:42.860 | that's really causing these women

03:18:45.100 | to have low ovarian reserve and go into menopause early.

03:18:48.640 | So not only is that impacting fertility

03:18:51.220 | and how many eggs you get

03:18:52.200 | and how long you have to grow your family,

03:18:54.380 | but when you go into menopause earlier,

03:18:56.600 | you have lower life expectancy

03:18:59.060 | than people who go into menopause later.

03:19:01.500 | And that's why you even said it earlier,

03:19:03.260 | fertility is this variable kind of reflecting longevity

03:19:06.820 | and like health overall.

03:19:09.420 | So what we do know about menopause

03:19:12.220 | is that having that low estrogen,

03:19:14.020 | whether that happens at the average age of menopause at 51,

03:19:16.740 | 52, or at an earlier time period,

03:19:19.260 | it's not good for the brain,

03:19:20.900 | higher risks of dementia,

03:19:22.940 | increased risks of osteoporosis,

03:19:25.300 | increased risk of heart disease and stroke,

03:19:27.420 | and essentially higher risks of death.

03:19:29.140 | And that's not even to talk about the impact on your life,

03:19:32.640 | what it can be like to have hot flashes,

03:19:34.840 | heat and cold and sensitivity,

03:19:36.500 | to have profound vulvar and vaginal atrophy

03:19:39.940 | to the point that you no longer want to have intercourse

03:19:42.740 | and the changes that it can even have

03:19:44.480 | on your gut and your immune system.

03:19:46.600 | So we, as a community of doctors, especially OBGYNs,

03:19:51.600 | really recommend hormone replacement therapy

03:19:55.500 | in women who are going through menopause.

03:19:57.860 | And the key here is to initiate it right at the beginning.

03:20:02.100 | That big Women's Health Initiative study,

03:20:04.060 | which came out forever ago and showed all this harm

03:20:06.700 | with hormone replacement therapy,

03:20:08.980 | the big issue there was that these people

03:20:11.300 | were hypoestrogenic for 10 plus years in one group,

03:20:15.300 | and then started back on the hormones.

03:20:17.560 | And in that circumstance,

03:20:19.180 | they'd already been put into this higher risk category

03:20:22.140 | and their body had adjusted to not having the hormones.

03:20:25.100 | And when re-exposed, they had more adverse events.

03:20:28.920 | But if you are starting on estrogen replacement,

03:20:33.180 | and it can be various, but honestly,

03:20:35.260 | the estrogen that we try to replace in this time period

03:20:37.920 | much more mimics estradiol.

03:20:39.700 | We have estradiol pills.

03:20:41.280 | You can have vaginal inserts, you can have patches.

03:20:44.340 | So it depends on what's gonna work for your life,

03:20:47.020 | but it is not the birth control pill most oftenly.

03:20:51.640 | In some people, it might be that's what they choose,

03:20:53.560 | but we really are trying to pick an estrogen

03:20:55.800 | that is estradiol, more mimics that natural structure.

03:20:59.620 | And you can't have unopposed estrogen

03:21:01.740 | without reaching the risk of endometrial cancer.

03:21:05.020 | And so that's why we need to have some progestin.

03:21:07.420 | So some people will choose a daily progestin,

03:21:09.740 | some will choose a cyclic progestin and still have periods.

03:21:13.180 | Some will put in an IUD at this time period

03:21:15.300 | and then take their daily estrogen.

03:21:17.860 | There's a lot of different options.

03:21:19.720 | We're trying to find the lowest dose of hormones

03:21:22.800 | that relieves your symptoms to provide you relief

03:21:25.420 | from some of these lifestyle issues,

03:21:26.780 | but also helps you not just live longer, right?

03:21:30.560 | We're not just trying to live longer.

03:21:32.180 | We want to be healthy longer.

03:21:33.860 | We want to have a better quality of life.

03:21:36.180 | And certainly women's health has for long stopped

03:21:39.740 | at this menopausal period.

03:21:41.220 | And then it's been, you're on your own, kid.

03:21:43.500 | And this is when we're really starting to see

03:21:45.040 | that intervening at that place,

03:21:47.100 | especially for women who go into ovarian failure early.

03:21:51.260 | So those people who have low ovarian reserve,

03:21:53.260 | who I diagnose, I tell all of them,

03:21:55.260 | hey, if you don't freeze your eggs or I never see you again,

03:21:58.380 | you're going to go through menopause early.

03:22:00.320 | And when you do, I want you to go see somebody.

03:22:02.660 | I don't want you to just ignore it

03:22:04.440 | and suffer with these symptoms,

03:22:06.700 | which is something that does commonly happen.

03:22:08.860 | So just making sure that women are empowered to know

03:22:11.980 | that these symptoms are what happens,

03:22:14.260 | it's what happens naturally,

03:22:15.860 | but by giving their bodies more estrogen

03:22:18.220 | and not crazy high doses,

03:22:19.700 | but just these physiologic levels can really improve

03:22:22.380 | both the quality and the longevity of their life.

03:22:25.220 | - Is it just the presence of the symptoms

03:22:28.180 | that signals the onset of menopause,

03:22:32.580 | or is there, are there additional cues?

03:22:35.100 | Like for instance,

03:22:35.920 | if their cycle is getting shorter or longer.

03:22:37.900 | - You certainly will have cycle changes.

03:22:39.780 | And we consider that the perimenopausal period,

03:22:42.660 | where you're starting to really start seeing

03:22:44.460 | a spacing out of your period.

03:22:46.620 | So they're no longer coming

03:22:48.260 | at that perfect ovulatory pattern.

03:22:50.500 | When you get into the low ovarian reserve,

03:22:52.180 | but you're still ovulating regularly,

03:22:53.740 | literally they first shorten, as we said earlier,

03:22:56.260 | but then when they start lengthening

03:22:57.660 | or you start skipping months,

03:22:59.140 | that's a real big clue

03:23:00.580 | that things are not going in the right direction.

03:23:04.140 | And if you find out you have very, very low ovarian reserve,

03:23:07.300 | or you're approaching that perimenopause period,

03:23:09.740 | you're gonna start to have more prolonged periods

03:23:11.540 | of low estrogen and you'll feel mentally cloudy, fatigued,

03:23:16.540 | more headaches, more hot flashes, lack of libido,

03:23:20.740 | those vulvar vaginal symptoms,

03:23:22.620 | overall more likelihood to have depressed mood.

03:23:25.500 | And that's a lot.

03:23:27.660 | - That's a lot.

03:23:28.500 | Well, Natalie, Dr. Crawford,

03:23:31.920 | I want to extend a huge thank you on behalf of myself.

03:23:35.540 | I've learned so much from you today about fertility,

03:23:39.060 | about hormone health for women.

03:23:40.420 | And you've also touched on a number of important issues

03:23:42.220 | about hormone health and fertility for men along the way.

03:23:44.660 | So it's truly been a masterclass in fertility and hormones

03:23:48.980 | and really touched on topics

03:23:50.860 | that are so essential to everybody,

03:23:53.240 | even if people aren't seeking to conceive

03:23:54.900 | or maybe think they don't want to.

03:23:56.880 | I mean, there's so many considerations

03:23:59.340 | that really extend back to one's teens.

03:24:01.900 | And if one is beyond their teens,

03:24:03.340 | like whatever age people are, essentially,

03:24:05.340 | they need to think about these issues

03:24:06.660 | and make important decisions.

03:24:08.060 | And you've really also clarified a lot of the,

03:24:10.240 | what I think are quite destructive myths

03:24:12.020 | that are prominent out there about,

03:24:14.780 | for instance, egg harvest

03:24:15.900 | and what that does to one's fertility.

03:24:18.380 | So first of all, thank you for joining us today.

03:24:21.640 | I know you're extremely busy.

03:24:22.660 | You run a clinic, you manage a family as well,

03:24:25.440 | co-manage a family, I believe.

03:24:27.060 | But this is the sort of knowledge

03:24:30.020 | that is so challenging to find in one place.

03:24:33.400 | And yet you also have a number of really spectacular avenues

03:24:36.240 | that you deliver information, Instagram, podcasts, books,

03:24:40.480 | and things of that sort.

03:24:41.320 | We will refer everyone to those links.

03:24:43.880 | I've learned so much from you over the years, really,

03:24:46.940 | in following your content.

03:24:47.980 | And today you've just like far exceeded

03:24:50.540 | all already high expectations.

03:24:52.700 | So thank you ever so much.

03:24:55.380 | - Thank you for having me

03:24:56.200 | and just thank you for giving a space

03:24:58.820 | to talk about women's health and fertility

03:25:00.380 | and reproductive medicine.

03:25:01.380 | It means a lot to me and it means a lot to the people

03:25:05.220 | who really are trying to do their best every day.

03:25:07.260 | So we appreciate it.

03:25:08.620 | - We appreciate you.

03:25:09.540 | And with some luck, we'll commit you to come back

03:25:11.300 | and talk to us about pregnancy

03:25:13.020 | and a bit more on some of the topics

03:25:14.820 | that we moved through quickly.

03:25:16.740 | Thank you.

03:25:17.580 | - Thank you.

03:25:18.500 | - Thank you for joining me for today's discussion

03:25:20.220 | about female hormones and fertility

03:25:22.200 | with Dr. Natalie Crawford.

03:25:23.660 | You can find links to her clinical practice

03:25:25.740 | as well as to her social media handles

03:25:27.580 | in the show note captions.

03:25:29.000 | Please also check out the link

03:25:30.180 | to her excellent podcast entitled "As a Woman."

03:25:33.340 | If you're learning from and/or enjoying this podcast,

03:25:35.780 | please subscribe to our YouTube channel.

03:25:37.580 | That's a terrific zero cost way to support us.

03:25:40.100 | In addition, please subscribe to the podcast

03:25:42.100 | on both Spotify and Apple.

03:25:43.700 | And on both Spotify and Apple,

03:25:45.160 | you can leave us up to a five-star review.

03:25:47.560 | Please also check out the sponsors mentioned

03:25:49.280 | at the beginning and throughout today's episode.

03:25:51.400 | That's the best way to support this podcast.

03:25:54.000 | If you have questions for me or comments about the podcast

03:25:56.560 | or guests that you'd like me to consider hosting

03:25:58.360 | on the Huberman Lab Podcast,

03:25:59.800 | please put those in the comment section on YouTube.

03:26:02.120 | I do read all the comments.

03:26:03.760 | Not during today's episode,

03:26:04.880 | but on many previous episodes of the Huberman Lab Podcast,

03:26:07.660 | we discuss supplements.

03:26:08.900 | While supplements aren't necessary for everybody,

03:26:11.080 | many people derive tremendous benefit from them

03:26:13.400 | for things like enhancing sleep,

03:26:15.200 | hormone support, and improving focus.

03:26:17.480 | If you'd like to learn more about the supplements discussed

03:26:19.400 | on the Huberman Lab Podcast,

03:26:20.880 | you can go to Live Momentus, spelled O-U-S,

03:26:23.400 | so livemomentus.com/huberman.

03:26:26.600 | If you're not already following me on social media,

03:26:28.480 | it's Huberman Lab on all social media platforms.

03:26:31.200 | So that's Instagram, Twitter, now called X,

03:26:34.300 | Threads, Facebook, LinkedIn.

03:26:35.800 | And on all those places,

03:26:37.040 | I discuss science and science-related tools,

03:26:38.980 | some of which overlaps with the content

03:26:40.440 | of the Huberman Lab Podcast,

03:26:41.880 | but much of which is distinct from the content

03:26:43.760 | on the Huberman Lab Podcast.

03:26:44.960 | So again, it's Huberman Lab on all social media platforms.

03:26:48.400 | If you haven't already subscribed

03:26:49.560 | to our monthly neural network newsletter,

03:26:51.800 | the neural network newsletter

03:26:52.920 | is a completely zero cost newsletter

03:26:55.200 | that gives you podcast summaries,

03:26:56.800 | as well as toolkits in the form of brief PDFs.

03:26:59.440 | We've had toolkits related to optimizing sleep,

03:27:02.720 | to regulating dopamine, deliberate cold exposure,

03:27:05.640 | fitness, mental health, learning,

03:27:07.840 | and neuroplasticity, and much more.

03:27:09.920 | Again, it's completely zero cost to sign up.

03:27:11.740 | You simply go to HubermanLab.com,

03:27:13.440 | go over to the menu tab, scroll down to newsletter,

03:27:15.800 | and supply your email.

03:27:17.360 | I should emphasize that we do not share

03:27:18.880 | your email with anybody.

03:27:20.700 | Thank you once again for joining me

03:27:22.100 | for today's discussion with Dr. Natalie Crawford.

03:27:24.760 | And last, but certainly not least,

03:27:26.960 | thank you for your interest in science.

03:27:28.720 | (upbeat music)

03:27:31.300 | (upbeat music)

Dr. Natalie Crawford: Female Hormone Health, Fertility & Vitality

Chapters