Welcome to the huberman live podcast where we discuss science and science based tools for everyday life. I'm Andrew huberman, and I'm a professor of neurobiology and Ophthalmology at Stanford School of Medicine. My guest today is dr. Natalie Crawford. Dr. Nathalie Crawford is a medical doctor specializing in Obstetrics and Gynecology reproductive endocrinology and infertility. She also holds a degree in nutrition science. Dr. Crawford runs a clinical practice see
in patients daily as well as being actively involved in public education both through social media and through her popular podcast entitled as a woman today. Dr. Crawford teaches us about all aspects of female hormones and Hormone Health and fertility beginning as far back as in utero when we were still in our mother's womb and extending as far forward as menopause. We discuss topics such as the timing of puberty and what the timing of puberty in girls means for their fertility and we discussed birth control both hormonal.
Non-hormonal forms of birth control and how birth control may or may not relate to long-term fertility and different aspects of female Health. We also talked extensively about measuring fertility that is egg count. We also talked about egg retrieval AKA freezing one's eggs as well as in vitro fertilization, and we also take a deep dive into the popular and important topics of nutrition and supplementation as they relate to fertility as they relate to pregnancy. But also how they relate to female hormone Health generally indeed. Dr.
It provides us with a masterclass on female hormones and fertility one that I know that all women ought to benefit from and that men would benefit from listening to as well before we begin. I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is however part of my desire and effort to bring zero cost to Consumer information about science and science related tools to the general public in keeping with that theme. I'd like to thank the sponsors of today's podcast. Our first sponsor is Maui Nui venison Maui,
Adenosine is the most nutrient dense and delicious red-meat available spoken before on this podcast in Solo episodes. And with guess about the need to get approximately one gram of high quality protein per pound of body weight each day for optimal nutrition there many different ways. That one can do that but a key thing is to make sure that you're not doing that by ingesting excessive calories. Now a new event assassin has the highest density of quality protein per calorie and it achieves that in delicious things.
Like ground Meats venison steaks jerky and bone broth. I particularly like the ground venison. I make those into venison burgers probably five times a week or more. I also like the jerky for its convenience, especially when I'm traveling or especially busy with work and know that I'm getting an extremely nutrient dense high quality source of protein. If you'd like to try Maui Nui venison, you can go to Maui Nui Venison.com huberman and get 20% off your first order. Again. That's Maui Nui venison.
/ huberman to get 20% off. Today's episode is also brought To Us by Helix sleep Helix sleep makes mattresses and pillows that are tailored to your unique sleep needs. Now sleep is the foundation of mental health physical health and performance when we are sleeping well and enough mental health physical health and performance all stand to be at their best. One of the key things to getting a great night's sleep is to make sure that your mattress is tailored to your unique sleep needs Helix sleep has a brief two-minute quiz that if you go to their website, you take that
quiz and answer questions such as do you tend to sleep on your back your side of your stomach. Do you tend to run hot or cold in the middle of the night? Maybe you don't know the answers to those questions and that's fine at the end of that two minute quiz, they will match you to a mattress that's ideal for your sleep needs. I sleep on the dusk the usk mattress. And when I started sleeping on a desk mattress about two years ago my sleep immediately improved. So if you're interested in upgrading your mattress go to Helix sleep.com / huberman take their two minutes sleep quiz, and they'll match you to a customized mattress for you and you'll get up.
350 dollars off any mattress order and to free pillows again if interested go to Helix sleep.com huberman for up to three hundred fifty dollars off and to free pillows. I'm pleased to announce that we will be hosting for live events in Australia Each of which is entitled the brain-body contract during which I will share science and science related tools for mental health physical health and performance. There will also be a Live question and answer session. We have limited tickets still available for the event in Melbourne on February 10th.
As well as the event in Brisbane on February 24th hour event in Sydney at the Sydney Opera house sold out very quickly. So as a consequence, we've now scheduled a second event in Sydney at the aware super theater on February 18th to access tickets to any of these events. You can go to huberman labs.com / events and use the code huberman at checkout. I hope to see you there and as always thank you for your interest in science. And now for my discussion with dr. Natalie Crawford, dr. Cross
Welcome. Thank you so much for having me. I'm honored to be
here. Well, I've been paying attention to your content for a long time and I find it to be incredibly clear informative and for many people actionable. So today I'd like to talk about both fertility and of course hormones, but as we both know fertility is not limited to a discussion about hormones and actually relates to things like behaviors. Yeah sex behaviors and other behaviors nutrition supplementation, so we'll get into all of it.
But if we could just back up developmentally and talk a little bit about female puberty because I think pretty much everything will talk about today is related to what happens puberty forward mostly in females, but we will also discuss male fertility and hormones a bit and the question I have is is there anything about a woman's timing or
Let's just say patterns of puberty, right how frequently they menstruate early on what the timing of menstruation is in terms of their age Etc that provides hints or maybe even facts or directives about her future fertility or how long her fertility might last.
This is a great question and I think defining some terminology before we begin as helpful. So if we go all the way back to when you're a fetus
Inside your mom. So when there's a female fetus inside her mom, you have the most eggs are ever going to have it about 20 weeks gestation have about 6 to 7 million eggs by the time you're born you've already lost more than half of those and you continually lose eggs all the time. So the analogy that I always use and you do too is imagining that there's a vault inside the ovary where all your eggs are kept and every single month since the moment you have an ovary you lose a group of these eggs and when there's more inside
I'd you're losing more. So you're losing all of these eggs throughout early fetal development and then up until the time period even of puberty when you reach puberty you have a lessening of the number of eggs in your ovary to the point where you can start to respond to the signals from the brain. So we think about puberty onset in females first. We have released the Larkey which is the development of breasts. So that happens about two years on average before you have menarche, which is your period starting.
What happens is the brain as we know from the hypothalamus sends out GnRH and then we have FSH coming out which really starts to stimulate those follicles. So FSH or follicle stimulating hormone well-named hormone for the female, of course men have it too and it's less well named for them, but it starts to get those follicles which housed the eggs to grow and make estrogen women have about two years of estrogen exposure alone. So unopposed estrogen with no progesterone because they're not
Yet ovulating and that's when you start to see breasts budding and you start to see the development of some of those secondary sex characteristics before you actually have a
period what are some of the other secondary sex characteristics that precede menarche. So you said breast Bud development and then breast development on average about two years before
for you have sexual hair development. So actually adren our key is one of the first usually comes right before at the same time with breast buds. So two to three years before you'll see your period and the
genital
Underarm
hair typically a general hair usually first and then under arm here
and we're getting right down into the weeds here, which is good goal of this podcast is to normalize all aspects of Health, including sexual health and reproductive health. Is that commensurate also with the development of body odor, you know, because as a young boy who eventually hit puberty and became a young man, and now I suppose I'm in middle age 48 I can tell you that the
The locker room smelled a lot different the before and after Middle School, right? Right, like the in other words boys start to smell stinky,
right you yes, and that's usually around that same time of sexual hair development is when you start to have those glands around the hair making some of those odors that start to produce stink.
They reflect hormones themselves.
Not this like the smell the actual smell doesn't actually reflect levels of hormones or anything like that it is
Just that your body your gonads whether it is testes or ovaries are now starting to respond to those brain signals. The brain is turned on they're starting to respond in your body starting to mature and a way to get to the point where it can support
reproduction. The reason I asked that question is not to get people thinking about stinky smells but and by the way, some people love the musty smell of their own body arms heads are others, you know, you're referring to adults by the way, but the reason I ask is that
that there's a wealth of data in animal models including non-human primates suggesting that exposure to the odors of others can either stimulate or accelerate puberty. Is there any evidence for that in humans?
So there's mild evidence and it's murky because we also know that anything that could be an endocrine disruptor, which a lot of sense or fragrances are also can accelerate the onset of
Pretty by disrupting part of this system. And so we know that toxins and you know sense and a lot of the world that were exposed to is part of the reason why we're seeing puberty hopping at such a younger age now in females specifically but in both but in females than we have before we have young girls seeing their onset of menarche or their period at a much younger age how
much younger I've seen the various graphs for different countries, but can we say that, you know ten years ago on average?
Girls in the United States and Northern Europe were getting menarche at about what 12 to 13 years
old age. So, you know start both use menarche for the purpose of this so having your period, you know, 10 to 20 years ago. You will see most data would say, oh 13 to 15 would have been kind of the average age and now we're really seeing it shift to be starting at 10:00 to 11:00 and completing by 1314. So most girls are definitely going through the puberty change earlier and
The other thing to note is that most girls get their final height growth right before they start their period to so not only are we seeing a change and this getting starting earlier. Well, we're also seeing is probably some reduction in height from having gone through puberty at an earlier process because once you start actually menstruating, once the ovaries have really started to learn how to respond to that FSH and grow the follicle and it gets to the point where you can start ovulating so about two years.
Later, then that ovulatory period those high levels of estrogen are going to go and they're going to close those growth plate. So you've really started to limit your final adult height as well when you go through puberty earlier and that's definitely something that's a huge concern for precocious puberty or very young puberty. Right and we can use blockers when there are children who start to exhibit signs of puberty and one of the main reasons people do that is to try to get them to a greater adult height.
if they're really starting to go through puberty at a very young
age is that also true for males
that is happening
earlier puberty means that your growth spurt terms of height is going to be
truncated not the same and you probably most mental say oh but I had my growth spurt, you know kind of after I started having some of the puberty change that happened but because it is this estrogen related process and women that we see that grossberg really your final height is within that
At year of when your period
starts interesting. Yeah, this discussion is certainly not about me, but I was one of these but I thought was kind of an odd duck. I hit puberty about 13 14. Let's just say I knew I did but I didn't shave until I was after college my growth spurt between freshman and sophomore year, I grew a foot, right? So I was like, you know grow full foot but I was the same weight real tall real skinny or pre tall, you know real skinny, and then it seems like, you know, some people my life would argue that puberty still occurring for me. It feels like it's
Long and protracted which leads me to a very specific question if puberty arrives was again defined as menarche for sake of discussion right now if puberty arrives early in a girl does that mean that her fertility will shut down earlier as
well when it does not so the age of which you start the onset of your period does not impact how long you're going to have a reproductive life span and that's because you have the eggs.
Eggs inside that Vault you're losing them every month no matter what so you lost them all those years before your period started no matter if your period came at 10 or at 15, it's just about when did they start allowing your body to ovulate determine by being able to carry a baby your body nothing's you can be
pregnant. I think this is so important to highlight because it puts together what you said earlier about the loss of eggs, even in as a fetus. I think most people sort of assume that
The reduction in egg count is due to ovulation and the fact that you know, one egg ovulates typically but that other eggs are deployed in that ovulatory cycle. And then those those basically are taken out of the Vault and out of the opportunity for fertilization. But what you're saying is that the eggs are constantly being called from The Vault starting from early embryonic development and that ovulation is a distinct step in some sense unrelated.
It to lots of so that's a loss of eggs. I think this is going to be very important for our discussion later about potential egg Harvest because I think some people have it in
mind a lot of misconceptions that you're losing eggs from your fault and that's not the case. You're just accessing the ones
outside are so you're not so we can just answer this now perhaps it seems if I understand correctly that if one were to harvest eggs for IVF what for embryogenesis in addition or set them aside later or freeze them for later if they want to use them eggs or or
Realized embryos, that one is not reducing the total number of eggs any more than they would they just let their their Cycles proceed natural exactly. That's such an important point. I think that I think a lot of people believe the opposite they
probably the number one thing that patients fear when they come talk to me about egg freezing or going through IVF is I don't want to harm my future fertility. I don't want to cause myself to run out of eggs earlier or going to menopause earlier and it's explaining this process to them that
your ovaries are on a pathway that you can't change. Those eggs are coming out of the Vault regardless of if you're on birth control pills, you're pregnant. We do IVF. What did we're modifying is ones not going to ovulate and have the rest of them died. We're going to try to give you medication to get them all to grow so we can take all of the ones that have been released from the Vault that month and give them a chance for later and the next month. You'll have another group come out.
So IVF is not about stimulating hyper release.
Or excessive release of eggs. It's about stimulating the growth of the ones that have been released so that they can be frozen a stage either for later fertilization or fertilize in addition than Frozen is
embryos. Is that right? Exactly and we just use the hormones that your body normally makes and a different way the medications we use our FSH and LH to get the eggs to grow. So people will say I don't want to take all these weird hormones or strange medications, but we're just manipulating that normal process that happens and the natural menstrual cycle in order to say hey this month, let's
get all these eggs to grow. Let's try to improve the efficiency of finding which eggs are going to be normal or not and help you along this process.
I think a good number of people are now going to head to the IVF Clinic. I think again, I really want to highlight this I think most people that I've spoken to assume that the process of harvesting eggs for freezing for fertilization then or later is going to diminish their fertility because they're basically pulling more out of the savings account so to speak right? Okay, so we making
Draw no matter what
great. Well such an important point for people to know and propagate getting back to puberty little bit later on. I wanted to get into endocrine disruptors and things of that sort. But since you brought it up, you know, I've heard things such as okay things like evening primrose oil if Mom is putting evening primrose oil on or is has it in her shampoo that I've heard of young males getting precocious breast Bud development. Keep in mind folks that some
Um transient breast Bud development is characteristic of some normal puberty's in males it sometimes shows up and goes. I knew some kids like that in the neighborhood. They got teased a little bit and then they stop getting teased. Hopefully nowadays. They don't tease those kids, but when I was growing up those kids got teased not by me but by other people but it was normal and it passed for some right it occurred normally and then past but I've heard that things like exposure to evening primrose oil maybe even just through contact with Mom can increase the frequency or degree of that.
Male breast by development. Is it also true that young girls can undergo precocious puberty or let's just say accelerator exacerbated puberty through contact with things like evening primrose oil, which is a I think has some pseudo estrogen-like
properties. It's important to differentiate that the secondary sex characteristics. We see like respite development are from estrogen, but it's not really puberty being initiated when it's from an endocrine disrupting chemicals. So taking, you know being
Exposed to evening primrose or lavender or tea tree oil in a male isn't going to cause them to start to go into puberty, but it is going to expose him to estrogen when his body is not and therefore stimulate some breastfed development. Same thing can happen in young girls. We need they could show some of those secondary sex signs earlier than they normally would and this is why if that's happening at a really young age kids should go to a pediatric endocrinologist who are going to check things out.
Bone age and see if you've really started the puberty process or not, or is it an outside exposure which is causing it interestingly about the young child exposure and development. The other thing to say, that's really interesting and relevant in my field. Is that when we think about how many eggs are in the vault and everybody's born with this different number and I'm sure we'll talk about ovarian reserve. What we now know is that the Vault your ovaries are most susceptible to whatever.
Your mother does when she's pregnant with you and that that epigenetic that programming which is happening is predisposing young women to probably having some of them low ovarian reserve some of them having diseases. We associate with infertility like PCOS or endometriosis and we haven't yet characterized what all they are. But if we look at the incidence of some of these disease that we see now what we do know is that the time period of which these people were pregnant.
The 80s and 90s was not the healthiest time when it comes to endocrine disruptors and plastic exposures and chemicals and all of this processed stuff. Let's just say that people have been exposed to that were really seeing that those that ovarian susceptibility to egg quality and quantity happens in that fetal development
period it's interesting because there are some
parallels to male fetal development like the fact that the of these are early organizing effects of hormones like dihydrotestosterone which essentially stimulate the growth of the penis but also then establish a propensity for hormones during puberty to activate growth of the sex organs, but also activate the brain areas are responsible for a host of different things. So I only mention that because what I'd like to kind of illustrate in the background here is that basically are
Reproductive Health begins really prior prior to conception really it's a dependent on Mom and Dad but certainly to a great degree on Mom. But then fetal development is going to be important. So sort of us being able to pick our parents. I do have a couple questions about lavender tea tree oil and evening primrose oil. I was aware that evening primrose oil oil scuse me can somehow bind estrogen receptors it or mimic some of the estradiol or
something similar to it. I wasn't aware of tea tree oil or lavender here. Are we talking about oils? What about Aromas and how concerned do people have to be about this stuff? Because I mean, you know, you'll go into a restaurant bathroom. They'll be potpourri some people wear perfume. I mean, we don't want to set a paranoia. No, but but I but I think people should know about this stuff tea tree oil is in a lot of those natural shampoos that are the ones that
burn the one that tingle your scalp. So people some people love them though.
Constant exposure is very different than a one-time hand-washing in the bathroom. And I think that's the big difference for everything when we talk about chemicals or toxins or exposures in the world. You can't live in a toxin-free world, but choosing what you put in and on your body on a regular basis does set the tone for certain physiologic changes and so, you know using unscented products, especially with children as a really an important thing because
want to make sure that their lifetime exposure to some of these things especially during critical times is much less and so you'll see people recommend things like your laundry detergent, you know, what sensor in your laundry detergent this shampoo and conditioner are a big one and the Soaps that you use on a day-to-day basis in your house or the oils you put on your body lavenders huge because there's this whole community of people they want to rub lavender oil on their baby's feet and help them sleep but really we can see and if somebody goes
Goes and shadows a pediatric endocrinologist for a day. They'll see some kids come in and this will be the reason why
what about cloth diapers versus non cloth diapers. I've heard you know that you have your like very strong cloth diaper proponents, right and that because they seem to feel or believe that non cloth diapers. Somehow contain things that can get into babies skin, and maybe there's a bigger question here is baby skin more permeable than
adults do.
No, that baby's skin is more permeable. Don't even read
this to me. It seems it seems like it'd be hard to imagine it is but but babies do seem to have this incredible skin right there skin is so smooth. You want squeeze their cheeks and I all this kind of stuff. But yeah the idea they would be more permeable.
I think it's more that their development is this time is very important and setting the stage for a lot of what happens later verses in adulthood. Those stepwise developmental processes have already happened. So I think that's why we pay so much attention to what happens.
As in the you know, childhood period of time because we're now learning about those later consequences of what you're exposed to. It's not that you know, regular diapers versus cloth, whatever we want to say, it ones necessarily better than the other it's more honestly a personal preference babies are exposed to them a lot and there's been a lot of attention to that but similarly somebody could use cloth and wash it with a detergent that then you know has certain chemicals in it. So there hasn't been a study showing that this
One thing is an exposure for a baby that somebody needs to be worried about there's definitely companies now which are promoting and talking about traditional diapers that they are making sure have less toxins and them and I always think anytime you can decrease toxin exposure to a child is going to be very
important. Is there any evidence for you know breast milk versus Formula in terms of impact on future reproductive development.
Of or free reproductive status of a child
that's a complicated question because breast milk exposure at least for the first six months of a child's life certainly helps with the immune system development and we know that poor immune development can lead to higher risk of autoimmune disease later what people call leaky gut and some of those diseases certainly are correlated with fertility. So I wouldn't say we've gone so far to say that if you don't breastfeed your child or going to have fertility issues,
We do know that there's an in-between correlation with things that breastfeeding is protective against and how those diseases themselves May relate to fertility and the female leader on.
Okay. So if we're thinking about a young girl / woman because we're talking about puberty right? So I don't know what the exact nomenclature is there. You know, my experience is I'll I'll offend and somebody no matter what but a girl who undergoes puberty, right? So young woman who's maybe 13 or so.
So so she's early teens undergoes puberty and therefore is continuing to lose eggs from the Vault but now is undergoing presumably roughly every 28 days menarche but let's talk about this 28 days thing because I think a lot of people think that quote unquote normal menstruation is always 28 days and and we know that's not true. So what is the range of normal durations between
Menstruations Cycles or duration of the menstruation cycle and let's also Define when the menstruation cycle starts probably for the male's mostly in the
audience. Sure. So let's think through the cycle will do a quick one over and then answer the questions. So what we think of as cycle day one or when you're going to say this starts is going to be the day that you start bleeding. So that's actually shutting the endometrial lining from what grew the last
time so any spotting even would be considered a 10
K. So it is
if we can get back to a problematic if you have a lot of spotting before that full flow starts a day or so can be really normal just as the body is adjusting to the drop in progesterone, but let's just start at the beginning day 1 you have a period am in sees this is when you're actually bleeding at this time period we like to think about all of those new eggs being out of the Vault being susceptible to that FSH which of course is that well-named hormone because it stimulates a follicle to grow and each egg isn't a follicle that egg starts to grow and makes
That estrogen stimulates the proliferation of the lining of the uterus and preparation for potentially that pregnancy that may come and also that estrogen makes you feel really great. Right? That's the follicular phase named so because that follicle is growing and it's an FSH dominant phase where you have a lot of estrogen
and people feel great when they have a lot of estrogen because
women feel good with estrogen
because of the relationship between estrogen and other neuromodulators like dopamine serotonin and N is that
happening in parallel or they somehow related like his estrogen controlling the release of Serotonin somehow and vice versa or they just kind of coincidently happening in
parallel. We definitely think that there's more of a correlation causation than just coincidence because we know there's time periods of people are more depressed within your cycle correlating with those low estrogen levels, and we know that when you go into menopause or you run out of eggs, and you're now in a low estrogen phase we see a lot more of a depressed mood and
You know anhedonia lack of response to things which would normally give you pleasure happens more frequently the female brain loves estrogen and it's protective against things like dementia. So this is a time period where women are going to be more energetic. They're going to have more energy more Focus. This is the estrogen dominant phase of the cycle. And when you have seen that estrogen at its high levels, which it's only made from a mature follicle and it's very specific 200 picograms per ml for 50 hours. That's the brains clue.
We must have a mature egg and it can send out that surge of lhr luteinizing hormone. And now you ovulate and when you ovulate the follicle opens up releases closes back and then it's the corpus luteum and we've entered the luteal
phase and the corpus luteum is the name suggests a corpus. It's like a body. That's basically the it's basically it's basically the corpse of what before and it what I find so amazing. I mean biology so
Beautiful write it instead of just taking that tissue and saying okay, like let's just discard this or that becomes the trigger for the next phase of it is
essential for life, right the corpus luteum, which makes progesterone opens and closes the implantation window. It is what allows somebody to get pregnant and for our species to continue its so it's extremely fascinating and that corpus luteum gets stimulated to produce progesterone impulses throughout the entire luteal phase because it's still controlled by the brain.
You get pregnant and then in that luteal phase progesterone is fascinating. It's trying to protect you from things which could potentially harm your baby. So suddenly now you have less energy. You want to sleep more you want to eat more you maybe do not want to have sex as much because your body is suddenly saying let's just protect this potential implantation that you're going to have if that pregnancy doesn't come the corpus luteum can only live 12 to 14 days. It has a
very distinct lifespan and then it dies your estrogen and progesterone both drop you bleed starting over the next cycle and a new group of follicles comes out to be released. And the reason why walking through that very succinctly but is important when you're asking how long is the normal cycle because the luteal phase is pretty set at 12 to 14 days the follicular phase can vary in person to person and what we know though is for one individual if
Or menstrual cycle your reproductive hormones are working right it should be relatively constant for you. And so if your periods are every 24 days, but they've always been every 24 to 25 days. Then that's not concerning and if your periods are every 33 days, but they've always been every 33 days but that's not concerning but we do get concerned when there's a change in your period or we get concerned when people have what I like to say is irregularly irregular.
Periods because what you'll see textbooks tell you is that your periods could be as short as 21 days as long as 35 days and that can all be normal but people will hop between them and they'll have one cycle that is 24 days in length from day one to the last day before the next day one then the next Cycles 32 and then it's 26 and then it's 34 and that's not normal. That's too irregular and that can be a sign that something is not.
Incorrectly within your reproductive hormones. So what I tell patients is in general your period should be less than 35 days apart and you should be able to look at a calendar and with your finger put a finger on the date and within a couple days of accuracy be able to predict when your periods coming and if you can't there could likely be something that is interfering with the hormonal signals between the brain and the ovary and one of the biggest really one of the only
The things we see as women start to have fewer eggs in the vault is a shortening of their Cycles. So you have a regular period and suddenly now you have less eggs in the vault. So lesser coming out each month and when the brain sends out that FSH signal now, there's fewer eggs. So it's not getting as dilute and you have one starting to respond sooner. So suddenly you're ovulating shorter faster in your cycle. You're ovulating on cycled 89 instead of 14 your
Your face is still set but the person who comes to see me and says my periods have always been 28 to 30 days. But now they're every 24. I just figure it's no big deal. I am have red flags going off everywhere because I'm now really concerned that potentially their ovarian reserve has dropped to a point where we are starting to see clinical changes. Now, of course things like thyroid and prolactin and other hormones can also cause such changes, but that's why you'll hear most
active endocrinologist say your periods of Vital sign and what we really mean is the regularity at which it comes and the predictability of it is telling us if your hormones are all communicating in a normal fashion or something could potentially be off
as we all know quality nutrition influences, of course our physical health, but also our mental health and our cognitive functioning our memory our ability to learn new things and to focus and we know that one of the most important features of high quality nutrition is making sure that we get enough
Demons and minerals from high-quality unprocessed or minimally processed sources as well as enough probiotics and prebiotics and fiber to support basically all the cellular functions in our body including the gut microbiome. Now, I like most everybody try to get optimal nutrition from Whole Foods. Ideally mostly from minimally processed or non-processed Foods. However, one of the challenges that I and so many other people face is getting enough servings of high quality fruits and vegetables per day as well as fiber and probiotics.
That often accompany those fruits and vegetables. That's why way back in 2012 long before I ever had a podcast. I started drinking a G1 and so I'm delighted that a G1 is sponsoring the huberman Lab podcast. The reason I started taking a G1 and the reason I still drink a G1 once or twice a day is that it provides all of my foundational nutritional needs that is it provides insurance that I get the proper amounts of those vitamins minerals probiotics and fiber to ensure optimal mental health physical health and performance.
If you'd like to try a G1 you can go to drink AG one.com huberman to claim a special offer. They're giving away 5 free travel packs plus a year supply of vitamin D3 K to again. That's drink AG one.com huberman to claim that special offer. Let me see if I have this correct. We've got this thing that we call the menstrual cycle or the ovulatory cycle the there's two phases follicular phase in the luteal phase flicker precedes the luteal phase the Lydia.
Fades tends to be if I heard correctly fairly fixed about 14 days the follicular phase can vary in duration, maybe 10 to 14 days, maybe even 10 to 18 days. Depending on the person is something about their brain to overeat communication for those that aren't familiar with this the I always learned that estrogen Prime's progesterone this kind of the really basic top Contour description of the ovulatory cycle that you know, estrogen is going to slowly climb.
I'm toward the point of ovulation and then there's a there's a peak and then a drop and then progesterone is going to dominate in the luteal phase the second half you said that estrogen is associated with with a psychological level and a physiological level more energy feelings of Vitality. And some of that estrogen increase is actually coming from the one egg that got stimulated the most the one that got selected right? So it picked for the team potentially for the team but got picked.
Potentially for fertilization and that egg sheds its corpus luteum, which is this piece of this of the egg that then triggers the progesterone that dominates the luteal phase. Do I have that right? Honestly most. Yeah, please correctly
World in which the egg grows right? When you ovulate it ruptures the cyst burst the follicles assist assist as a fluid-filled structure follicles of fluid-filled structure that holds an egg. So when you ovulate and you get that LH surge the cyst burst it opens up and the
Comes out of it and then it re heels and becomes the corpus luteum got it. So just a little bit different and timing and you're right with estrogen Prime's progesterone. But really we think about it the layer of the uterus because estrogen stimulates the growth of that lining and then progesterone stabilizes it and allows implantation to occur, but the sequence of events of when your estrogen dominant and progesterone deficient, which is the follicular phase and people will come in having lat
is drawn randomly and they're all concerned that they don't have progesterone and when you talk to them about where they are and their cycle you say you're not supposed to have progesterone. That's your follicular phase. This is perfectly normal.
Okay, great. Thanks for that clarification. I get a lot of questions about birth control, but on my social media handles,
we all got we are
to be clear.
It's a vast topic for exploration. But along the lines of what we're talking about. Now, I've heard and I suspect it may not be true. But tell me is there any evidence that taking birth control can disrupt the process that you just described and when we talk about birth control, we should probably Define what we're talking about. So there are hormone base birth controls aka the pill they're also hormone based birth controls that are not in pill form. There are iuds that
Copper IUD is there are other iuds. Let's just talk about hormone based contraception in females. Okay, if which many of them as I understand are estrogen mimics or estrogen themselves that suppress ovulation do they diminish or increase? The number of eggs that are taken from the
Vault fantastic question. Let's talk about what people say is the pill. So let's specifically talk about combined oral contraception the pill which has ethanol.
Estradiol and some type of progestin no contraception does not change the release of eggs out of the Vault. They are occurring at the same process and the same pathway. You're not ovulating because that estrogen does prevent FSH from coming from the brain. So you have the group of egg still come out of the Vault. There's no FSH. They just all die the next group comes out. So when you are saying are you going to run out of eggs faster? Is it going to harm your fertility does birth control a the
The answer is no but there's a couple important caveats one is that the birth control pills especially if you take them continuously or for a prolonged period of time the body smart and the ovaries start to say well, we're not really doing anything and one of those markers of ovarian reserve we have is a MH and that's anti-mullerian hormone. And amh is made from the granulosa cells or the cells that surround every follicle. So in the shortest way possible more eggs in the vault more come out.
Every month higher, amh fewer eggs in the vault fewer come out lower. Amh if your amh is being suppressed because of the birth control pill because it's decreasing the activity of those granulosa cells. You might get a low. Amh value when you've been on the birth control pill for a long time that is completely reversible, but it can be significant. So if somebody is wanting to get an AM each level, let's say somebody comes to my clinic they're not trying to get pregnant and they're on the pill.
They're considering freezing their eggs. So we're going to check their ovarian reserve if we draw it. I always say this. Amh, maybe up to 30 percent lower in somebody who is on the birth control pill so we can still draw it and if it comes back in the normal range, we feel good. But if it does come back low, we're going to have to make a decision. Are we going to stop the birth control pill for a period of some months use alternative contraception if you don't want to be pregnant and then repeat this test, too.
To see if this is a true low because we do see that young women. Do you have low ovarian reserve sometimes or was this just depressed because you are on the birth control pill. So we see it impact some of the hormone testing that we can do and I think that's an important distinction and we can see that the longer you take it that potentially it might actually improve your fertility if you had underlying endometriosis or some medical conditions that we see associated with infertility.
So prolonged pill users can potentially improve their fertility versus people who are trying to get pregnant that same age who were not on the pill those studies are complicated right? Because a selection bias because if you've been on the pill for 10 years, you're a little bit older. So is it that they were preventing pregnancy and the other group potentially had some exposures so they were inherently more infertile than the group that was on the pill but we do know that the pill doesn't cause infertility and I use it all.
All the time all the time in IVF Cycles. We put people on the birth control pill because we can actually synchronize that group of eggs that comes out of the Vault to grow together because your body doesn't want to have 20 babies at one time. Right and what we're trying to do with IVF get 20 eggs to grow if that's what's out of the Vault really goes against the check and balance of the human body to not have 20 babies at
once. Why is it that males who take testosterone synthetic testosterone?
It shuts down their own testosterone production and sperm production, but females who take estrogen in the form of birth control pills that doesn't shut down estrogen production by the ovaries.
So I love this question, you know the answer so I like it extra because I know you're asking spermatogenesis is a constant and ongoing process, right? So in women, you're born with all the eggs are ever going to have and what we're talking about is if we stop FSH at that moment, we're just impacting the ability to ovulate at that time, but we're not changing this.
Instant loss throughout the Vault spermatogenesis, right? The sperm is made every single day. You're making brand-new sperm. So 72 days for the sperm to be created in the testes and 18 days to find their way out the ejaculatory system and so exposures that you have that stop the production of FSH and LH inhibit the development the creation of new sperm. So somebody who's been on testosterone will tell the brain. The brain doesn't know is from you're taking it.
As hey we have plenty of sperm. We're good. We don't need any more. So the brain then gets suppressed and doesn't make that FSH and LH therefore not stimulating both further testosterone production because you don't need that but testosterone production and sperm production go hand in hand. So therefore you're no longer making new sperm and in fact the longer you're on testosterone the harder it may be to get sperm production to come back and in 25% of people they may not get it back if they've been on prolonged testosterone exposure.
Bossier so it's really because of what women will sometimes say is unfair which is the fact that you're born with all these eggs and you run out of them. They accumulate the wear and tear of your life. Right? We see egg quality being a huge issue and female reproduction yet men get to have new sperm every 90 days they get to wash away whatever bad Deeds they did and can change their lifestyle and their exposures and have very different sperm. But because of that same process things that shut off the production of FSH.
Age really impact sperm quite significantly,
you mentioned bad Deeds for sperm not by sperm. I said for sperm and you know, we know that heat is a pretty traumatic insult to the to the spermatogenesis cycle saunas and hot tubs and whatnot. I did receive the question as to whether or not heat exposure saunas hot tubs Etc. Are they detrimental to
ovulation or egg production in anyway, I mean obviously things are more internal in females the ovaries are internal but is there any evidence for that? I mean the body does heat up?
Yeah, there's no it doesn't harm the ovulatory period or the ovaries and just like we know the reason why the testes are so susceptible is because they're supposed to be at a cooler temperature. That's why they're in the scrotum outside the body. That's why the testes are so susceptible to heat changes, but the ovaries being inside the body. They're not in the same way. Now when somebody's pregnant important distinction, right?
We know that the development especially organ development of an embryo can be more sensitive to certain things and that heat exposure at that time, whether it's hot tub use or extreme fevers even can make a difference in development of a fetus. But what's coming to the ovulatory cycle or hormone production heat in the female doesn't make any
difference.
I want to be clear before I ask the next question that I don't want to be responsible for any unwanted pregnancies. But when I was in high school, they told us that women can get pregnant even while they have their period is that true seems like a lie based on everything you're saying but I don't want anyone to run out and test that hypothesis without having the facts
first. So in general if somebody has extremely regular Cycles, then that's a complete lie. You can't get pregnant on your period the
Then why they tell us this is one especially when you're younger your period Cycles tend to be irregular. They're not your body hasn't fully mature to have that regularity and that we know that sperm to live in the reproductive tract for much longer than the egg does so sperm can live there for up to five days. So if somebody did have a shorter period window, let's say they're normal periods are going to be 24 days. They're ovulating on cycle day 10 if they have
A a regular period that's five or six days. They could potentially have intercourse that end part of that period the sperm could live for five days and be right there when you have the egg in route. So it's not the most fertile time for sure. And in most people that is considered a time when you're not going to get pregnant, but especially when you're younger and you have more irregularity or in people who have a short cycle window that might not be the
case. So by extension can we conclude then that the most fertile?
Time is going to be when sperm meets egg. Let's save timing of intercourse for yep for the time being but because there's can be a delay there when sperm meets egg on obviously day of ovulation or day day after day of day of the
eggless for 24 hours. So the egg can only be fertilized for 24 hours while it's in the fallopian tube. Once the egg is entered the uterus. It can't be fertilized anymore. So it
has this very short window of time where it will allow sperm to enter it now sperm can live for five days. So we'll say the fertile window is this five day period ending on the day of ovulation. You will hear a lot of us a lot of doctors say the day after ovulation because you really know exactly what time you ovulate it on and if the egg has 24 hours then that extra day could potentially be helpful. But really it's five days ending on the day of ovulation and people with very regular.
Or who can track them and they know when that ovulation is happening the day before and the day of ovulation. Those are the two top heading day. So if you're kind of not in the mood to have lots of sex, those are going to be the days you target to have the highest chance of
conceiving and what is the relationship between estrogen libido and ovulation and
females the higher your estrogen is the increased libido that you're going to have and of course you see those Peak estrogen levels, which are going to trigger that LH surge. So the body is made.
To get pregnant you're going to have that Peak estrogen that Peak libido right before and right at that ovulatory time period so that hopefully you also want to have intercourse and get
pregnant. I've heard before let's just say that some people be careful here can sense the literally the deployment of the of the egg the ovulation they report that they can feel that this let's just say that the departure of the of the
Egg is that an imaginary thing. I mean, I always liked I always liked that image that people can know when that happens. It's so real it's not real men generally know when they're when they're sperm are leaving their body. Let's hope they do but why wouldn't there be an internal sense for women also of what's going on? I mean we have interoception. There's a ton of nerve innervation of that area
does not communicate to the brain excellent as far as tracking to wear that
Station is but you're right. I already said ovulation is the rupture of a cyst, right? It is rupturing and the egg is being released. And those follicular fluid is also exiting and going into the peritoneal cavity. And so there is a group of women who can feel that especially people who are very in tune with their body and it has a name. It's called middle smarts, the pain almost feels like a crampy pain that happens in the middle of the cycle and that is your ovulatory pain.
Jane
how interesting what is it called middle smarts? Okay. We'll put that in the show notes captions. And whoever does is going to have to get the spelling right amazing amazing amazing and foreign to me but for obvious reasons, but amazing. I'm always astonished in the how incredibly well orchestrated. This whole process is it's just such an incredible feat of biology this I mean the number of things that have to be timed correctly and the you
Sin, and once they reused but the the repurposing of tissues for different things and like it's what an incredible dance that's just amazing
fall. I mean, I'm so nerdy because I just love how everything has to communicate just perfectly it makes you an all of all the pregnancies that just happened just all the time because really things have to synchronize really at the wonderful time period And even though this isn't what we're talking about, I've heard you say that so I want to say this people always ask every single day. Well, how much sex did you have?
When should you have sex is there too much sex and what we know is that you definitely should not decrease your sexual intercourse interval. So if you are in a relationship and you are sex every day people have sex every day, you will 100% hit intercourse throughout your entire fertile window on the day that you ovulate you're depositing the same sperm there because you're not generating new sperm. It's whether the load went half and half and half and half or if it went in, you know one big.
Group, but if you're constantly putting more sperm out there you have a higher chance and so studies go back on always say daily intercourse associate with the highest chance of accountability, especially during the fertile window. However, for couples who are not sex every day people that idea can cause a lot of stress stress of course impacts the system in a lot of different ways it can also cause sexual burnout where they no longer feel like being intimate.
Or having sex on the day. They're actually ovulating because they've been doing it this whole time leading up and that's where the time period of saying have sex every other day throughout the fertile window. So starting five or six days before you think you're going to ovulate and then try to Target having intercourse on the day before and the day of ovulation and the reason why people said every other day or a few days prior to kind of get some sperm exposure there in case you ovulated early, but really to try to prevent some of that increase
Trust that can happen when you're trying to conceive especially if you have programmed or timed intercourse that needs to happen on an everyday interval but the odds of getting pregnant by saving up sperm for two or three days. That's not hire
curious. Then why if let's just say hypothetically someone is donating or freezing sperm or doing IVF why they instruct the mail to not ejaculate for 48 to 72 hours prior to
Let's just say depositing sperm is such a funny word, but it works. So
two points one if we're doing a semen analysis now, we're trying to evaluate this sperm and any test has certain normal parameters, and these are all based on a 48 to 72-hour abstinence period so yes, if you ejaculate more frequently you're going to have less sperm and that can be very normal. But if we're looking at a test was set normal parameters that are based on
Two to three days of not having intercourse. That's why we want you to do it for that. If we're doing let's say IUI or intrauterine insemination also known as artificial insemination or where we take the sperm and put it in a catheter and put it in the uterus. We're trying to get more players further down the field and in that case. I know when you ovulate because I'm timing it perfectly and I am trying to get as many possible in this process because we're not just having them deposited in the vagina. We're trying to get them further.
So we want more because that's part of that treatment process and similarly with IVF. I want to have as many sperm as possible to sort through and pick out the best looking the most modal the most normally shaped ones. So we're trying to get just a better sample and by having these normal guidelines were able to judge. This is low for what it should be which can also be a clue to other problems
don't want to talk about chemistry both interpersonal chemistry and literally ejaculate and vaginal chemistry, but
before we do that, I'm curious whether or not we can just touch on a few of the things that a lot of people wonder about in terms of egg quality and if they touch on sperm quality, maybe we can also just mention that but for instance does cannabis either by edible or by smoking cannabis impact at quality in either direction alcohol would be the next and then I'm going to assume
And I have to do this strictly because of what I understand about, you know drugs of abuse like cocaine and amphetamine methamphetamine that none of those can be good for systems of the body because they provide the create so much stress for the body, but let's just say alcohol and cannabis. I read a statistic when researching episode on cannabis that shocked me which is that 15 percent 15 percent not 1.5 fifteen percent of American women at least in this one study.
You survey reported having consumed or smoked cannabis during known pregnancy, which is wild wild unless of course I'm just naive and THC is not harmful to the fetus. But I have a hard time believing that so what gives I mean we're we're and and there I actually just threw in fetal development. So is cannabis is alcohol bad for egg quality.
So they're different things into the same thing.
And one so let's answer them each individually. So we'll go with the one that everybody knows and has accepted now that they wouldn't have accepted 40 years ago right smoking cigarettes. So that's obviously bad decreases. The number of eggs you have in the vault smoking cigarettes actually gets into your Vault decreases. The number that you have you have a higher chance of going into menopause earlier and it increases the risk of having abnormal chromosomes, which is what we really think about. We think about egg quality right impacting those mitotic spindles inside the eggs, which hold the chromosomes and they're perfect.
Sean they are associated they get wear and tear from things that cause inflammation or are toxic so cigarette smoke we know decreases at quality a good quantity increases miscarriage and then of course has fetal
impacts. Could I just ask you because when we talk about there's nicotine which itself is not carcinogenic and then there's the smoking process which brings in a bunch of other things. The question I know is burning in everybody's mind is vaping. Yeah, right because vaping is
I'm very bullish on this. I mean, it's very clear that the chemicals associated with vaping or just oh so bad for Everybody's Health, but it's distinctly different from saying that nicotine is bad for one's health and it can be but without doing too much of a deep dive is are there any data that show that vaping is bad for a
quality? Of course, there's not as much data because it just hasn't been around as long but yes vaping definitely has chemicals that looks like it's associated with poor success rates and I
Up cycles, and that's really kind of one of the most finite measures of equality we can see because we're really testing the egg add a level in a lab versus just are you getting pregnant
naturally, sorry to interject again, but any time a conversation like this comes up, especially between two people in the health science space there. Are these shout because I hear them it literally where people say. Well listen I Vaped every day and I've had three healthy babies and I think that my response is always okay, there's going to be a distribution of responses.
Has and then of course how much healthier could your babies have been had you not Vape during pregnancy or Vaped prior to pregnancy or I mean, I think these are the key issues that like you can't you can't rewind the clock as far as I know right in the absence of a time machine. You can't rewind the clock. So I mean basically everything you're saying is that smoking cigarettes or vaping nicotine just can't be good for egg
quality. You know that it's not good for getting pregnant. We know that it's not good for sperm and therefore
We also know is going to impact pregnancy rates, you know, things like cannabis right decreases from production decreases sperm motility changes for morphology the shape of it changes the DNA increases the fragmentation of the DNA if your partner uses cannabis and you get pregnant, you have a higher chance of miscarriage because of these sperm association with the Cannabis now edible cannabis as well as smoking because you can't study something that's illegal. So a lot of this data is just more
You and a lot of it's going to be observational and in
States like Colorado and California where you know canvas is essentially legal. Yeah, I'm assuming they're more data. But okay so smoking and or vaping nicotine cannabis either edible or smoked very likely detrimental to egg quality and sperm quality, which is not to say that one can't conceive. It just means that the quality of your
Maybe your child will not be as high as the quality of that baby if you didn't do that. And is that right? Yeah, some not enter my trying to demonize anyone that did did do this during pregnancy. A lot of people didn't know but at this is this is really about people trying to make choices in anticipation of future
pregnancy. Yeah, and when you're trying to set yourself up for Success because we know infertility is becoming more common. We don't always know who is going to have it and when you find yourself in that position specifically, you know want to
Demise everything you can so if there's something that is going to make these sperm quality worse and the Egg quality worse and your success with treatment lower and your miscarriage rate higher. We're going to recommend that you not do it. If you're trying to get pregnant naturally all these things correlate over but of course, there's always going to be outliers and exceptions. I'm going to sit here and tell you that the odds of getting pregnant at age 43 are less than three percent per month and every single person is going to be like, but my Aunt Barbara or I know this person who
Did because three persons na
0 and you're trying about natural disaster there by
having intercourse fashion way. Yes. Okay, right. But yes, so people will get pregnant people will have healthy children who do have exposures to nicotine to cannabis even to alcohol, even though we know that alcohol can cause fetal alcohol syndrome zero percent of alcohol should be the acceptable level in pregnancy and then does alcohol impact fertility such a complicated question, and this is probably due to
The amount you consume in the frequency of what you consume it alcohol is a toxin that your liver must filter out and We Know It causes inflammation anybody who's had a fun night with alcohol knows they can wake up the next day and they feel different their body is processing that alcohol and that inflammation, especially if it's chronic chronic exposure. We know chronic inflammation is one of the things that we see impacting egg quality and sperm quality. So certainly if you
Choya, alcohol, it should be something that is done in moderation one or two drinks a week at the most and you should not do it at all. Once you find out you're pregnant.
I'd like to take a quick break and thank our sponsor inside tracker inside tracker is a personalized nutrition platform that analyzes data from your blood and DNA to help. You better understand your body and help you reach your health goals. I've long been a believer in getting regular blood work done for the simple reason that many of the factors that impact your immediate and long-term Health can only be assessed.
The quality blood test the problem with a lot of blood and DNA tests out there. However, is that they'll give you information about certain lipid markers or hormone markers but no information about what to do with all of that data inside tracker makes it very easy to look at your levels of hormones metabolic factors lipids Etc. And then to assess what sorts of Behavioral nutritional supplementation or perhaps other interventions, you might want to use in order to bring those numbers into the ranges that are optimal for your health inside trackers ultimate plan now includes three new hormone markers that are
critical to measure during a woman's reproductive and menopausal years. These are estradiol progesterone and thyroid stimulating hormone. If you'd like to try inside tracker, you can go to inside tracker dot coms huberman to get 20% off any of inside trackers plans. Again, that's inside tracker.com huberman to get 20% off when we were talking about birth control. I unfortunately moved us forward and forgot to ask about iuds. Oh, yeah, so my understanding is that the copper IUD works by creating a sort of
Um, not actually electric but a kind of a electric fence that kills sperm sperm don't like copper. Yeah from that one copper copper likes to kill sperm. There's some interesting history. I've been reading up on the history of Medicine of people who you know for whatever reason were forced into or chose to be in the sex trade prostitutes using inserting copper coins into their vaginal tract to try and kill sperm but to varying degrees
He's of success. Obviously. There's a whole socio economic landscape around that so I think it's obvious what I'm referring to but very interesting but that's just one form of IUD right there. There are some other there iuds, and then there's of course the ring we didn't talk about that. So maybe just touch on a few of those within the context of whether or not it Alters egg quality and/or future fertility. When one takes the ring out takes the IUD
out. This is a great question because a lot of people don't know this and I'll roll through a few of
Top birth control methods and just thinking through copper IUD has already said no hormonal involvement is causes inflammation and a toxic environment inside. The uterus isolated does cause sometimes heavier periods, but they should still be regular if they re regular that's a sign of a hormonal issue because you still ovulate with the copper
IUD. Is it literally a copper wire woven in
yeah, what is a little T. And the arms are have copper wires
wrapped around them. And they and those are they grow into
To the uterine lining they don't
grow into the uterine lining IUD just sits in there and just the presence of that copper causes that inflammatory reaction in that toxic
environment. And is it toxic to the environment in ways that are detrimental to the woman or just a
sperm both? I mean implantation is not going to occur likely right? I mean no nothing is 100% successful, but it's much harder for an embryo to implant within that highly inflammatory environment
to me amazing that people figure this out before the ass enabling
Laboratories,
right. Let's just put some copper in some uteruses and see what
happens. You know, it really speaks to the the urgency that must have existed to preventing pregnancy and that just how costly biologically and
pregnancy is financially pregnancy is pregnancy is not Health neutral. So it is something that somebody needs to be in of right health or it can be a deadly circumstance when we get back to other iuds. So I use that more people are more familiar with are the progesterone based. Iuds. This is going to be
Your Mirena kaileena Lara. They have a bunch of different names based on the amount of progesterone and how long they last for these work mostly by thinning out the uterine lining as we already said progesterone compacts the uterine lining to prepare it for implantation and a normal cycle. But if you have constant exposure to Progesterone, what is going to happen is it's going to prevent the uterine lining from growing and it gets it very very thin. Not all I
Ud's and fact, most of them don't prevent ovulation only in about 50% of people do they actually prevent ovulation. So their main mechanism of action, is this endometrial effect when you remove the IUD, especially if you already ovulating no problem the problem we do see in some people with progesterone. Iuds, that maybe isn't talked about as much is that this prolonged progesterone exposure because people are putting iuds in for five to seven years and not having a
period for that length of time because the endometrium has become so atrophic or non-existent that you're no longer bleeding despite the fact that you may be ovulating it can take a while for that lining to grow back. And so it's not uncommon to have an IUD in place and if you have no period you're going to say this is great. I don't have a period wonderful you get it removed. And now your period hasn't come back and that leads people to sometimes be concerned that the iuds cause
Them not to ovulate or they have this infertility caused by the IUD, but really what it is. Is that the Linings become so so fun that it can take many months of that unopposed estrogen exposure on the follicular phase to get it thick enough to finally bleed when you're ovulating. So I do tell people if they have a progesterone IUD to get it removed three to six months before they want to get pregnant you some other form of contraception, but give their body time to make sure they have that
Allure period pattern back important distinction if you're still ovulating and having a period on an IUD, then this is going to be less of a concern because if you're growing them enough of a lining to then shut it we're less worried about it. But if you are aiming a react or have absence of your periods with an IUD, we need to think about removing it for a period of time before you get pregnant so that your body can grow that lining again when it comes to some of the other things that you mentioned one are you didn't
That I want to mention is the depo-provera shot. The double prepare shot is a high dose of progesterone high enough to actually prevent ovulation. So in that circumstance, you are not ovulating and therefore if you don't ovulate you're not going to get pregnant W prepare has proven to prevent ovulation for three months. So when you take it you need to get it every three months to have a proven contraceptive benefit. However, it can last in your system for 18 months and prevent ovulation.
Elation for up to 18 months. So I will see people who liked that option for contraception and now they haven't had a period in a long time. But their last Depo shot was 6 months ago and they're all frustrated by the fact when I tell them well, you still may not have another period for a year plus because this high level of progesterone that you've already injected into your system can last a substantial amount of time. So that is a contraceptive option that I tell people to discontinue a
Year and a half to two years before they want to get pregnant which sometimes people don't know that yet. And so that's something that can be a contraceptive option for if you're very remote from wanting to have a child but in people who are in their childbearing years contemplating family building soon, that is not my favorite option. So you
haven't mentioned because I haven't asked any negative consequences of birth control of any kind and I'm not encouraging you to if you don't believe in
Them. I know they're this is a very controversial topic. But you know, one of the more popular studies discussed on social media as one that I've spent some time with the paper and a few of the papers that stemmed from it not a huge study, but describing that how women rate the faces of men as either more essentially what happens is there seems to be at least in this study a there was a statistically significant bias.
For women to select particular male faces as attractive and those male faces tended to be of the more, you know Square ja-a-ke masculine features right here in air quotes, right? This is what the study found but that when women were on oral contraception presumably estrogen progestin type oral contraception that that effect was smeared. They had a not a statistically significant tendency.
E to choose the quote unquote more masculine face that have to be very careful of my language here because you know, it's easy to get description of a study like this wrong and that has led a lot of people to think that birth control is going to throw off their partner choice. Now, of course, it is a small study studies like it are not always so well controlled but is there any evidence that birth control or oral estrogen progestin based birth control just to keep it specific can
Rates of cancers can decrease rates of cancers can lead to any sorts of disruptions in bodily function or health? That's really like a rock solid result. That's been seen by multiple studies clinical trials or are we still just in the dark about a lot of this stuff?
Okay. So nothing is without risk getting pregnant is not without risk taking the birth control pill is not without risk. We do see that there's been a lot of not it.
Informed consent and people who are taking the birth control pill meaning maybe they weren't educated about what all of their options were the positives and the negatives about each one of them if we're going to reference the combo to the pill estrogen progesterone pail important understand that neither the estrogen or the progesterone are the same estrogen progesterone that your ovaries make right. It's ethanol estradiol which your brain interprets as an estrogen, but other parts of your body may not and then it's various types of progestin.
some of which have even androgenic or male hormone like properties and some of which do not so there's a ton of variation even the amount of ethanol oestradiol that each pail has with your low low in your low pills having less and even with the modern-day average pillow having a lot less estrogen than it used to when you're on the birth control pill your ovaries aren't making estradiol and that estradiol is important in growing the you
Turan lining but also for the general structures and so we think about vaginal health and both our health. We certainly see that especially with continuous use so if we distinguish you take the pill for 21 days and you have a seven day break where you might bleed or you take sugar pills and then you take them again. A lot of people now are taking continuously where you have exposure to these compounds every single
day. So in like the the wheel the little low
Pouch with a wheel of different colored pills may have seen these on the countertop in previous relationships. So they and then there's the ones that sometimes people just opted not to take because those are the placebo that Sugar pills are like there's no need to take estrogen during that phase and then and then they repeat is that okay, but some people are taking estrogen
continuously very common right now so people and they're not wrong they say, oh well why have a period in these little breaks? It's not really a reflection of my hormone status, which
Is accurate and so they're taking them continuously you also have less pill failure pregnancy. So if you're using the pill for contraception, but I can be a great strategy but the longer you take them we do see some vaginal bar changes, right and so atrophic vaginitis people who notice increased sensitivity decrease elasticity increase discomfort with intercourse increase in yeast infections that can sometimes be see because that environment is different now, that's just one.
Thing that can come from the pill. We also see the pill be life-saving for other people. They have terrible, you know PMS or premenstrual dysphoric syndrome where their mental health when they change from high to low estrogen. It's always the change in estrogen that interferes can cause some people to really have mental health issues that are so severe that having that stable hormone level is helpful. And so the pill can be extremely beneficial for some people when it comes to mental health it can
Be beneficial for people who have issues with very heavy periods. And anemia instead of getting blood transfusions, you know taking the birth control pill might prevent the lining of the uterus from growing so much that they bleed so much same thing with fibroids people with PCOS. PCOS is polycystic ovarian syndrome. If we want to put it very simply you have a lot of eggs in your fault. So you release a lot of eggs every month and what this does is the FSH signal gets diluted and so you're not responding to the
Signal and you don't ovulate and because the ovary is a hormone making factory. It gets really bored when it can't make estrogen because that eggs not growing so it starts to make testosterone. So you start to see this antigen dominant environment associated with lack of ovulation and having a lot of follicles inside the ovary that are not really
responding androgens that excuse me intragenic ization of other tissues, like like body hair deepening
of the voice typically the level of
Testosterone made in PCOS isn't truly deepening voice it can if there is an ovarian tumor making testosterone or certain other conditions, but typically with PCOS you see an increase in body hair increase in acne and you can see some even like male pattern balding some temporal balding of women. So some hair loss A was
like the widow's peak in. Yeah
the Widow P clean and then finding out and these two areas and then we see an increase in body composition towards a male level. So if we think about
Male body holding your fat in your abdominal region and if we think about the traditional female body holding more fat in the hips and thighs area. We see that when this hormone shifts and PCOS you tend to get more abdominal fat distribution, which then leads to further insulin resistance and metabolic syndrome, but in PCOS, because you're not ovulating and those ovaries each little follicle makes a tiny amount of estrogen will say each little follicles.
So when it's not responding will make you know, 122 picograms of estrogen, but if you have 50 of them each month, you're having some constant estrogen exposure. So that lining of the uterus is being constantly stimulated to grow and you're never getting the progesterone to stabilize or the progesterone withdrawal to bleed. So endometrial cancer is much higher in people with PCOS who don't ovulate and the birth control pill can prevent that any unopposed estrogen situation because the body is made to have both estrogen and
Progesterone. So we see an immense decrease in endometrial cancer an immense drop in ovarian cancer ovarian cancer comes from the remodeling of the ovary. So every time you have a follicle grow and it ruptures and it makes the corpus luteum and then it heals up. Those are opportunities for those cancer cells to go away in that remodeling process and lead to ovarian cancer. And because you're not ovulating on the pill your incidence of ovarian cancer drops.
matically 10 years of Pell use has dropped the chance you could ovarian cancer by more than 90% And of course ovarian cancer is super hard to diagnose because the innervation to the peritoneal system is poor and you don't have any outward signs often till late stage disease that being said,
Could you potentially have an increase in breast cancer in some people by taking the Pill by taking the pail that that's a concern especially in people who might be predisposed to this for some other reason
might have braca mutations or something like that.
And then is there a situation where the pill certainly masks what's going on with your menstrual cycle? And I really think this is where Women's Health has a huge history and paternalism meaning doctors would just tell people this is
You're going to do so, your periods are irregular here is the birth control pill and they're not explaining why or the pros and cons to it. And what happens is people are not being taught how their bodies work and now they are because of your podcast amongst others and now they're able to know that my periods of Vital sign and I don't know what it is because the pill is producing a different environment the pills also been associated with potentially development of things like leaky gut or IBS, and so
There is a definite change in your environment when you're on the birth control pill increase risk of blood clots because of how its processed in the liver increasing your clotting
factors. Can I just threw up there? You know, I'm aware that a fair Fairly high percentage of people have mutations in Factor 5 Leiden a clotting Factor fewer people are as we say homozygous have to deficient copies mutant copies, I should say but there many
Go out there that have one mutant copy of factor 5 Leiden in my understanding is that oral contraception and females can really exacerbate the factor 5 Leiden mutation. Do you suggest that people get get their Factor 5 Leiden genetics analyzed and it's pretty inexpensive to do right? I think on a standard blood tests, you can just ask for the factor 5 analysis and it's not like a really in-depth thing. You don't have to fly to something like that. Yeah, you don't suppliers. You don't have to fly to another country, you know like you do for many things.
It's important that that's not the norm right? Like that's not the recommendation when you're talking about putting somebody on the birth control pill you want to make sure they don't have high blood pressure because it can increase their blood pressure. You want to make sure they don't smoke cigarettes because the combination of the pill and cigarette smoking can increase the risk of a stroke but the recommendation is not to screen them to see if they have any inherited clotting disorders that said if you ever have a blood clot on the birth control pill because you're traveling on a plane or you're just on the pillow you're living your life you're now going to get this.
Work up to find out if you do have that is by no means wrong and specifically you should if anybody in your family has ever had a DVT. So a deep vein thrombosis or blood clot in your leg or a pulmonary embolism or PE. So anybody in your family has had one of those you should 100% get worked up for clotting disorders. And if you have something like it you carry Factor 5, you should no longer take the birth control pill and specifically the pill because it's an oral pill and how it's metabolized.
In the liver is actually what is causing the change in those clotting factors because that's where there are made as well. So it doesn't mean you can't take any form of contraception but we do want to make sure that we counsel you appropriately. I never think it's wrong to be an advocate for your own health or to ask questions. It's important to know that screening. I mean, I'll get on my soapbox because we'll talk about screening for ovarian reserve and it is 100% not recommended even though I think it should
be
The my next question was going to be about testing amh levels and we'll return to that for those that hear that and it sounds cryptic as well as getting an ultrasound. Just seeing basically how many many eggs are unlikely to be in the Vault on both
sides. Okay. So we have to remember that screening recommendations come from at what point in the population. Does it make sense to spend the money to test for a disease based on the likelihood of finding it? So if we think about right that's
What your pap smear guidelines and your colonoscopy and your mammograms? Everything is all based on. When are you going to find enough cases at some age to make it worthwhile testing which is a crazy principle, especially in the u.s. Because the government is not paying for our Healthcare. So why should these guidelines be based on when is it cost effective to do
testing? Well, I'll put in a this is going to sound a little bit conspiratorial but it's not I mean, I think that given that for people who have insurance private paid insurance or through their work.
That there's a cost to doing these tests of any kind colonoscopy a maid should cetera and they must have figured out the you know, optimal point on the graph with which they can reduce their pay out to people who for instance get colon cancer. If they didn't get the colonoscopy at 45 as opposed to 50 as opposed to 60 as opposed to 25. I mean, this is I mean the reality we know is that the more information you have the better choices you can make I mean the only caveat to that would be that for some
Um, not all but for some people sort of the hypochondria attic type sometimes more information leads to more anxiety which leads to more problems, but that's a rare
instances. I always think that in general data is always good. I agree having the information at hand about your body and being able to make educated choices versus being in a position where you say I had no idea that I had Factor 5 Leiden and I had this terrible blood clot because pulmonary embolisms can kill people we all know that right.
We talked about this rare thing, but it can happen. But this is really where it can be tough. It can be tough to find even a doctor who made like we said Factor 5 is a blood test and relatively inexpensive. So that one is not hard but Physicians live in a weird world where you know, they have recommendations based on screening based on the likelihood of finding disease that they follow and when they go off of those they start introducing themselves to why are you not following medical guidelines?
Lines, but for an individual this is really tough to advocate for yourself. And the one thing that I'll say to this is why paying attention to your body is so important right understanding your stool habits and what's normal and what's not so that you can catch early signs of things and present for that colonoscopy earlier the current screening guideline for should you get your ovarian reserve checked is that you should not a cog the American College of Ob-Gyn has an entire
Practice bulletin situation saying there's no utility and screen for a mage. Okay. I mean I totally disagree but
I'm glad you just dreaming to me. It just seems nuts or ovaries. Rather. I mean the the am H is a blood draw Amy. Just a blood test a blood draw it one could opt to do the ultrasound as well which is of course more invasive, but but women who are seeing their OBGYN are probably familiar with
With pelvic exams.
Yeah, I mean that's not ultrasound but it's not painful
painful but different than a blood draw just to just for in full disclosure. So and you know, I've heard of women in their early 30s going in getting their amh levels checked getting their ultrasound and then going oh my goodness, they're down to like, you know, I don't want to throw out numbers because this actually can get tricky, you know, they'll say oh you have whatever, you know for follicles and then someone in the
their early 40s will have 20 follicles and then people started using sort of becomes a scorekeeping thing and and of course follicle quality, they're a bunch of other things and you can tell us more about those but let's say someone did not have insurance or or Insurance permission to get this pay for what is the approximate cost of getting ones? Amh levels
analyzed $79
$79 to find out essentially where your ovarian reserve is
that so let's talk
About this artist has my soapbox. So ACOG says you shouldn't screen it because amh does not predict your fecund ability, right your body's ability to get pregnant in that month is independent of your amh. And for the most part that's true, right because let's say you have a person and they're both 30 of two people one has low ovarian reserves. They have five eggs coming out of the Vault and this one has normal ovarian reserve and they've 20 eggs coming out of the ball. We
should probably clarify that the number of because you
Said this earlier but the number of eggs coming out of the vault is an indirect measure of how many eggs is in the vault when that number is going down. It means the number of eggs in the vault is likely going down this way down kind of like your body starts to take a smaller withdrawals as you start to run out
of the Vault wants to be a like equilibrium, right? It really wants to be in this Middle Ground. So when you have too many it shoots out more every month. It's too crowded. It doesn't want that and then when it starts to get low, it gets scared about being empty and sends out fewer per month. So what you see outside the vault
That is called an antral follicle count or an AFC. It's an ultrasound based measurement of how many eggs you have outside the vault at one point in
time it on the ultrasound if one looks this is going to show up as what look like little Hollow spaces like so not gray stuff.
But yeah the bodies I think chocolate chips and the chocolate chip cookie if we can imagine that overeat. Yeah, like looks like a chocolate chip cookie the chocolate chips small little dark fluid-filled follicles each one of those houses an egg
some bigger than others because they're more mature than
others based on when you check
in the cycle. So if you're looking in that early follicular phase when somebody's on their period through they all should be small because nothing's been stimulated. If I'm looking Perry ovulatory. I'll see that dominant follicle that's about to ovulate and then everything else will be
small. And is there a graph that people can look at or that we could link to that says okay the average with a distribution of you know standard error on either side for let's say a 28 year old woman or a 37 year old woman or a 45 year old woman of the number.
Follicles on the right and left side and as I understand asymmetries or common tends to be you know, like if someone goes in and they you got six follicles on the left side and 12 on the other side. Are they how do people gauge what
what fans are points one because their doctor should tell them but that doesn't always happen. But yes, we add these counts together to get your antral follicle count because there is often a symmetry but what we should expect let's say in somebody who's 30 years you should have in the 16 to
Auntie range of total
follicles per month right and left side combine.
Okay when you're 35, that number is closer to like 14 to 16. So starting to drop it still pretty good when you're forty eight to ten when you're 40 42 24, right? So you start to have this immense drop that exponentially starts to increase really around age 37. So things start to kind of get into this severe Zone really after age
37 we do.
We talked about ages 18 to 25, but there are people who get pregnant in that age bracket R is the follicle count very very high as their serve an ace is a nonlinear drop off or
the other follicle count will be higher and I mean, I occasionally have patients who are very young but have infertility or want to freeze their eggs. I also had patients and that age range who are in premature ovarian failure, right? Because there can be things that go wrong even early,
but we should probably highlight again something that you said earlier, but gosh, I you know this
What contradicts so much of what's out there which is that even if you have low follicle count if you collect eggs, you're not changing what's in the vault you're not pulling from the ball. You can't write that those eggs are spent you you now have the opportunity to turn them into potential pregnant,
correct? I mean side note, right. We haven't even drove into IVF, but that's the next wave of technology is what we call IVM and vitro maturation people are trying to figure out how can you get eggs from the Vault and get them to grow in the lab because that would open up possibilities for people
Who have fewer eggs to have our higher efficiency of this process? Because one of the limiting factors when you're doing fertility, you're doing egg freezing or IVF is how many eggs can you get per month? And that's why some people have to do cycle after cycle because they can only get five eggs or five eggs. But if we Circle back to what we were saying when we got off on this beautiful tangent, is that no matter if you have five or you have 20 eggs outside the Vault you're ovulating one. So you're trying to get pregnant. Naturally. That's what fecund ability is.
Is probability of getting pregnant per month? Naturally, you have the same chance. If you're the same age regardless of if you have five eggs, or you have 20 eggs, and that's why A call came in and said well, amh doesn't impact for accountability. It doesn't predict your ability to get pregnant or who's going to have infertility and who's not going to have infertility. So there's no utility and screening for it in people now
for once I'm speechless. I mean that that argument makes sense through the lens
Just probabilities of pregnancy through natural conception, but it completely erases the very very very real situation where people are making choices about for instance whether or not to stay with a given partner, whether not to leave a given partner whether or not to accelerate the process of building a family
should have a baby now,
there's so many factors that this American College of whoever whoever is like completely
OBGYN, but they're crazy.
And that's what I say, they argue and their statement that finding that you have like, you know, it's like reeling it in. I mean, I think it's I think
of an analogy that doesn't fail but it's like if you can it's like saying okay, if you can walk now great. There's no reason to test for this inevitable paralysis that's going to happen at different rates in different people and they're things that you can do to offset. In other words. You could like take a little bit of some tissue that will allow you to walk right in the future, but we're not going to do that because if you can walk now you can
walk good.
Now that's absurd and that's really what it is. And they say well finding out that you have low ovarian reserve at a young age is going to cause undue stress that is unwarranted because most people don't have infertility. And so they're purely putting it through the lens of your likelihood to get pregnant, but it's actionable stress exactly.
Right if it was just dressed like hey, guess what and you know, I know people who have family members with Huntington's mutations and some opted to not know whether or not they themselves have have the Huntington's mutation and it's a very personal choice.
Choice, right but here that whereas unfortunately there still isn't a cure for Huntington's hopefully someday there will be knock on wood. But in the meantime, there is essentially a cure for this situation, which is the Harvest and potential
fertilization at least an opportunity. And this is what I say, and of course you and I feel some Early Education and data like being the one to make the choice is an extremely important distinction versus having it happened to you. So if you are young and you find out you have low
Very reserved. Is that going to make a difference and it very well might you might now freeze your eggs when you wouldn't have otherwise you might now start to try to get pregnant if you're partnered when you otherwise we're just waiting but now he's a
conversation with your partner to write because a lot of people think they can just wait because of
age right? We're in our 30s when or 33 wait, but if you have a low ovarian reserve then that you may lose the opportunity for Parenthood. And for a lot of people this is a life goal and this is what's Wild to me.
When on earth besides reproduction do we have life goals that we take the approach? I'll just wait and see if it's a problem later never right? If you want to become a doctor you want to become an athlete you are constantly working towards that goal or understanding what it's going to take to get there. But why does the goal of Parenthood the attitude is completely I'm not going to think about it until later and then I'll deal with it if it becomes a problem because
You can make change choices. You could freeze your eggs. You could try to get pregnant sooner. You could evaluate for reasons of low ovarian reserve give a genetic mutation or an autoimmune disease. Why is it low? It's not just always a big unknown there can be some actual things that potentially might be impactful for your health long term. So I think it's wild that this is the current conversation and I will say I know personally a lot of OBGYNs who won
100% will draw on. Amh blood task if you're at your annual and you asked and I recommend all of my OB friends because I see people at a different stage right when they see me they're struggling to get pregnant or they want to freeze their eggs when we talk about this I say, hey just like you say are you trying to get pregnant now? And if somebody says no and your follow-up question is will do you want to be on birth control the same question should be will do you want to be pregnant at some point?
And if so, should you consider freezing your eggs or getting this blood test checked and very often people will make a different decision with that
information. So glad that you're highlighting this because my understanding is at least in the state of California. I don't know about other states or if it even varies by state that the opportunity to harvest eggs and freeze them.
There's a hard cutoff at age. I think it is 42 prior to age 42. They'll do it after 42, they'll do it. If and only if you're willing to do in vitro fertilization to actually fertilize and then they'll freeze embryos, but they're far more reluctant to collect eggs after age
42. Yes or no. So when you think about egg for use in an IVF are really the same process right when you're going through the exact same thing you're taking the eggs out of the body and then you're either just freezing them as an egg.
Or you're fertilizing them in the lab and that's IVF and making an embryo right away egg freezing has changed dynamically over the past 10 years, whereas ten years ago survival rate of eggs, and the lab was 40% really terrible. And so we really didn't offer it to many people. It wasn't something that was talked about and now it feels trendy almost but it's really just the tech has gotten so much better and cheaper. Yeah a 90% of eggs now survive the freeze-thaw. So 90% is not
Not a low number by any means embryos are much stronger. Right an egg is a single cell. It's a single cell an embryo when we freeze an embryo that stay five or six is three hundred plus cells. So it's so much stronger and those embryos survived the freeze thought 99% of the time. So, yes, there's a nine percent difference that being said making a uses a lot more expensive exist cheaper. You could do two rounds of eggs and have just as many eggs or have more eggs.
then if you'd made them into embryos right away, so I never recommend that somebody commits to a sperm source that they don't want to have a child with unless that's the sperm Source they want to have a child and this has changed because when embryo survival was so much greater than egg survival, especially if you had few eggs or you are older making embryos was the only option what we do know is that egg quality decreases immensely as we get older and we've touched on this but we haven't really
We mentioned it. So not only do you have fewer eggs, as you get older the chromosomes inside start to lose their positioning. And so we think about equality we think about genetic normalcy and we know that the rates of aneuploidy or abnormal chromosomes increases proportionally to your
age which for people that aren't aware are going to predispose not always two miscarriages if they're implanted or potentially even the formation of it of a fetus.
That carries for instance trisomies. So chromosomal repeats or lack of lack of certain chromosomes. These could be deadly or they could be capable of carrying to term and then but have undetectable to mild to severe developmental abnormalities.
Correct, correct? And this is this is why it you have a lower probability of pregnancy per month as you get older. So if we look at your natural fecund ability, it's not because you have fewer eggs because we already said your egg count per month. It doesn't impact your probability of getting
Pregnant it's because the normalcy of those chromosomes has changed so dramatically that the odds that your body's randomly choosing the good one to ovulate become so low and that's why those natural fertility rates are so low because most genetically abnormal eggs. Do not fertilize or implant. But if they do they have a significantly higher chance of miscarriage, it's 40% at age 40, right? So you have a much lower chance of seeing the positive pregnancy test, but then your chance of losing that
See a significantly higher as well. So when we are counseling somebody about egg phrasing what we know is that not every egg is going to fertilize with sperm going to make an embryo going to be genetically normal or even implant when it is genetically normal. There is huge loss and human reproduction meaning the more eggs. You have at a younger age. The better the ROI on this process is going to be it doesn't mean you don't do it when people get older but every Clinic
it does have a cut-off and every clinics and be a little bit different a lot of different reasons why we actually probably an older cut off so we will let somebody go through IVF or freeze their eggs UPS age 45 and it's a lot about informed consent and having the approach that you're smart enough that if I give you the odds and I walk you through how many eggs you are and the likelihood of them making it two embryos. You can say. Yeah, but for eggs or 10 eggs is way more than 0
based on my circumstance and that is worth it to me because it gives me the opportunity to potentially have a child when otherwise my opportunity is going to be 0 so a lot of this is rooted in paternalism that people can't as a patient understand these odds and they have unrealistic expectations and there's a huge shift in Reproductive Medicine to really counseling patients and giving them autonomy and some of these decisions but there does become a point where
There's little likelihood of finding a normal egg is so so low that the money or the expense of the process doesn't make sense and people should utilize egg donation or other opportunities for conception this drop in both the number of eggs and the Egg quality. They really start to become so profound at age 37 and on and that's when we really start to see both these things are overlapping at the same time. So if you're waiting till age 35 36 for your first kid
But you want two or three we've got to really look forward about is that is that strategy makes sense? Well, what is your amh one or you're going to run out of eggs before then to how what other issues could be going on is the sperm fun or the tubes open because we are seeing that when people start families later when people have more chronic illness and autoimmune disease and obesity that it's much harder to get pregnant. And so the birth rates, right?
For the first time in a long time across the board are dropping and infertility is rising because of all of these factors
combined So based on everything you just said and yes, I'm going to say it a fifth time because a misconception about this is one of the primary reasons why people avoid harvesting eggs, it's not the only reason but when you harvest eggs freeze them sounds like the viability of those eggs is quite quite strong compared to a few years ago. So that's great 90 percent.
Every when they fall them is not going to diminish the number of eggs in the vault such a critical point and post their age 37. There's a sounds like a nonlinear drop-off and egg quality foremost. And these are averages of course, right? So everyone should be accepted by the people that got pregnant with healthy kids in their late 30s and 40s, you know, yes, we hear you. Congratulations. We're happy, but this speaks to the
None of that the logic anyway, we're not putting any emotion or circumstances on this but the logic of somebody in there. Let's say late 20s early 30s getting their amh levels through a roughly 80 dollar blood draw and then perhaps based on their life goals and circumstances doing either one or several rounds of egg collection and freezing, especially since it sounds like you don't need to fertilize those eggs. So if one doesn't have a partner is concerned about what they're going to
do who's going to be who's gonna provide the sperm, you know, because of course some people choose to raise kids on their own but parenting is a whole other issue, but they could do that later. So that raises the questions of what are the health risks if any pain levels if any and and that includes psychological pain of egg Harvest, I mean, it's so going back to what you said earlier. This is going to be injecting synthetic.
Ex of FSH and LH follicle stimulating hormone and luteinizing hormone, maybe some growth hormone. I hear nowadays. There's also the practice of injecting these are essentially platelet-rich plasma PRP platelet rich plasma scuse me PRP in perhaps even into the ovarian Vault we can get back to that. So there's a bunch of stuff that's being done to someone there's low stem where people are getting like low doses of these drugs. There's Heist and wears like a full blast Maybe.
Can walk us through that procedure and it just sort of General Contour because you know require a lot of time to go through it all in detail. But is this a horrible thing to go through is it mild to go through? Is it like a walk in the park?
Well, let's walk through it all so I love this is my bread and butter and this is what I do every day studies tell us that if you are not ready to have a family by age 32 to 33 that is the optimal time for the average person to intervene and freeze their eggs. It's not up for debate. It's when you have both the intersection of still a good egg.
Woody and Good Egg quantity on average and so that is younger than a lot of people are thinking about having families. And the reason why is when we really think about what happens to the egg afterward. That's what's really critically important. So I'm going to answer the question about what you go through but just thinking we already said you freeze your eggs 90% of them are going to survive the freestyle about 75% will be fertilized by sperm and about 50% of those will even make it to an implantation stage embryo or a
blast of force.
Zooming healthy sperm so a square firm. No DNA, excessive DNA
fragmentation of the nail on the head. One of the biggest issues with egg freezing is I don't know the future. I don't know if this firm is going to be great or not. I
don't understand my pot smoker just kidding pot smokers
not kidding it pot smokers or not, but we don't know right so we have this future yet undetermined sperm source. So I am going to assume you're going to fall average on these data points that we're going to walk through but the reality is you buffer the risk.
Having more eggs frozen and that's why people are going through multiple rounds or Cycles because we don't know we don't know how that fertilization will be. If you have 20 eggs and 18 survive the freeze-thaw and 14 fertilized and seven make it to the blastocyst stage. If your age 30, we would anticipate around 60 to 70 percent of them are going to be genetically normal and you're young. So that's that's already kind of a big head at that age. So let's say of the seven four of them are genetically normal.
When I go to transfer them, I have up best a 65% chance of live birth / embryo, which is really good. When you put in the lens of accountability and Peak success tends to be closer to
20% You're going to plant one embryo to
time hundred percent. We're going to plant one embryo at a
time now has anyone asked for two
people? Ask for two doctors will do to it is it lowers live birth rates if we are looking at giving each embryo the healthiest opportunity at becoming a baby number one.
Rio's with IVF have a slightly higher chance of monozygotic 2018, right? So 24 Channel 20 incomes. If you ovulate two eggs, they both get fertilized. So each baby is completely different genetically oneg on sperm monozygotic is from an embryo split because of the IVF process likely putting the embryo in the catheter may be having that, you know outer surface touched predisposes it to splitting after you put it into the body.
So the more identical
in Zoe monozygotic
three percent chance of monozygotic twins with IVF and the natural chances point 0 3 percent. So it's significantly higher even though ultimately not a probable outcome. I'm going to have a couple patients a year who are going to have monozygotic twins. And if I put two embryos on I've now one taken this from a potential twin pregnancy to a triplet or even a quad if they both
split and presumably like the octomom cases and things
like that.
They just literally put eight embryos inside but that's a whole system. That's medical malpractice. Right but really most of the time when we're talking about embryos, we're talking about people with infertility or people who spend a significant amount of money a huge portion of fertility as embryo quality, right the competency of the embryo of the genetics of the embryo. It's expensive to go through egg freezing and IVF yet. The uterine environment is another component. It doesn't make sense to waste multiple embryos in the same. Uterine environment statistically doesn't make sense it.
Also doesn't make sense to make your embryos compete against each other.
So we'll people put one embryo into let's just say DNA Mom, right and one into surrogate mom and and try and get two siblings simultaneously.
I've definitely done that and had patients do that. It's not common because Sarah gissy using a gestational carrier is so expensive and there's such limited Supply. It's very hard to find somebody who wants to go through the act of carrying a child for somebody else.
But that definitely is a strategy that some people utilize especially if they're older or they're concerned that they might have a lower chance of implantation, but they want to give themselves a try. But if we look at one embryo 65 percent chance of success cumulative probability after the second is 88% Okay, almost everybody's pregnant after two and these are euploid genetically normal embryos. Okay, and then if you go to the third so human
Lee after three, you played embryo transfers each one being a single embryo 95 percent of people have a baby in their arms meaning the incidence of recurrent implantation failure is actually pretty low five percent. But how many normal embryos do you need for what family size if you're freezing your eggs because you got 20 eggs at age 30 and the example I gave and you just made for normal embryos, right? So that's really unlikely to make three or four kids it.
Would it has a really good chance of making one gives you the opportunity for a second. But that's also presuming that everything happened perfectly that the sperm is not pot smoking sperm. But you know what, I mean, not bad quality sperm. There's not other environmental issues when it comes to your own health when you're trying to get pregnant or other diseases you may have so we really need a higher number of eggs specifically when we don't know what the equation will truly look like for one individual person when they go through the process.
And one of the only added benefits of embryos, especially if you are partnered if you're with somebody who you do want to have children with you just don't want to have them yet is that I know the downstream. I know the number. I know how many embryos I have and if it's not enough to give you a high chance of what you want your family to be you can intervene now, right because by definition with egg freezing, we're not wanting to be pregnant for years. So if you're doing
Doing this with a partner and you're making embryos and now I say we only got one genetically normal embryo. You have the opportunity to choose to either go through more cycles and store more embryos for later to maybe try to get pregnant sooner because there's some underlying issue with your fertility. You can make a choice because you're falling off the curve
there. Could I ask you a question? So this you mentioned H about 30 to 33 in an ideal circumstance with the finances there at?
One would Harvest eggs unless they're already starting a family through natural means what about for sperm. I mean, we we've all heard the studies that with increased age of the sperm that there's a higher although still statistically pretty small incidence of things like Spectrum conditions. So do you recommend to young girl males men in their late 20s early 30s to free sperm
I mean, he's never going to be wrong to save your gametes because we don't have crystal balls for the future. Right? So your gametes are your eggs and your sperm that increase and we'll just say negative outcome from Advanced paternal age really starts to be seen at age 50. So most men are not looking at primarily starting their family after that age. However, what I run into all the time is maybe you're working on the second family or maybe life has gone down a different pathway and now you're with a partner
Potentially is younger and wants to conceive and you now have older sperm having sperm in the bank. It's so cheap and easy to freeze sperm eggs. I haven't even answers your primary questions and
the process of collecting sperm. Well, well not entirely without its issues is far.
It's embarrassing at best but it's much
simpler. That's where simpler there's generally doesn't require hormone injections. Although you know, maybe for rare instances where people are hypogonadism or something, but if
you're going to freeze your sperm, you're right you typically you're going to get some blood
I work done because most places that store sperm per FDA guidelines have to make sure that if you carried an infectious disease, it's stored in a special tank. So you'll to get blood work done. You have to abstain for your two to three days collect into a cup you're
done which by the way guys you can do at home and bring it in sperm are so stable. If you've ever done this you just bring it in. It's pretty listen. I'm a little bit a little bit of I think I'm not going to feign that my friend did this and told me but you know, it's kind of outrageously easy in the sense that you just bring it.
And they'll like take it out in the lobby and be like is that your name and they'll do like the very different than the egg collection procedure.
So here's the here's what I'll say about sperm and what I wish more men knew / Mormon dead, if you're going to get a vasectomy because you are choosing that you don't want to have kids and we see many men who do this. They say they don't want to have kids. They want to go get a vasectomy yet later on in life. You don't have a crystal ball about life is dynamic and things can change if you're going to get a vasectomy Go free sperm first.
Why are so many men getting
vasectomies?
I don't have the answer to that. I hadn't heard this. Yeah, a lot of men are getting vasectomies even just take control over not having a child out there when they don't want to so maybe this
explains the drop in birth rates, and I'm just I'm just kidding. This is multifactorial.
So many people even if you're in your family of two kids and y'all decided you're going to get the vasectomy so that you don't have any more children.
Things happen terrible things happen and Life Changes. There might be a circumstance where you potentially would have another kid if something really bad happened or you just changed your mind freezing sperm is so easy and so much easier than if you don't not all vasectomy reversal is work, especially the longer that it's been reversed the lower the likelihood that it's actually going to work and very often if it does you don't get sperm insufficient levels for timed intercourse and you're seeing me and the
First and freezing sperm is cheap. I mean it's relatively
cheap like $400, right? So it's much much cheaper all in than the entire egg freezing process. So to answer the original question when you go through egg freezing most people do fantastic and we'll just use egg freezing and IVF interchangeably here because what you as a person is going through to harvest your eggs, or to take them out of your body is exactly the same, right the distinction between egg freezing and IVF is all
out what happens on the lab and of it after they've come out of your body. So if we have this group of eggs that comes out of the Vault your body doesn't want to allow them all to grow even if it's a low number right? That's the check and balance to not have so many kids. So we need to override that process and what we tend to do with this is to use a combination of hormonal medications and very often. I described it to patients as suppressing your body and then stimulating it so if I can temporarily stop the production of FSA
Each and you have a group of eggs come out of the Vault and we can imagine that FSH is there food and there is no food because you're taking the birth control pill for three weeks. These eggs are going to synchronize be very small be very hungry for lack of a better word there. FSH receptors are going to open all up. It's like a nest of baby birds that are all now starving instead of the hungry bird gets the worm. So now we go with this oppression period for a few weeks we can come in and give
Pens, which is FSH and LH F sh is now synthetically made in a lab. It's very easy as a synthetic compound that mimics the structure of the brain FSH. We actually can't synthetically make LH very interesting. We don't have a way to make it yet. And so we use the purified urine of menopausal women because when you're in menopause your FSH and LH levels are naturally so high because they're trying to get that egg to make some estrogen
so
Here are some of the we've covered male hormone Health before and there's been a discussion of HCG human chorionic gonadotropin and which is essentially mimics
LH in the in the receptor. It
does. Yeah, right. So is pregnant human chorionic gonadotropin. Is it purified from postmenopausal woman's urine or is its in its synthetic
HCG is
synthetic. And so what why
can't why don't Mountain it's called menopur men up your men up here is a combination of FSH and LH.
Each the reason why we give HCG two men to try to stimulate the spermatogenesis process, which of course if we could just give LH would give a lake just the same reason why we give HCG for a trigger if we are going to go through fertility treatments and we're trying to mimic that LH surge which naturally would cause ovulation. We actually are giving HCG because it does mimic LH when it comes to the receptor action of it, but when it comes to really especially in getting follicular development
And the relationship between LH and FSH meaning LH is really providing some of the hormones substrate that we need to be able to make estrogen and so you really need some LH in a lot of people depending on your protocol or if you're older and you're naturally making less the example the offshoot would be like the PCOS patient who has some naturally High LH. Sometimes they don't actually need LH and their protocol
but the tailor these postponed
pause are women that are supplying their year and they're paid rate will be yeah, I sort of imagined them on some Island someplace. Yeah. Yeah. Yeah enjoyed it go to the menopause getting paid to
urinate. It is called menopur. Like it's purified menopausal urine, right? I did Wild no now now they know so we use FSH and LH will just say and lack of better terms. Those are the two primary compounds that were giving over the course of on average a 12-day period to get the follicles to grow.
And the eggs to mature so you can measure egg maturity by blood levels of estradiol and by transvaginal ultrasounds. So when you're going through egg freezing or IVF, you're taking these hormone shots of FSH and LH they are getting those follicles to start to grow. The eggs are starting to mature. We are monitoring them along the way trying to determine the time period where we think most of the eggs will be in the mature range these eggs have gotten to mature.
Dirty you then are going to take a trigger shot which allows that final stage of meiosis. So those chromosomes can separate right? We think about the egg remember that normal female genetics 46 xx and I always think about in the egg that these chromosomes are lined up. Your eggs are Frozen inside your body when you're born your eggs are in metaphase of mitosis. So that's when krait metaphase chromosomes meet in the middle and they're held apart by these mitotic spindles and this is why eggs
So stinkin fragile because their health like this and those mitotic spindles just absorb the wear and tear of your life. But when you use that trigger shot that LH surge naturally or that HCG and a cycle. That's when you're going to get that final separation into half the eggs, you know, half those chromosomes into the
egg. So for people listening is to think about like a zipper pulling apart of a zipper that then you now have the chromosomes just won $1
now have halved the chromosomes because why because in successful fertilization, the other chromosomes are going to come from
sperm the sperm and that's why this process has more error the older you are and the longer your chromosomes have been sitting there because those spindles are going to break down and we're going to have that increase in aneuploidy. Like we already said purely because of this
impact. Can I ask a question about that specifically I think now would be the right time to ask which is that my understanding is that a lot of the Dynamics of pulling apart of this a zipper like thing.
Chromosomes and then is related to mitochondrial DNA because they're a lot of mechanics. We're literally talking about an egg splitting itself, you know in half and that Powerhouse. Yeah and the mitochondria and so mitochondrial health is a big topic these days and so we will be sure to touch on nutrition supplementation and prescription drugs that impact mitochondrial Health, but I've heard of a new procedure called 3 parent IVF where they're taking basically the DNA from the intended mom that
and a from intended dad and then putting it into a surrogate like a donor egg that is where the DNA has been sucked out and then you know because it has Health healthier younger mitochondrial DNA. So you're essentially let's say you've got a couple in there. Like let's say late 30s early 40s, and they're not getting successful. I'm reos or in plantations or whatever's the things aren't working. They'll take the DNA for Mom and Dad in the
The merger with a third parent encapsulation that there are clinics that do this. I know that a lot of this was actually being done in Eastern Europe until until recently Mexico offers their places in Mexico that do this in England. It's been used to solve mitochondrial dysfunction. But in the US this is still not legal. Is that right?
Yes. So the purpose of what you're talking about. Essentially we think about utilizing a donor mitochondrial or
A donor add the point of that technology existed to help cure mitochondrial diseases which are 100% fatal. And so you would have this subset of people who would because if you're the mom you always pass on your mitochondria to all of The Offspring. So if there's disease inherent in your mitochondria, everybody's going to get it and these are very severe diseases. So the idea of this was first to say, hey, can we overcome?
There's mitochondria disease and give people the opportunity which it has done that right
now. So it works when done
properly when done properly especially for that purpose. Now that purpose is distinct because those people aren't infertile, right? There's something else going on within their mitochondrial disease utilizing that technology to overcome age-related changes in the eggs has not been successful yet. Are we hopeful that it can whoop
I will charge you money for it and certain places. Yes, but you're hitting on a really important topic is that the political environment of embryo research in the United States makes it extremely hard for us to be the pioneers of new technology in this space. And that is because a lot of views about an embryo or Windows life began that happens here in the US that results in limiting the availability and the
Possibility of doing research in a meaningful way on human embryos,
right? Because it would require the destruction of a lot of of and it would also and you know, I looked into this a little bit as it from an academic perspective to be clear. It would also require that the abortions be performed differently because suction abortions destroy embryos in ways that extraction abortions don't so that there's a very controversial topic. I mean, it's something that maybe we'll return to in an episode about
stem cells in the future.
It's fascinating because especially if you look at IVF whole separate issue is that there's millions of embryos that people are no longer using because they have had success. They had extra embryos in the bank. They got divorced a variety of reasons and a lot of people would like to donate their embryos to science feel like hey, I don't want to have this embryo implanted. I don't want to carry this child, but potentially could
Think good or could it help Advance the field but that's not really a tangible option when people do that. What is actually happening is their embryos are being utilized to train and biologists which is valid right to teach them how to thaw and freeze and biopsy and do different things. So it's still useful but it's not in a meaningful way. Like we'd really love to be able to utilize to advance the science especially for these embryos that have been created yet people no longer need them.
Them for family
growth. So what happens to all the embryos that people don't
use it's fantastic question right now. They sit in storage. This is well. This is a new problem. Okay, IVF is only 40-ish years old embryo freezing alone. Right the first IVF, we have even gone through the whole process, but the first IVF baby, there's no FSH LH to stimulate more of the eggs outside the Vault to grow so they followed the single follicle and they didn't have the procedure which we do now, which is a minimally invasive procedure to
Cracked eggs, we go vaginally with a needle attached to the ultrasound and we enter into each follicle and we drain it the very first idea if you followed one follicle and you went in abdominally with a surgery to get put that needle into the follicle and drain it out and give that just one egg a chance and then of course, there was no embryo freezing originally. So the field is still rather young to understand some of this and as technology rapidly improves.
We see things like better success rates with freezing and thawing embryos better process of getting more embryos to grow. But now we've a lot of embryos in storage that may or may not be used. I personally tell people you should keep your embryos. You should pay the storage fee until no matter what the worst thing on planet Earth happens to you. You're done having children because sadly I live in a spectrum with my field where I see a lot of sadness
And people who maybe love lost a child something else has happened and they have maybe a sibling who they feel like they really want to give this sibling child the chance to be a sibling again and often you're much older when you're experiencing this and if you had had embryos Frozen that you could have used but you got rid of them. You're going to be really upset if you find yourself in that circumstance, so I would say you should save them until you know that you are not going to need them. And then what do you do with them?
Most people just discard them. Some people will donate them to Labs which is called for research. But mostly it's for embryologist training to get better at doing it, which is also important but embryo donations and new thing. So being able to just like we have people who donate sperm and donate eggs. Embryo donation is the next evolution of an opportunity to allow more people to become parents. It's a little bit of the Wild West people finding
People in Facebook groups and connecting is this whole other Dynamic when it comes to what we call third-party reproduction or you know, what do you do with known donors and things like that, but it's a very interesting concept. So this problem is emerging as the technology is getting better.
I'm realizing now remembering rather that when I was in college and graduate school you would see these ads in the
Paper the first time for egg donors and sperm donors sperm are generated throughout the lifespan. So that's a kind of less controversial issue. But this is now not allowed most places to advertise for for egg donors on college campuses. That's my understanding. The egg donors were often paid, whatever whatever they were paid. I'm not gonna say it was reasonable amounts or not because I don't recall what they were paid. Everyone circumstances are different but
The argument that most people use against this is oh, well these these people are giving up eggs that they could otherwise use but we now know that's not true. So, do you have any knowledge as to like what was the rationale for for kind of limiting the recruitment of egg donors? Anyway, I'm not arguing for or against. I just it's no longer supported based on what you said by the by the argument that they're losing eggs. They would otherwise
Be able to
tell others about proper informed consent, especially at an age where the financial incentive can be very persuasive without understanding not that it harms your fertility later, but that you're going to have genetic children out there and you might potentially and we are seeing this now. We don't know if you individually will have infertility for a variety of reasons because you're not trying to have a family until much later.
The same concern doesn't seem to exist for men who are
donating sperm. I mean, it's should but there's this whole donor conceive Community where people are really talking about putting new restrictions on will you sperm donation? For example, there are sperm donors who have hundreds of children hundreds, right? There are these sibling pods because it's been so unlimited and sperm banks are a business that work to make money and they make money by selling more sperm, but that's not healthy one for a population. You need genetic.
D but also, it's not healthy necessarily for one person to have all these half-siblings and to just not know when you're going to run into somebody who could potentially be your sibling is that this guy at the bar that you like. Do you have to worry about that if your donor conceived so we're starting to see sperm banks finally start to reel back and put limitations on how many families total children's tough. Right? Because one family might have a child and you want them to be able to have sibling children, but at least
least for how many families that that donor can contribute to and we're seeing sperm donors deal with the fact that now there's no Anonymous donation. We can act like Anonymous donation exist meaning it is not identified at the time that somebody's utilizing the sperm but with you know, direct-to-consumer testing for genetics like 23andMe and ancestry people are being connected with their sperm donors with their egg donors with their sibling pods.
And we have to believe that technology is only going to improve over time. So what people do for money, especially when they're young I think without understanding the potential ramifications and I don't want to act like sperm donation or egg donation are bad. They give people the opportunity to become parents that otherwise might not be able to and that is a lovely and a beautiful gift but you need to understand what that might mean and how that might impact your own potential children.
Aaron later to to know that there have genetic half-siblings out there egg donation people do get compensated much better than sperm donation. There are certain characteristics that are hard to find that it get compensated even more so and certain, you know, ethnicities doctor degrees and things like that where somebody can really pay for their education by donating their eggs.
It's a it's a dilemma because what you'd love to say is like freeze some eggs for you, too. If you're going to do that, you're at the perfect age to freeze your own eggs, and there's been strategies to try to mitigate this and I don't want to get off too much on a tangent, but
it's a really fine line that you walk with what people understand so there is a company and I won't name them but they are promoting that young women donate their eggs and they will freeze half of them for you and half of them will go and become donor
eggs interesting business model, but I could see the potential ethical
concern. So I think ethically this sounds good because you get to freeze some eggs, but I think more people will donate eggs than otherwise would have for some of the reasons we previously stated and I
So you think you would get more money by simply donating your eggs and then turn around and paying for us round of freezing your own eggs. You would get paid more and you'd have more eggs because one of the issues is do you now falsely believe that you have enough eggs in the bank because you did this split but you don't really have enough because we already walked through the math at 20 eggs doesn't really result in such a high probability of having a multi child family. So, you know, there's
A lot of ethical debate in Gammy and embryo donation. It definitely is the wild west and there's a Uncharted Territory. Even an embryo donation. There's places who are very unethical about it who will only allow people to have embryos if they are heterosexual been married for three years make a certain income submit to a home study yet. They let the people have no say over the embryos that are transferred be it how many what stage was?
quality and they are taking people's money and putting terrible embryos inside of them and really wasting their resources which could have been used in another
way the dangers of profit ization of
biology, right and timing Tech entering spaces is amazing, but also technology starts to advance before studies right Tech is going to become has more Finance backing than we see scientific studies
get I feel like one of the major
ER questions out. There is whether or not IVF babies. We'll just call them that have a higher incidence of things like Spectrum conditions or other developmental trajectories. Let's call them and I'm not trying to be politically correct here. But you know, I think nowadays the word disorder has to be like really carefully examine when considering any neurologic and psychiatric situation.
Had discussions about this on this podcast before but but a lot of people are wondering just to be to be direct a lot of people are wondering do more IVF babies have autism then non IVF babies.
That's a good question and it's changed over time and couple different ways. And I think this is important to understand. So if we just think about the hormonal environment with natural conception and you know, you have a peak estrogen, let's say of 200 something you have progesterone being made the place.
Uh Santa is implanting and what is the main difference with IVF babies? And a lot of it has been tied back to the uterine environment, especially in what we call Fresh embryo transfers, which is really not a common practice anymore. So in a fresh Embryo transfer, I'm going to take the eggs out of your body fertilize them in the lab and grow out embryos. And then I'm going to put the best embryo back in your body five days later at the natural time of implantation and if we rewind the clock
That's how IVF was done right when you couldn't freeze embryos very well and they didn't survive and you'd put lots of embryos inside because they wouldn't survive and that's the early days of IVF when you saw a lot of multiples a lot of high order multiples and of course multiples have their own distinct issues that put them at higher risk for developmental disorders and issues with development and birth rest in general right
there. Come to be fair. They're commonly referred to as disorders. I just think
Around autism in particular there is there's a camp a growing camp out there that want it referred to differently. We've covered this any time. This comes up I bring up both just to highlight the fact that yes, we are aware and sensitive to that emerging issue right now. Unfortunately for sake of conversation, there's no new nomenclature so we could easily get caught down in the in the in the attempt to try and like, you know, I'm smooth over everything with everybody and it as a consequence confuse everybody, so I think we'll go for clarity for
With the understanding that the nomenclature is changing can't even say alcoholism anymore because it's alcohol use disorder and I don't have a problem with that. But a lot of people wonder if those are two different things
and confuse the and we want to simplify science or people
actually so feel free.
So when we first were doing IVF, we're putting embryos back in extremely unnatural environment. If you have 20 eggs growing and each egg makes 200 mg of estrogen suddenly. Now, you have these extremely high super physiologic estrogen levels.
Higher progesterone levels because there's more corpus luteum 's and this environment is not the normal for how the placenta would invade into that maternal blood circulatory. And a lot of these issues that are commonly associated became so because of placental issues. So a lot of things like growth restriction small for gestational age preterm birth, which further puts you at risk for other developmental disorders were associated with these fresh transfers. The field has changed. We do a lot of
Frozen embryo transfer is a lot of it for this reason. We see a huge Improvement and neonatal outcomes when you bleed off that high hormonal uterine environment and then regrow the lining of the uterus and a hormonal level. That's more natural and then transfer the embryo and we see completely different fetal outcomes. So that's fantastic as far as looking at the change over the field. But of course if you take all IVF babies overall time, it's a little murky because you have
Turn Practice and old practice. We also know that infertility.
People if you get diagnosed with infertility, so you're under age 35 and you try to get pregnant with regular periods for one year and have not had success or your 35 and older and you've tried for six months and you've not had success. You meet the medical definition for infertility when that happens you now statistically regardless, if you get pregnant naturally in the next month or you do IVF, you have a 1% higher chance of birth defects and you have
A slightly higher chance of Developmental disorders. So is it more population based versus procedure base? And there's probably something to that to underlying a lot of potentially what goes on or what can cause infertility when it comes to you know quality of eggs or sperm or uterine environment or things that we're still learning about when it comes to autism specifically the number one strongest Association we have is Advanced maternal age. So when you look at the people
and the male sperm comes from an ejaculation after age 50, that one does have the highest significance associated with autism and also with some other very interesting autosomal dominant disorders. So we don't want to take Advanced paternal age likely although it does get so much less attention than what we call Advanced maternal age or being over age 35 and a woman and that is purely because of the differences and the sperm and the Egg environment and
Their quality is impactful.
Thank you for that answer. I think it's really important for people to hear that because you know the lure out there is that IVF higher incidence of autism and IVF babies, but it sounds like a good percentage of those could be because of age related factors as well as technology related factors that and that the technology is getting better all the time if I understood correctly. We didn't complete the
Discussion of IVF and I want to do that talk about Dixie and a few other things. I know that's that's definitely your wheelhouse before we do that. Can we inject a little sub conversation around this because I neglected to bring this up earlier and I know there's a lot of curiosity about this and then we'll and then we'll finish off IVF. Can we do that sort of a pause in the IVF? So the eggs are out there Frozen sperms out. It's frozen or maybe they're going to put live sperm on non-frozen scuse me sperm directly onto those
Negs will pause there intermission for those potential embryos and talk about something that you've been very open about which is and a lot of people are not frankly in your profession. So I really appreciate this which is nutrition and supplementation to optimize the the health of egg quality and not just for people who want to get pregnant but for but for people who believe that fertility is a proxy for
our overall health. So I mean are there things that people should eat and not eat things that people should supplement and not supplement in order to optimize their fertility. I
mean, this is definitely an interest of mine right all my fellowship research Cycles around fecund ability and natural fertility. And I think we really do a disservice by how medicine really is categorized by organ systems because we act like things in one place don't impact the other as if right but it's you have a body and your body and especially
Your hormones change and fluctuate and they're meant to they are meant to be a dynamic system, but the world and the environment of which you are subjecting your body to has proven changes on both hormonal function. And also when it comes to egg and sperm quality, and so if you are somebody who just wants to live your healthiest life and have your most regular periods and have your hormones as well balanced as they can be for a lack of a better word.
Word will just say that that means that they're functioning normally then paying attention to the things that you do are really important. And so I know this is a big one for you sleep is probably the number one thing that people don't do that doesn't pack their reproductive hormone system and therefore can impact I can sperm quality because sleep is when you have cellular repair and when you can drop your inflammation levels, we know that inflammation is just toxic to eggs and sperm it is the inflammatory environment is not ideal for
Sean and then for a female you have to deal with the fact that you have your egg quality, but you also have how inflammation or what you're exposed to impacts your uterine environment. So you have a two-fold situation here. So none of this should be shocking news when it comes to nutrition, but it is not talked about enough. You're right decreasing inflammation by the foods that we put in our body is consistently shown with an increment in fecund ability.
Tea and Improvement and ovulation and Improvement and success with IVF and a decrease in miscarriage rate. Huge Studies have looked at these now the big caveat is that nutrition studies are super hard because people who consume flax for example tend to have other good health behaviors that sometimes make it hard to identify what blacks did versus their General Health versus somebody who eats fast food every day.
So nutrition studies tend to be observational and Fertility Studies are really hard to because what in point are you using? Is it getting pregnant? Is it live birth? Are you looking at IVF? Are you looking at natural fertility and we have a lot of different overlap that makes both of these a little bit difficult. And so they're all cohort based or population-based studies where you analyze how people perform when it comes to fertility treatments or getting pregnant naturally based on their exposures to certain things.
These diets high in fruits and vegetables are good for you. Right fiber antioxidants fruit is not bad fruit. Got this really bad reputation. I love her. I love her too, but people think that it has sugar and that it's bad for you. That's fructose, but it is no it's not that type of sugar is not bad for you. If we can just agree on the fact that fruit has a lot of nutritional benefit, especially when it comes to vitamins and antioxidants that can be extremely beneficial in decreasing inflammation grain. So whole grains especially that your
You know provide a lot of great fiber. So, of course if you have Celiac or you're gluten intolerant, you're a different category, but there was so much focus on keto and people eliminating grains as a food group overall. And even though that might be utilized in a dietary strategy to lose weight and losing weight can improve fertility likely because of inflammation being the primary driver because we know that even in studies where I take donor eggs, and I transfer that embryo into
Somebody who's overweight they have lower odds of success than if they were a normal BMI. So we can't act like that causation is just on egg quality from obesity, right? There's also some inflammation some inflammatory changes that impact the body's ability or desire to allow an embryo to implant. So fruits veggies whole grains are all good interestingly, you know, dairy dairy tends to be okay and most
He's but what we do see is that if you're going to have dairy have whole have the real thing the process dairy the skim milk that actually decreases your fertility and likely because the processing to make it still look like milk when you take out the fat is adding in things that are unnatural potentially impacting your
fertility. I don't drink milk anymore. But when I was a teenager, I drank half and half I'm not recommending any wonder that remember. I was just getting teenager trying to bulk up. Well, no, I just could afford to I wasn't.
At that age, I wasn't trying to at all but it was just delicious. But so Cheese's whole full fat milk yogurt and half yogurt. Okay.
Yeah, but don't don't use the skin one choose the actual one that comes with some of the milk fat fat is not bad for you. There's also this rate we're hopefully we're getting away from it. But there's been such a low-fat craze or this real attention. That fat is so bad, but fat comes in so many important.
Arms avocados and oils and nuts very meat fat and cholesterol or the backbone for all hormones 48. So you need that in order for your body to make the estrogen and progesterone that it needs to allow this whole process to happen. And so there's this idea that those are bad for you. That's just really not so healthy fats whole grains fruits veggies
and what about proteins and meats because I think within those categories, you know, I'm a big fan of
an oblique, you know, like raised meets if possible. Some people choose not to eat meat but fish eggs,
love it all. Okay. So let's just go through the meats and the myth and the facts so we'll do tofu. So there's this big issue that I would tofu has soy and that too much soy can be bad because so I can be a phytoestrogen tofu does not negatively impact fertility even in Men In fact, it can improve it because it does have some antioxidant like properties lots of iron when it comes to fish fish are
Fantastic sources of healthy fats and omega-3 fatty acids, which are very crucial in the reproductive process. We do worry about if you're pregnant having too much fish and over exposure to Mercury and how that can impact fetal brain development. So the general recommendation is three servings per week.
That doesn't mean yes a serving is like 4 to 6 ounces as opposed to like a real human that needs you know, you know
And I think it's important to say even though people will tell you that when you're trying to get pregnant with the idea of we don't know when you're going to be pregnant. If you're going through things like egg freezing or IVF. And you know, when you're going to be pregnant, I wouldn't feel like you have to restrict yourself on the consumption of seafood during those time periods when you know, you're not pregnant yet because really the concern is about that mercury and what it could potentially do to a fetal brain and
raw seafood. Correct? No, sushi. No
Sashimi. Well when you're pregnant, correct, and that's mostly because of the risk of infection.
Just disease that can cause you know severe brain development and other issues they do in Japan. I don't know I don't live
there. They probably laugh at this
they probably do laugh at us but probably do laugh at someone
who's been pregnant in Japan reach out. Tell ya or conceived in Japan tell us don't tell us the story of the conception like but tell us tell us who did you have sushi Me
overall meat is a really broad category and study study it differently. Like is it all meat are you
wishing Now red meat and chicken. Are you putting it all together? I mean, obviously I think we can all come to the agreement that processed meats are not good for a variety of different reasons in addition to being carcinogenic those toxins do negatively impact fertility now so deli meat no bueno. So yeah, but in specifically those things like the bacon and the product like the things that are really highly prostate hot dogs. Sorry the Fourth of July hot dog picnic, but those
Really do not provide nutritional advantages and only harm especially then when we have red meat for the most part red meat when isolated individually and most circumstances in moderation tends to be fine. I usually tell my patients I went there to eat a plant forward diet. That doesn't mean know me but I say look at your meat sardines, I don't want it red meat every single day because there was a study looking at IVF and looking at embryo.
Rose and the more servings a lot of nutritional studies base things on quartile. So who eats the lowest and the second-most and the third most the topmost and people who ate in that top quartile of red meat had lower progression of embryos through the culture. So less embryos that developed less normal embryos and lower success rates. And
what do we know anything about the how that meat was arriving are we talking
about? We don't like
what hoagie sandwiches are we talking about like grass-fed
steaks, right?
Studies are not wonderful, but that doesn't mean that they don't hold Merit and helping us guide counseling but no that one was how many servings of red meat do you eat in a week? Right? So we don't really know does the really ethically sourced the grass-fed, you know this environment which we feel like is much less toxic than potentially. Let's say like a cattle Factory where the cows are injected with all sorts of things. Is there a difference and how those impact your reproduction probably right if this cows
Being injected with a lot of hormones. Why are we thinking that it's not impacting the meat that you're then injesting into your body.
I think our audience will certainly subscribe to that idea. I think most of them will I mean the notion that like the pollutants you breathe in the air somehow are not the the air that you breathe into your lungs is just like completely White and the
idea feel that way and they hold strongly to this idea that it can't be this thing that I love that is causing this problem.
Guam right the denial of the association between what we put in and on our body and how it impacts. Our bodies function is really strong and some people and I think it's really just lack of education and awareness because the medical community for so long did not address these factors write your doctor never talks to people to you about nutrition. And so it just became this idea that it must not matter. Otherwise your doctor would talk to you.
About it. I think sugar is the last thing I just didn't mention but added sugar and artificial sugars are bad for you artificial sugars artificial sugars to so
including Steve EOS or plant-based are too low calorie.
Sweetener. Stevia itself hasn't been studied as much as the other ones things like Sweet'N Low and all of those mmm, but what we do know is that they interfere they cause inflammation inside the body and then they also cause can cause a stress reaction and they can cause
Higher rates of miscarriage when you intake more sugar and artificial sugar. So that's a lot to wrap your head around and I say the same thing to every patient.
One cake one this one hot dog. And those things individually are not going to make a difference right? It's the choices that you make every single day that are going to set you up to be your Healthy self or not. And so you should make choices in line with how you want to treat yourself. You want to be in your best health. You want your hormones functioning the best and if that added helps you get pregnant when you want to helps you have a better chance of success with IVF. Oh my gosh, what a fantastic benefit, but that
I mean, you can't enjoy some of these bad things here and there as long as you've set yourself up on the day-to-day where you're giving your body lots of nutritious food that it needs to make hormones similarly being, you know, very underway in calorie restricting. We all know is really terrible for your reproductive system and can cause the brain to totally shut down ovulation because it senses that you can't have a pregnancy
is simple miscarry scuse me for bye.
Virtue of being underweight does the body like I learned some years ago. I think this is still true that one of the signals for the onset of puberty and females is that leptin hormone is secreted from body fat then signals to the brain to the hypothalamus like okay, it's you know, there's enough reserves to create environment. It's a signal about environmental.
Yeah, there's enough extra fat to have a
baby and there's presumably enough food around to sustain that baby right are miscarriages and
Lack of body fat
correlated on both ends of the spectrum. Yes, right. So lack of body fat and being overweight. We see decrease in getting pregnant per month and we see increase in losing pregnancies. So certainly there is a healthy medium where your body has what it needs and that makes sense because if you have I like to even say hypothalamic dysfunction, so maybe your brain is not totally shut off where it's sending out no hormones and you're not
ovulating if you're not getting pregnant in that circumstance, but certainly ovulation disorders are on a spectrum where you go from a perfectly synchronized cycle 21 that prolongs it, you know gets shorter together then prolongs and then you have nothing there's this spectrum of dysfunction, which is representing your hormones not being necessarily perfect and that can have impacts on the placenta trying to grow into that uterus and the placentas fascinating write an entire talk just on the placenta, but it has
Does this incredible job or your body has to not reject it yet allow it to eat away at the side of your uterus and grow into your blood vessels. But that requires a very specific hormonal environment for it to be done in to be done. Right I think in the same breath of all this which are also asking is you okay. So that's eating healthy. None of that's really new news for most people a lot of those things. I just
said, well I think so, but I do want to thank you because I think I'm rarely if ever do we hear somebody so physician be really direct about like Hey listen,
And some red meat yes, not excessive amounts of Learning System. Ideally from sustainable sources, whole-fat milk products grains fruits vegetables. I mean those kind of Straight What bike to you seem like straightforward directives are actually pretty rare in the landscape of Public Health discussion because more often than not people talk about nutrition in these kind of Elimination Diet type things like, you know, eliminate all the grains or eliminate all the meat or you know, eliminate all the milk milk fats when in reality, I think people forget
That like most people out there omnivores and they can make better choices about not deli meat, you know less bacon if any bacon,
right, you know cheese with your lunch, right? You can make better choices on the day-to-day. I think that is a great point. I think there's a place for supplements. I think the big disclaimer that everybody's going to say with supplements is that they are not regulated like the way medications are right and I will say supplements and herbs are different things right a supplement but many
Me companies are adding herbs to their supplements and that can get into really murky territory. Especially when it comes to how some of these herbs do have estrogen and progestin like properties and can impact reproduction and
hormones and perhaps even
androgenic. / yeah, so we can't act like everything's created equal. So I always tell people if I recommend you take a supplement or your doctor does your due diligence is to look at what is also included and make sure it doesn't have these extra added things that they're
We're of because sometimes they can have negative impact at one stage of your life or another depending on where you are certainly, you know, a prenatal vitamin which has folic acid. We all know that folic acid is really important to prevent neural tube defects, but it's also important in cell division and how the ovary is growing follicles and growing
eggs. So should people women but also men be taking a vitamin with folic acid, even when they're not trying to conceive.
There's no harm in having.
Seeing it but very often pregnancies occur when you're not trying to conceive and that is a store that needs to be built up three months ahead of time. So we really need you to be taking that ahead of getting pregnant. So not just let's get pregnant right now. I'm going to start this prenatal vitamin. So I recommend anybody who's and their reproductive years take a prenatal vitamin. We also know that many many people are vitamin D deficient and vitamin D does impact
Reproduction and so I usually say a thousand international units of vitamin D is not going to be harmful in anybody. It's going to be helpful for most people some people definitely need higher levels. So we screen everybody with a vitamin D to see who needs to have extra but, you know a blanket statement that extra vitamin D is going to be helpful omega-3 fatty acids also extremely important in one being anti-inflammatory but to brain development of a fetus
And so most prenatals now actually do have those omega-3 fatty acids in them. But if they don't I recommend a patient take
those just two brief questions. I should insertion there the there's a laboratory up at the University of California Santa Barbara that's published some really interesting data showing that you know, essentially brain weight, which is just what one indirect measure of brain health, but brain weight in at Birth seems to be correlated at least in some positive way with the amount of essential.
The acids that Mom consumed during pregnancy. Does that sound does that?
Yeah, and I mean that does hold and there's
There's my studies about the mice are smarter when they have diets, you know with omega-3 fatty acids when they're in utero, right? So the exposure and the time period is really important and Omega-3s have a lot of health benefits when it comes to their antioxidant properties, especially in like an intimate rios's diseases that are very highly inflammatory. They can be very
beneficial. We're definitely to talk about your work about after baby is arrived and impact of essential fatty acids. But what would you say is the dosage cut?
On this podcast before I've thrown out numbers like 1 1 to 2 grams per day of the EPA form of essential fatty acid and then we could have a whole discussion my omega-3 omega-6 ratios, but do you think there's a upper limit is it truly that you know, let's say up to 4 grams per day of EPA is would that be advantageous as a better than one
gram. I tell people a gram per
gram. So that's in alignment with pretty much what we've talked about before.
So that's what I recommend. You know, what
I give my hand out to my patients and they're trying to get pregnant. It's kind of a prenatal 1000 I use the vitamin D G of Omega threes and then co Q 10 so cute on which you know essentially in general is trying to help the mitochondria. That's the whole idea here that it is helping Provide support across the body in a lot of different ways. Right like co Q 10 has used in a lot of different areas the body but in when comes to reproduction when it comes to meiosis and cell division and
On an egg quality and even sperm quality. There's a place for co Q 10 showing benefit without harm. Right? And so no, we said earlier nothing's without any harm or any risk of harm, but very very little so I usually recommend if you're trying to get pregnant and you take cookie ton a dose of 200 milligrams three times a day. So this kind of a higher dose than sometimes people are on often prenatals now have just like 200 total in it. And
so we said the expensive ingredients are usually the
The the lower concentrations I can handle
and just enough so they can put it on the label.
Right which includes co Q 10 does the form of co Q 10 matter because you'll find them in gel capsules. You'll find the also find them in powder capsules.
I always say I mean there might be for the individual person. I mean absorption of medication is really depend a lot on gut health and other factors, but the number one issue is supplementation is that people don't stick to it. So I always say whichever one you're going to consistently take is going to be the better form,
right?
Question about L-Carnitine. Yeah, um in researching a little bit for this episode and others. I you know, oral L-Carnitine has been associated with some improvements in Ford motility and sperm may be a quality, but we know that a very small percentage of the oral L-Carnitine that want to ingest is actually utilized. So some people actually purchase and use injectable L-Carnitine which is kind of painful because it's an alcohol-based suspension. So not not not comfortable. It's got to be done intramuscularly, but my read of the data is
Kind of impressive. I wouldn't say super impressive. Are you ever injecting patients or having them inject themselves with L-Carnitine? This would be both male or female or male patients or both or using oral. Oh carnitine or do the data just not impress you enough to to motivate
that we use a gram of L-Carnitine with a gram of vitamin C for our male patients who have any abnormal sperm parameter. And so that is kind of what we consider these sperm enhancement protocol. And so that's that spread multivitamin.
Those two with a multivitamin and co Q 10 so that's kind of like the mail protocol. Of course, there's different specifics for one individual person. I don't tend to recommend it for most females that being said those who have endometriosis fall into a unique category where inflammation is so high that usually it's a different environment where we recommend L-Carnitine and acetylcysteine vitamin C and E. They kind of fall into a different category because even known inflammatory disease, but if we're just talking about
Out the person at whole who maybe wants to take some supplements for their reproductive Health that have very little side effects. And for the most part can potentially be helpful is going to be, you know co Q 10 L-Carnitine vitamin C can be helpful, especially for the male or the female partner. We're going to be looking at that extra vitamin D in addition to the prenatal with folic acid. And
what about women with PCOS? I get so many questions about PCOS my nauset also and there are we talking -
And also tall or the what? Is it? The D Cairo do I have that right? You do
know that right? Myo-inositol is the main driver of inositol and how it can be helpful. If you most Blends are going to have a combination of both of them but a much higher ratio of myo-inositol 2D Cairo and so myo-inositol is probably the one that really is doing the work and PCOS. What is it doing? It is definitely helping the body when it comes to insulin and sugar helping the body be more sensitive to insulin.
Eleanor less resistant to it essentially helping you respond to what you eat in a better way and also looks like it does potentially decrease some of that inflammation pathway in PCOS and PCOS this insulin resistance correlates with this testosterone production from the ovary meaning even metformin alone can decrease testosterone levels based on some of the change that it has the
ovary take note men.
How many guys taking metformin or berberine thinking? Oh, this is great. I'm gonna lower my blood sugar mimic fasting and live longer. And and then these are also the same people who are writing to me go. How come when I take that form and I either have headaches because I'm you know, essentially hypoglycemic but also their testosterone levels are getting crushed not in every case, but it happens
and I think that's what thinks people just don't think about they read that a supplement might be beneficial for this one thing that doesn't apply to them and they start taking it so
also
The evidence on Metformin extending life. We had Peter t on your talk about this like that the evidence for that is is like, oh so poor is just not really that convincing it may change but then now all the excitement about rapamycin and so, you know extending your life while plummeting your testosterone, you know, I mean, that's a actually that strategy has been tried in the longevity commuters. Are there was this whole castration idea, right? Oh, yeah. This was like the Heaven's Gate cult where they castrated themselves. They lured younger. Well, they ended up committing mass suicide so so that you know, they ended the experiment.
An early early, you know, yeah. So in any event going back to supplement. Sorry couldn't help myself supplements that women can potentially take just to increase their fertility. Even if they don't want to get pregnant as just kind of creating a milieu of Health you talked about the nutrition you talk about co Q 10, maybe I'll carnitine vitamin C the essential fatty acids getting at least 1 gram of EPA so that might require taking two grams of
Fish oil to get that the EPA myo-inositol. So how much are you talking about? I've seen some pretty high dosages thrown out there
for my own office. Yeah for night what 2,000 milligrams?
Okay taken before sleep, or it doesn't
matter. It doesn't matter that one doesn't matter.
Thank you for covering the topic of supplements and supplementation. This is probably a good point to return back to those harvested eggs. So eggs are out and there's a collection of them Frozen. Maybe just maybe
Lives are always alive. Sorry. I mean, we're not sporadically fresh breath the fresh sperm. They're not always live some portion of the ejaculate is going to be dead sperm right some live some for motile some non for Ford Motel the twitchers I read is the name of the right. Yeah. And so okay, they're going to wash the sperm. Why because yeah, most of what people see as a jacket or no, excuse me, as a jacket is is not actually the sperm, right? Okay, so but
murmur wash their in one compartment get the eggs out your you or your embryologist at your clinic is then going to at some point decide to combine them. So is it kind of is it a sperm race or are you maybe could explain ixy? And why would one want why would one opt for ixy and is are there any risks with exceed because there you're really at some level this is the only place where I can sit back and okay somebody who, you know side neural development like some level you're saying
That's Burma looks good. Whereas when you run a sperm race nature saying hey, this sperm really did beat all the other sperm.
So let's segue first because I think this is nice because a question I get asked all the time. We talk about nutrition and supplements. And all of that is to now you're doing IVF or you're freezing your eggs. And what if what behaviors are good or bad? Of course, all of those same ones are but about how long do you need to do them? And this is why if you live healthy most of the days, it doesn't really matter because that's how
You're living but we already know the sperm cycle is about 90 days and the eggs. I like to say another in the vault. They become they start lining up getting ready to exit the Vault and become more susceptible to the things you're doing in that 90-day window and we know that to be true as well. So they start to be pre-selected for who's coming out the next month they start to line up and so making these changes as you start thinking about getting pregnant doing fertility treatment is still extremely
Official people will often say well, I haven't been doing that. So why start now it's not going to make a difference but truly it can
we're I'll drink up until the
week until the day after
like I'm gonna have my two glasses of wine, which actually equates to about six glasses of wine when you measure out by how much opposed by the volume right right up until the week before getting pregnant or
something. Yeah. No. No, so so people always ask. What should I be doing? Is these healthy behaviors? And you should be doing you know this whole time.
When we do IVF, and I'm like, it's all the things you just ask but earlier you said well, how tolerable is it the truth is?
You give taking shots. These are subcutaneous shots during the growth process. So next to the belly button next to the belly button, like how a diabetic gives insulin a very small needle. I mean nobody loves shots, but they're not a big intramuscular shot. It's not like a flu shot or something like
that. It's have been to Austin the Texan mosquitoes their way. Were they hurt way worse and then one of these
needles exactly so you're going to use those medications for about 12 to 14 days. You're going to have your follicles grow. You're going to feel that.
Have pelvic pressure as your estrogen Rises, you're also going to third space your fluid, which means your fluid your water component of your blood is going to start to just seek out a little bit and you're going to get more bloated. You're going to have more water weight. You're going to feel puffier. And that is very common. Just because of getting the eggs to grow your going to mentally be fine because the female brain loves high estrogen. So you're doing fine as that's one of the main concerns is how emotional will I be and during this phase of the project?
Process people do great when we take the eggs out of the body. It's about a 20-minute procedure. It is usually done under IV sedation like propofol and Fentanyl and we are watching while we drain those follicles and get test tubes full of the eggs
you some people opt to not use any SIU. I hear the word Fentanyl and I'm sure a lot of you were like wait fentanyl crisis and I you know, obviously if I knows a drug that has its usage valid uses in the medical community. Does anyone just kind of
Up for you know,
just I mean we have an anesthesiologist who is really talking to the patient's I mean propofol is the base of it. Certainly there's some patients who may want to avoid narcotic usage and they use different strategies. I mean there was this huge great the retrievals podcast came out from like the New York Times doing a deep dive into a fertility clinic Yale where a nurse was siphoning off Fentanyl and herself for herself and replacing it with saline and giving patients sailing these this Clinic did not do anesthesia.
Abased propofol so they were supposed to just get fentanyl and have kind of a less pain environment not a no pain environment and not not just a few hundreds of women reported extreme pain extreme pain through the procedure really speaks largely to pay not being taken seriously when they went and found this out
what happened to can't help it us what happened to this technician. Well, I mean, yeah, they're they're they're trying to find fun. No Behind
Bars. Yeah, I mean and but it's you just
Is to like I mean, I can't imagine I can't imagine doing I do this procedure like all the time, right? I've done thousands and thousands in my career and I can't imagine having people be in pain during it. So it's but it's important to know that some clinics don't use IV sedation or they don't use propofol. They don't put you to sleep understanding what your clinic is using is really really important to set the expectations or to know am I going to be awake or am I going to be
asleep patient asked you to what specific drugs are
going to give me to
kill painter and I mean
Some clinics only do one like I am not going to do a retrieval under no sedation. Now some clinics would allow that some clinics. That's all that they do, but you that's a huge piece of the puzzle that you need to know. If you're a patient. Are you going to be feeling pain not feeling pain? What's it going to be? Like I'll see most clinics use propofol and put patients to sleep. And so you take a nice little nap for 15 to 20 minutes. The eggs are retrieved from the follicles under direct visualization.
They're in test tubes you wake up and you're going to feel crampy and you'll get a period 10 ish days later. But you this was when you'll feel your worse and this is just the one thing I want to say about tolerability of
it. Can you get pregnant in that
time? Yeah. Yeah, and there's a case report of an egg donor who is donating her eggs, and she had sex with her boyfriend and because not every egg is always retrieved from the follicles or some small ones could ovulate to and she got pregnant with quintuplets. Whoa.
Okay, so you have to really tell people not to have intercourse one from an infectious standpoint because we really are poking, you know pretty large gauge needle through the vaginal mucosa into the peritoneal cavity. So we don't want to introduce infection but also for pregnancy and that time period And if you got pregnant your risk of what we call ovarian hyperstimulation syndrome or ohss is very profound. So what is normally happening is after the retrieval your estrogen and progesterone are going to drop you're going to feel a severe.
Ask for lack of a better word. So you'll be more emotional. You're still pretty bloated until this all heels if you get ohss which is very uncommon in modern practice, but when you did fresh and briault transfers or people who don't utilize some of the modern protocols, this means that HCG continues to encourage all those follicles to make estrogen and progesterone and if you are pregnant, you're just kind of a constant yet exponential increase and HCG.
She and so this is going to get worse and worse. So we really don't want people to get pregnant in that time period
so when during that time period so they avoid sex. So is it in the few days before the extraction?
So typically I usually say it's from like day 5 of your simulation. Okay. So usually the earliest egg retrievals are kind of around cycle day 9 or 10 if somebody goes fast until your next period comes
That's usually about a three-week time period where we want you to abstain from intercourse.
So for the most part though, the more eggs, you have the more you're going to feel about this hormonal and physical shift than the fewer eggs that you have. So if you have a low egg count and you need to do IVF or freeze your eggs, and you might do multiple Cycles arounds, you're going to tolerate it actually pretty fine because you're not going to have these huge shifts. Physically, you're going to feel fine. And that's always a big concern when you mentioned earlier about different stimulation types people have this idea that things that are more natural.
Are better right just like this human thought that natural is good and synthetic is bad. Naturally you ovulate one egg a month when we're trying to get eggs out of your body. The success is determined by how many eggs I can get and how young you are so it doesn't make sense in most circumstances to do a minimal stimulation protocol meaning purposefully under stimulating Somebody by saving the
the money in medication cost in order to purposely get fewer eggs, because their odds of getting the ultimate success of what they want is going to be so much lower is there
I don't want you to be in the position of I don't want to put you rather in the position of kind of like having to demonize your colleagues in your profession, but I could see how there's a pretty significant financial incentive for people who really desperate to have children or who just simply might want to have children down the road to the here lost him.
Better we're talking multiple low stim Cycles. They might be even a fraction of the cost of a full steam cycle. But then there many many more we got most him
Cycles. You got it make a lot more money by doing things that are not in the best interest of the patient. And I mean that's not uncommon in my field, which is very sad, but it does mean that because reproduction in IVF or so foreign and unknown so many people walk in blind not knowing if what they're being told really makes sense for there.
The situation there are a couple situations where minimal stimulation makes sense. If you're only going to make three eggs, you're only gonna make three eggs. I don't need all the drugs in the world to tell your body to make three eggs because there's only three and so that is a scenario where minimal stimulation does make sense. And then there's the scenario where there's something called invo cell has your research to expose you to this no info cell is a way to try to take IVF into making it more financially accessible.
Bull for certain patient populations. Mainly people who don't ovulate like you're very refractory PCOS patient who doesn't respond to medication or we have tubal Factor infertility. Right? So your fallopian tubes are blocked because of chlamydia or endometriosis and we just have a problem here that egg and sperm can't get together because you're not ovulating or your tubes are blocked and invo cell. It's a device.
That is plastic and you can fit up to 10 eggs in it. And there's a little Middle Chamber where the sperm can go and so you go through this IVF process with the goal to only get eight to ten eggs because that's what fits in the device and then you put the sperm in the middle of it. And then you put it inside your vagina and you hold it in place with a diaphragm and the vagina is the right temperature to incubate and so you incubate your embryos in this little envelope.
All Container inside your vagina and then five days later you come in and we take it out and we take the best embryo and we transfer it and you can do a fresh transfer because you didn't make so many eggs. So your hormones weren't so high
do people like this procedure. There's something that seems like yeah, like staying in proximity to the sperm and egg like you're taking it home. Okay.
So I love this procedure and serum some circumstances and I see it applied often in the wrong case and that can be frustrating because it's still not cheap, even if it's cheaper than I
IVF it is still not inexpensive and any means and so patient selection like most things in this field are so important. So let's just say if you've had no like if sperm if the sperm is the problem then it's probably not smart to just presume that the sperm and egg will be fine and they're right like that might be a case where you really do need help with assisted fertilization or if you have unexplained infertility. If we don't know why you haven't been able to get pregnant because everything looks good on
Paper what if fertilization is the issue and these are circumstances where you pull out an invoice L. And there's no embryos and you don't really know where it went wrong. Was it the fertilization step. Was it the growth step of the embryos and culture. So you do have less data notably. I like data you can't do genetic testing and this isn't really a strategy that allows you to freeze embryos for future family growth. That being said the young patient who's got great egg quality who might have really bad PCOS or two.
Well disease it can certainly allow them the opportunity for a child at a lower price point when they still have many reproductive years to finalize their family. It also is a lovely option for people who need donor sperm to conceive because the success rates with this are so much higher than an IUI, which is what a lot of people use an intrauterine insemination or putting the sperm in the uterus. So now we're able to improve this outcome. So like are same-sex couples or are
Single parents by choice if it's a single woman who's trying to become apparent that they need to buy donor sperm and go through the process. Anyway, this often can improve that efficacy through the process pending their age and other factors. There was a study that was just really neat. There's a lesbian couple and one of them the eggs came out of and the other one incubated the embryos and then the other one had the embryo transfer or so, but a gave both Partners away.
A to feel a little more involved in the process, which I just think is always a really cool way. When you have these different options with reproduction
seems also that it's a more of a three-dimensional environment. I always imagined that the petri dish is approach is that so two-dimensional compared to the body and all these things? I haven't done cell culture before and you know cultured neurons and things of that sort of like there's all these concerns about like the concentration of CO2 and the thing or you know, you know, God forbid if there's a fluctuation in you have backup
Raiders and things but in the electrical flow to the incubators that's disrupted. Whereas the natural environment of the body, even though it fluctuates in temperature. It's I mean, this is evolved over tens of thousands. If not, you know hundreds of thousands of years to be the process by which embryos are created. So there seemed so here's where I sort of default in my mind anyway to the kind of like, oh like it seems more natural you're incubating in the more quote unquote more
natural environment, but at the same breath, why are you having infertility if you're an infertility patients?
Ain't right. So if you need donor sperm you maybe don't have infertility or if you have to build disease you have a very defined reason why we don't think that there's this huge inflammatory issue in your body or something unknown. So again, I'll see it apply to people who really are bad candidates for it based on their age or based on their diagnosis. And so it's not always better but for the right patient, I mean I've had patients have babies that way who otherwise may not be
All to so they can it can really open up the door. So that's the most minimal of the minimal stimulation. Right? Then we have minimal stimulation because you don't have many eggs. So we don't really need that. But for the vast majority of people who go through egg freezing or IVF. We are really trying to get as many eggs as you potentially have everybody has a different number but whatever you have whatever that antral follicle count is for you is what we're trying to get and that's what these combination of medications is trying to do when the X come into the
the lab if you have egg freezing, very important to know is before we get into the XE discussion. The eggs are stripped of their outer cells, which is called the cumulus. That's what the sperm has to attach to an order to fertilize in order to freeze the eggs. This cumulus cells are stripped off. The eggs are frozen you have to do XE. So if we're going to lead into the sexy conversation, if you're freezing your eggs your having XE when you fertilize them, so I don't want somebody to ever not know that if that is what they are choosing.
Annex e is you can tell us
yes, he stands for its icsi or intracytoplasmic sperm injection. It is taking a sperm that under the microscope looks normal in shape and moves well and you're pulling it up into a little needle and you're essentially using a little laser on the side of the egg or the Zona pellucida the egg and you're injecting that one sperm into that egg
cytoplasm and you're picking the sperm on the basis of
Shape motility. You're picking what you think is the best sperm in the batch.
Obviously. Yeah, you're picking. I mean, there's gonna be one sperm parag. So there's multiple sperm that are chosen, but you're picking sperm that look like they have the highest potential.
My understanding is that there's a range from very low to potentially high but hopefully not high of DNA fragmentation and pretty much every cell of the body like the cells always repairing its DNA. So when visually selecting a sperm 4X 4X e it's based on morphology shape and motility
right you
See the DNA damage inside the head of the sperm or the DNA itself,
but we soon David technology where you could actually like get a Dye that could label DNA fragmentation and select because I feel like so much like when we talk about embryology not to get too far down in the weeds, but like the the methods of selecting eggs and selecting sperm. I mean, these are the same methods have been used in embryology for like since the 1930s like oh this one looks good. That one looks good in the skilled embryologist can can really develop a
real talent at overtime of like knowing what correlated with healthy pregnancy and and an offspring but I do like technology you would think that by now 20:23 that someone would have some dye that you could drop on the sperm and go will like that one has a lot of DNA fragmentation and that one
doesn't rate there should be better ways to choose which sperm there's definitely people are trying things. Nothing has proven to be helpful so far. There's definitely some interest in this because we're starting to get more insight as we have become better at embryo.
Sure, getting embryos to grow doing genetic testing on embryos to understand that that mail genome kicks in at day three and there's a subset of people who have beautiful fertilization and embryo growth day 0 to 3, and that's all on the edge. And then as soon as that male genome kicks in you have this huge drop-off in your embryo number and even some of this is in the context of normal sperm parameters, right? So things aren't really normal though, or there's something underlying it.
He ended every embryo failure on day three posts fertilization is
Columbus not but it definitely means that none of the ones before that can be blamed on the sperm. And once after that there's definitely still maternal and sperm contribution.
We don't want to create any, you know, couple disputes around this
but it can be an Insight when you're trying to look through somebody's IVF cycle about potentially modifiable factors, right? Can you improve sperm quality by some of these lifestyle measures?
There's I mean the debatable thing about a DNA sperm fragmentation. So what is that? It is not a normal semen analysis, but it is like that as far as its a sperm sample that is then sent off to be evaluated how much fragmentation or abnormal DNA is in the heads of those sperm the Studies have shown that people who have abnormal DNA sperm fragmentation should do XE. Okay, that's like the point of the study now exceeds become very commonplace. So exci choose.
Seeing the sperm to put into the egg originally didn't exist. Right? So what's the alternative conventional fertilization? This is having your petri dish your eggs are on it. You scored your sperm you cover it up. You put it in the
incubator. She didn't mean you squirt. You're spraying she meant she meant did Tech the embryology
then pulls it out and then they seized by which eggs and sperm fertilized.
Well, it's really devastating to pull out the dish and have no fertilization and it definitely is a cause of infertility and it can be very hard to know that because fertilization is not challenged on a cellular level until you challenge it so exci used to be an add-on cost. It used to be a separate thing because it was harder to find embryologist who could do it. It's so standard that a lot of clinics do it the majority of the time purely because you often don't know all the
Bubbles that are impacting fertilization and you're trying to give somebody as many opportunities as possible XE has in a lot of those original IVF studies got some of the bad reputation of being the problem with why you might see that 1% rise of birth defects. And so exci took the brunt from a lot of that. We really don't see that when we're growing out and we're doing freezing the embryos doing Frozen transfers and I was I mean,
I do have seen almost every patient. I'm just saying everyone but
higher probability of success
probability of success and when you get to this point and so few people have insurance coverage. So they're spending their money. They're getting second mortgages. They're taking out loans. If there's one decision that you say well, I don't know you could have zero eggs fertilized or I could have the embryologist pick the best sperm and put them inside the egg and we expect a 75% chance of fertilization. That makes sense for the majority of people.
Yeah, that makes sense to me. I because I'm obsessed with data and you know the blood work fairly regularly not I'm not obsessively but twice a year or so. I'm now I didn't always do that and I actually did one of these DNA fragmentation test. They're pretty expensive, you know, they're in the more than a semen analysis. Yeah, they're there in the you know, low other sort of twelve hundred dollars fifteen hundred dollars or so, at least the one that I did it was very informative. Like I was relieved to see not abnormal levels of DNA fragmentation, but I will
Say that based on everything. You just said it seems like it might be the lower-cost option because you know, the alternative is to go through repeated cycles of IVF, and it's failing and that certainly much more
expensive and I mean, I will say that there is some current thought by my Urology colleagues, right? So I'm not a urologist but definitely when I have a male who needs a sperm extraction may be set apart your vasectomy, maybe he's got very low sperm counts and we're going and we're doing a sperm extraction procedure that
tin chili, if you have a patient who has an abnormal DNA sperm fragmentation and even with ixy has this drop off an embryo growth after day three because the sperm are still be made the same way or are they still fragmented that potentially the ejaculatory process could cause some of that fragmentation and certain men and the by going in and doing a sperm extraction and not subjecting those sperm to the rigors of ejaculation for lack of a better word could
Ali lesson the fragmentation and improve outcomes and I have some patients who we've gone down that road and that has helped them clear to say there's not a study that's not the point of DNA sperm. Bragg is to try to distinguish if potentially exceed could be a helpful technology but a lot of doctors are offering or doing exceed because we want you to fertilize your eggs when they grow it and culture as we talked about IVF changing the metabolic needs of the embryo, you know change throughout the process.
Us and so embryo culture has become so much more successful. But even in those best-case scenarios, we're looking at 50% progression. So you're going to have lost throughout that culture process. No matter
what and you said 50% progression. So half of the fertilized embryos that make it past a less a day seven, then they're screened for chromosomal abnormalities. So then okay, then you've got let's say two or three of those and maybe four depending on how many eggs were harvested and your age and then and and age. Yes, thank you. And then and then you said of those that are in
planted into let's say a woman you 45 or younger you're looking at about anywhere from 30 to 65 percent successful in Plantation and pregnancy would like baby healthy baby.
It's usually a 65% chance of live birth. If it's a genetically tested embryo that that a strike is the F and that's why you're going to see such varying IVF success rates because if you don't do genetic testing of embryos, let's use the 40 year old who makes four embryos, and I send them off for genetic testing. I anticipate she has one normal.
If I do genetic testing which takes its called PGT pre-implantation genetic testing, I am testing for aneuploidy as the traditional testing meaning does it have the right number of chromosomes. You can also importantly test for single Gene disorders like cystic fibrosis or Huntington's but if we're just doing PGT for aneuploidy, I expect an age-related proportion of your eggs to be normal or abnormal. So at age 40, I expect 20 to 25% normal so I can choose that one and put it in you and have
Of a 65% chance that you have a baby I could not do it. I sold the same for that one is in there. But if I go and transfer them each independently, I'm now going to have closer to a twenty to thirty percent chance of success, right? So it is not that I'm changing the embryo by testing it but I'm allowing myself to have higher utility of success higher efficiency putting somebody through less failed transfers, which is extremely important and less miscarriages because those also take time.
I'm and one of the most important things is that you have the opportunity to understand how many potential normal embryos you have and batch Cycles so you could go and do another cycle because I'm 40. I just met my person. I really want to have two kids because my sibling is really important in my life yet Naturally by the age I would be for that second child. It's going to be very hard to conceive. I can go through IVF and batch some embryos so I could save two or three.
For that second baby that I'm not going to transfer for a few years and that's called embryo Banking and that is changing the ways that people can potentially grow their family at later ages, but you don't know that unless you know, what's normal or not? And it also gives you the chance to go and intervene right now because right now especially if you're older I'm gonna have a higher chance of success then if I am for transfers down the road and maybe there was one miscarriage and there to we're
You know eight months down the road before I can go do another cycle and get more eggs versus of I found out that none of those were genetically normal the average 40 year old might have zero to one if they have average ovarian reserve per cycle. So they're going to need multiple Cycles. It's not that it's impossible, but it's just setting that road of expectation for them. But if I don't get any normal embryos, I can turn right around and go get more so I am using what's left and that ovarian Vault each month to try to get to that.
Uni of a pregnancy for you and a much more efficient way by utilizing genetic testing of these
embryos. This is where we can put an ellipse in then it sort of like dot dot dot healthy baby. Right and maybe in the future if we're lucky. We'll come back and talk to us about healthy pregnancy and a healthy baby on word. That would be a fun and important set of discussions.
I would like to touch on the one called the issue but the topic of menopause which I assume is defined as the cessation of Menses but there I'm guessing and I'm guessing it's a constellation of things that happen and I have a very straightforward question which is is there an acceleration of the onset of menopause. Are we seeing that nowadays are there good data on that should people try to delay menopause. What are some of the things that you talk to patients?
It's about in terms of their considerations of ways to ease that transition or maybe even offset that transition with hormone replacement therapy or other other
approaches. These are great questions. And I do think this is going to be a huge interest in upcoming years as we have learned more about the menopausal transition and the health risks really associated with being hypo estrogenic or having low estrogen menopause. If we Define it as ovarian failure, so your ovaries now have
have no eggs or so few eggs that they are refractory to the brain sending out FSH. So your brain is sending out all the FSH and LH that it can your ovary is done and not making any estradiol or progesterone anymore in this time period what we know is 1 are we seeing a population-based increase in earlier menopause? There's not been a study to say that observational and clinically I would say yes because I see so many younger.
In having low ovarian reserve or having premature ovarian failure or premature ovarian insufficiency, which is the more politically correct way of saying it but when we think about what this is is there are modifiable factors, right if you're running out of eggs is a variable and we already said certain things like smoking cigarettes and exposure to toxins and likely chronic inflammation and untreated disease. We know that having diabetes those things increase your risk of going into menopause earlier.
So paying attention to the lifestyle that you have when you're not concerned about your fertility right when you're in your younger years and maybe you're not worried about getting pregnant yet, or you're not worried about menopause, but those choices that you're making and those time periods at least for women. Your eggs are going to hold on to them. So they have an influence later similarly trying to live a lower inflammatory life and getting sleep and avoiding talking.
things of which you can is some of the best that you can do to try to naturally prolong when you'll go through menopause with a huge caveat that everybody is truly born with a different number and you do not control that you don't and so you might have been born with a lower number and you can't change that trajectory and you might have cancer and be exposed to chemotherapy which also will deplete your ovarian reserve but so do things like endometriosis
especially if it's not being treated in any fashion, so that's where we think the birth control pill or purchased an exposure or surgery ways to go and decrease the inflammation. It's that inflammation associated with endometriosis. That's really causing these women to have low ovarian reserve and go into menopause early. So not only is that impacting, you know fertility and how many eggs you get and how long you have to grow your family, but when you go into menopause earlier you have
Lower life expectancy than people who go into menopause later. And that's why you even said it earlier fertilities this variable kind of reflecting longevity and like Health overall. So what we do know about menopause is that having that low estrogen whether that happens at the average age of menopause at 51 52 or at an earlier time period it's not good for the brain, you know higher risk of dementia increased risks of osteoporosis increased risk of heart disease and stroke.
And essentially higher risk of death and that's not even to talk about the impact on your life what it can be like to have hot flashes heat and cold and sensitivity to have profound vulvar and vaginal atrophy to the point that you no longer want to have intercourse and the changes that it can even have on your gut and your immune system. So we as a community, you know of doctors, especially OBGYNs really recommend hormone replacement therapy in women who are going through menopause.
Pause and the key here is to initiate it right at the beginning that big Women's Health Initiative study, which came out forever ago and showed all this harm with hormone replacement therapy the big issue. There was that these people were hypo estrogenic for 10-plus years and one group and then started back on the hormones. And in that circumstance, they already been put into this higher risk category and their body had adjusted to not having the hormones and when re-exposed they had more
Adverse Events, but if you are starting on estrogen replacement and it can be various, but honestly the estrogen that we try to replace and this time period much more mimics estradiol we have estradiol pills if you can have vaginal inserts, you know patches so it depends on what's going to work for your life, but it is not the birth control pill most often lie in some people it might be that's what they choose but we really are trying to pick an estrogen. That is estradiol.
Or mimics that natural structure and you can't have unopposed estrogen without reaching the risk of endometrial cancer. And so that's why we need to have some progestin. So some people will choose a daily progestin some will choose a cyclic progestin and still have periods some will put in an IUD at this time period and then take their daily estrogen. There's a lot of different options. We're trying to find the lowest dose of hormones that relieves your symptoms to provide you relief from some of these lifestyle issues, but also,
So helps you not just live longer right? We're not just trying to live longer. We want to be healthy longer. We want to have a better quality of life. And certainly Women's Health has for long stop at this menopausal period and then it's been you're on your own kid. And this is when we're really starting to see that intervening at that place, especially for women who go into ovarian failure early. So those people who have low ovarian reserve who I diagnosed. I tell all of them. Hey if you don't freeze your eggs, or I never see you again.
And you're going to go through menopause early and when you do I want you to go see somebody I don't want you to just ignore it and suffer with these symptoms, which is something that does commonly happen. So just making sure that women are empowered to know that these symptoms are what happens. It's what happens naturally but by giving their bodies more estrogen and not crazy high doses, but just these physiological levels can really improve both the quality and the longevity of their life.
Is it just the
Since of these symptoms that signals the onset of menopause or is there are there additional cues like for instance if their cycle is getting shorter or longer
you certainly will have cycle changes and we consider that the perimenopausal period where you're starting to really start seeing a spacing out of your period. So they're no longer coming that perfect ovulatory pattern when you get into the low ovarian reserve but you're still ovulating regularly. They first shorten as we said earlier, but then when they start link
Neener you start skipping months. That's a real big clue that things are not going in the right direction. And if you find out you have very very low ovarian reserve or you're approaching that perimenopause period you're gonna start to have more prolonged periods of low estrogen and you'll feel mentally cloudy fatigued more headaches more hot flashes lack of libido those bolvar vaginal symptoms overall more likelihood have depressed mood and that's a lot.
There's a lot well Natalie, dr. Crawford. I want to extend a huge thank you on behalf of myself. I've learned so much from you today about fertility about Hormone Health for women and you've also touched on a number of important issues about Hormone Health and fertility for men along the way. So it's truly been a master class in fertility and hormones and really touch on topics that are so essential to everybody even if people aren't seeking to conceive or maybe think they don't want to I mean
So many considerations that really extend back to one's teens and if one is beyond their teams, like whatever age people are essentially they need to think about these issues and make important decisions and you've really also clarified a lot of the what I think are quite destructive myths that that are prominent out there about for instance egg Harvest and what that does to one's fertility. So first of all, thank you for joining us today. I know you're extremely busy run a clinic you have a image of family as well co-manage a family I believe but
But you know, this is the sort of knowledge that is so challenging to find in one place and yet you also have a number of really spectacular avenues that you deliver information Instagram podcasts books and things of that sort. We will refer everyone to those links. I've learned so much from you over the years really in following your content. And today you've just like far exceeded all already high expectations. So thank you ever so
much. Thank you for having me and just thank you.
Giving a space to talk about women's health and fertility and Reproductive Medicine. It means a lot to me and it means a lot to the people who really are trying to do their best every day. So we appreciate it.
We appreciate you and with some luck will commit you to come back and talk to us about pregnancy and bit more on some of the topics that we move through quickly. Thank you. Thank you. Thank you for joining me for today's discussion about female hormones and fertility with dr. Natalie Crawford. You can find links to her clinical practice as well as to our social media handle.
Owls in the show no captions, please. Also check out the link to her excellent podcast entitled as a woman. If you're learning from and are enjoying this podcast, please subscribe to our YouTube channel. That's a terrific zero cost way to support us in addition, please subscribe to the podcast on both Spotify and apple and on both Spotify and apple you can leave us up to a five star review, please also check out the sponsors mention at the beginning and throughout today's episode. That's the best way to support this podcast if you have questions for me or comments about the podcast or guess that you
Me to consider hosting on the huberman Lab podcast, please put those in the comment section on YouTube. I do read all the comments not during today's episode button on many previous episodes of the human Lab podcast. We discussed supplements while supplements are necessary for everybody many people drive tremendous benefit from them for things like enhancing sleep hormone support and improving Focus. If you'd like to learn more about the supplements discussed on the huberman Lab podcast, you can go to live momentous spell do you s so live momentous.com hubermann if you're not already.
He following me on social media. It's huberman lab on all social media platforms. That's Instagram Twitter now called X threads Facebook LinkedIn and on all those places. I just got signs and signs related tools some of which overlaps with the content of the huberman Lab podcast, but much of which is distinct from the content on the huberman Lab podcast. So again, it's huberman lab on all social media platforms. If you haven't already subscribe to our monthly neural network newsletter, the neural network newsletter is a completely zero cost newsletter that gives you podcast summaries as well.
Toolkits in the form of brief PDFs. We've had toolkits related to optimizing sleep to regulating dopamine deliberate cold exposure Fitness mental health learning and neural plasticity and much more. Again. It's completely zero cost to sign up you simply go to huberman labs.com go over to the menu tab scroll down to newsletter and Supply your email. I should emphasize that we do not share your email with anybody. Thank you. Once again for joining me for today's discussion with dr. Natalie Crawford and last but certainly not least. Thank
You for your interest in signs?
