Everybody should get an AMH test. I

think it's a very important marker. If

you are listening to this and you want

kids one day, ask your doctor for this

test. It is not a test of egg quality.

And we talked about what egg quality is,

right? Genetics and egg competency, but

it is a ch of how many eggs you have.

And that knowledge can be really

impactful for how you view your future

and your plan.

>> Welcome to the Hubberman Lab podcast,

where we discuss science and

science-based tools for everyday life.

I'm Andrew Huberman and I'm a professor

of neurobiology and opthalmology at

Stamford School of Medicine. My guest

today is Dr. Natalie Crawford. Dr.

Natalie Crawford is a double board

certified physician specializing in

obstetrics and gynecology, fertility and

reproductive health. Today we discuss

the actionable steps that all women can

take to improve their reproductive and

hormone health. Both to enhance

probability of successful pregnancy, but

also because fertility and hormone

health are strong coralates of general

health and longevity. Dr. Crawford

shares what all women, regardless of age

or reproductive goals, can do to enhance

their health using lifestyle, nutrition,

supplementation, and prescription

medical tools that she indeed uses in

her practice. We also have a very honest

discussion about biological versus

chronological age infertility. Why age

is not just a number, but also why it is

that many women do successfully conceive

in their 40s. Of course, there's a lot

of information online nowadays about

women's hormones, fertility, and health.

Today, thanks to Dr. Crawford, you'll

learn what is known and documented and

what she has herself consistently

observed clinically in her practice

about women's health and fertility. Few,

if any, people have Dr. Dr. Crawford's

training, clinical acumen, understanding

of the new research, and incredible

ability to communicate the well and

lesserk known actionable steps for

improving female health. Dr. Crawford

also has a new book out entitled The

Fertility Formula: Take Control of Your

Reproductive Future, which again focuses

on reproductive health, but also hormone

health and how both of those things

impact female health in the short and

long term. 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,

today's episode does include sponsors.

And now for my discussion with Dr.

Natalie Crawford. Dr. Natalie Crawford,

welcome back.

>> Thank you so much for having me. I'm

thrilled to be here.

>> And congratulations on your new book,

The Fertility Formula. It's no small

feat to complete a book. And it's and

it's especially a big feat to complete a

book that offers people so much advice.

not just people who want to get pregnant

but also looking at things through the

lens of fertility as an important health

metric.

>> Yes. Thank you so much. You know what

goes into writing a book and it's always

been this aspirational goal of mine and

after educating and talking about

fertility with patients and people

online. It's been something I've wanted

to do. But I will say it is a much

bigger feat to go through it to work

with editors to try to refine

>> within your word count. I, you know, was

20,000 words over and try to bring it

back in. So, thank you for having me and

for holding it up and reading it early

and sharing your endorsement for it to

you. That means so much.

>> Yeah, I am insisting as much as one can

insist that various people in my life

read this book um including family

members and other people because again,

it's not just about people who want to

have children or who already have

children, but fertility as a way of kind

of knowing where one is in their health

arc, in their life arc. Um so if you

don't mind um how should people think

about fertility purely as uh a readout

of health? I mean just how do you how do

you frame this for like if somebody

comes to you and says listen uh they

have kids or they don't want kids or

they're not sure if they want kids but

um why use fertility as a lens on

general health? Yeah, fertility is a

health marker. And I love that you bring

that up the top of the episode here

because so often patients, women

specifically, think fertility is only

the ability to get pregnant. We really

simplify it into this one phase of life.

But if we want to zoom out, your

fertility is a sign that you have good

hormonal health, good cellular, good

metabolic health because it takes so

many different moving parts to ovulate,

for an egg to allow a sperm to

fertilize, to implant, to get pregnant.

But also, your hormonal health and the

ovarian function is really going to

impact your entire life, how you feel on

a dayto-day as a woman. But if we want

to be really specific, if you have

infertility, you have increased rates of

metabolic syndrome, cancer, heart

attack, stroke, and dying early. Those

are extremely scary statistics. And you

know, I had my own infertility journey.

So I fall into this category. But the

reason why is not that infertility

causes any of those things directly.

It's that for most people, it's one of

the first warning signs that something

is not right in their body and that

there's higher levels of chronic

inflammation or insulin resistance that

we know can impact long-term health

outcomes.

for women who are still of reproductive

age. And I realize there's no strict cut

off um we can and and certainly will

talk about what are the measures direct

and indirect of fertility that um can

give them a window into their kind of

health span risk factors, lifespan risk

factors. For women that have already

reached menopause or in pmenopause, um

how should they think about fertility as

a health marker? Meaning if somebody is

has passed the point where they can

safely um get pregnant,

>> does that mean that their periods are no

longer informative? I imagine their

periods features about their menstrual

cycle are still very informative about

their general health.

>> As long as you're having a menstrual

cycle, it is a sign that you're

ovulating and you theoretically could

get pregnant. So I think it's really

important to say that even in pmenopause

which is the transitional time between

having regular appropriate hormonal

function that reliable characteristic of

the ovary responding to the brain. This

is the transition time as you're

starting to get to a lower egg count

that you will eventually start to see

some cycle changes but you also have a

lot of hormone dysfunction. But you can

still get pregnant. And in fact I see a

fair amount of patients who said I

thought I was past that stage of my life

based on my age. But if you're still

having periods, it's a really important

window into your hormonal health. It can

tell you a lot about your body,

especially if you know when you ovulate.

And we can look at the distinct phases

of the cycle, the follicular phase and

the ludial phase. When we're a little

bit past this, menopause by definition,

which I hate, is 12 months without a

period. So menopause is one single day

in time. Really, it means you've been in

ovarian failure for 12 months before

you'll magically get this diagnosis. But

menopause at its purest is ovarian

failure. The ovaries no longer have the

capability to respond to the brain

signals. You're not going to make

estrogen or progesterone anymore. At

that time, a woman's metabolic health

completely changes. But the age of which

you went through menopause really can

impact your reproductive health outcomes

long term. And some of the

characteristics you might have had in

your cycle when we look backwards can

inform us some about your cellular

health now. So, it's still really

important to think back and move

forward. And then on a bigger scale,

we're seeing the tide turn on hormone

replacement therapy. And I know that's

not what this entire episode's about,

but as a reproductive endocrinologist, I

love estrogen. I love hormones. And I

think it's really important for women to

know that you can start hormone

replacement therapy at any time. So even

though long time ago we felt really

comfortable starting it right at the

time of menopause, we're starting to see

benefits starting it in the

permenopausal period. We see a benefit

starting it once you have menopause. But

I think it's a disservice to women to

make them have no period ovarian failure

for 12 months, no estrogen, feel

terrible before we'll allow them to have

hormone replacement therapy. Yeah, this

is such an important theme and and if I

may um I I realize I have to be very

careful uh to not draw parallels to

men's hormonal health when talking about

women's hormonal health because it's not

a one for one. They're very diff

distinct processes. On the other hand, I

think thematically what I'm about to say

I believe holds. So hopefully it won't

upset too many people which is you know

for many years now um for reasons that

uh are unfair. Um

hormone replacement therapy was

>> sort of became widely available for men

before it became widely available for

women. There are reasons for this. We

don't have to go into it but they're the

kind of obvious ones. Um uh that things

were pushed to market more quickly and

and so forth. But there's been this

idea, you know, should there it's

usually testosterone replacement

therapy, right? Um, and there was this

idea that unless somebody fell below 300

NOGS per deciliter for for a male that

they weren't um uh that they shouldn't

get testosterone replacement therapy.

Now, it's kind of understood that if

somebody chooses, they can usually find

a doctor that if they're at the low end

of normal, they can push to the high end

of normal or to the middle of the of the

range so that they can get their

symptoms away and just feel right to

optimize within the normal range. That

sort of And so I'm relieved to hear that

you're saying the same is true for

women. And I'm relieved to hear it

because I think that having these strict

cut offs of like no periods for a year,

well, I mean, it could take a long time

to reach that. I mean, what if it's, you

know, two periods per year, right? Does

that mean that that person doesn't

deserve the therapy? Which is what

essentially what I think you're saying.

So, the R in hormone replacement is the

dangerous letter in my opinion because

there is this notion of augmenting

hormones.

>> Exactly.

>> Okay. So, for forgive me for going long,

but I think the two situations it would

be great if both women and men could

augment their hormones to be at the high

end of normal or wherever puts them in a

place where they're not experiencing

symptoms.

>> Absolutely. We know that as humans, we

now have longer lifespans. We outlive

our reproductive hormones. Yet, they are

essential for our day-to-day function

and to feel our best. And we should at

least be given the opportunity to have

our symptoms evaluated, to be offered

hormone therapy if we want it, and to

not have to have these harsh cut offs,

especially for something that can be so

protective long term. I mean, for women,

we see it be cardioprotective. It can

help lower the risk of Alzheimer's

disease. Of course, it can be protective

for your bones. So, I love this greater

discussion and it really stems from

learning about your body, knowing what's

normal so you can advocate for what's

not normal, and really feeling like you

have your own agency over your health

and your own future.

>> I'd like to take a quick break to

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I wish that the medical profession um

could agree on nomenclature that

included hormone replacement, the R

replacement therapy for people that are

out of range, you know, that are too too

low, out of the normal reference range.

Hormone augmentation therapy. um for

people that want to push within the

normal range. And then of course there's

super physiological stuff and that's

kind of how all of this got here was

there were a bunch of mainly guys taking

tons of anabolic steroids and then

>> estrogen's a steroid, you know,

testosterone is a steroid and then it

just became a long road to get to this

point where people like you are able to

even talk about this, right? I mean, I

think 10 years ago, I think the medical

profession was not open to the idea that

a 40-year-old woman, for instance, who

had not yet undergone menopause by the

strict definition, would take estrogen.

It was seen as a risk as opposed to a

benefit.

>> Isn't it interesting? And, you know, by

professional organizations, they would

even call it menopausal hormone therapy,

MHT, not even just hormone replacement

therapy. And I talk about this a lot

with my patients, the difference in

replacing a hormone, we'll use in an

embryo transfer cycle. If I'm going to

give you estrogen, you haven't ovulated,

I now have to replace your progesterone

or I have to give it in a certain format

that it can get to high enough levels

versus supplementing. Your body's making

some and we're supplementing that or

augmenting it like you said to get it to

the appropriate level or to make sure we

have enough.

I've given hormone therapy for a long

time, right? I've been out of practice

for over 10 years. And what's so

interesting is that we'll use premature

ovarian failure. So going into ovarian

failure before age 40, well accepted

that these women need hormone

replacement even when they still have

the low end of hormonal function. So in

this population, we've been doing it for

a really long time, but for menopause,

it's been so frowned upon because of the

WHI and fear-based tactics about what

would happen with hormone replacement.

So, it's interesting and I'm really glad

to see the tide is turning and we're

really allowing people to

stand up for themselves to also know

what's normal within their body, which

sounds so common, but if we think about

it, many women have been dismissed and

gaslit for so long. And if you go to

your doctor and you talk about your

painful periods or your irregular cycles

or your bloating that you have with your

period and some of these red flag

warning signs, the spotting, the this,

and it gets pushed to the side, when you

start to go through actual hormonal

change later, it's really hard to then

believe yourself. And so I think it's

really important, you know, I have a

whole chapter in the book about how to

learn to track your cycle and your

ovulation and really learn to see the

red flags your body gives you. Not just

if you want to get pregnant now, but to

know that your hormones are really

functioning as they should. And that's

going to help you stand up for yourself

later when you're in this transitional

period. Because pmenopaused or

diminished ovarian reserve, like we call

it in the fertility world, I mean, that

can last 5 to 10 years. That can be a

really long transitional period that

women are going through and they deserve

support if they're not feeling their

best.

>> Are all um now I want to call it hormone

augmentation, hormone, let's just call

hormone replacement for for sake of of

simplicity. Um hormone therapies uh for

women, do they always start with

estrogen when it comes to trying to

encourage fertility or push fertility or

well-being out into um more years?

>> That's an interesting question. I think

when it comes to hormone replacement

therapy in general, we've got estrogen,

progesterone, testosterone. Most women

when they start not reliably making

estrogen, that's when they really start

to feel bad. And so, typically, some

type of estrogen replacement, and

there's many different ways, right?

There's patches, there's pills, there's

vaginal inserts, there's vaginal cream

often helps some of the symptoms they're

having. But progesterone alone or in

combination can be a big player.

Progesterone also is not made if you're

not ovulating well. So there's this

tandem where often you need both of

them, but I have some permenopausal

patients who feel great on just

progesterone. To me, testosterone's the

last one we add to the mix and it will

always depend on clinical scenario.

There's nuance. Estrogen and

testosterone can convert back and forth.

So for most women, if they are

adequately being replaced on estrogen

and they still have functioning ovaries,

so in this transitional period, they

tend to not need testosterone, but

that's never 100% of the time. I think

greater to your question about how is

there a way for us to extend the ovarian

lifespan is a really good one.

We know that women who go into ovarian

failure early, so when we look at that,

we call it POI, the premature ovarian

insufficiency group, their ovaries have

more inflammatory markers. They have

more chronic inflammation and fibrosis

inside the ovary. There's a higher

prevalence with autoimmune disease or

chronic inflammatory disorders. So I

think there's also something to be said

despite have not having the perfect

paper to sit here and say that we know a

variety of different things that

increase chronic inflammation cause you

to have a lower egg count and are

associated with earlier menopause or

earlier ovarian failure that paying

attention to these factors earlier in

your life whether it's controlling an

autoimmune disease earlier diagnosis of

Hashimoto's whether it's treating your

endometriosis

or cultivating a lifestyle that's

decreasing inflammation, right? Avoiding

certain toxins, eating anti-inflammatory

foods, the type of exercise, and how we

deal with those lifestyle tenants that

that likely has the capability to extend

our ovarian lifespan to the degree that

it can.

>> I know these days people are very

concerned about plastics. Yeah.

>> And you mentioned toxins, so I was going

to get to this later, but I'll just ask

now. How concerned are you about plastic

water bottles? And um I mean, we can't

avoid exposure to plastics. And I think

one thing that Dr. Rhonda Patrick has

done nicely is to highlight the fact

that the really small, hence

microlastics are really the ones that we

worry about the most because they can

get into so many tissues. But we're

constantly ingesting plastic. Some of

them are just excreted um because

they're big, but some of them get into

our cells. Are

>> are there any data that have you or

observational um data that have you

genuinely concerned that plastics are

becoming more of an issue visav

fertility?

There definitely is concern. I I always

want to frame this and you did a nice

job of it. So I'll I'll double down. The

goal when we talk about toxin avoidance

is you can't avoid everything. You

cannot avoid every toxin in this world.

Nor should we try to have this all or

nothing mentality, which is what so many

people do. Oh, if I can't avoid it, I

just will totally ignore it. Then in

general, when we want to think about

toxins, there's many different

mechanisms why plastics can be harmful.

When it comes to microplastics, as you

mentioned, we know they can accumulate

in the ovary. So, if we want to be

really transparent and simple, your

ovaries must function in order for you

to make estrogen and progesterone, in

order for you to ovulate, in order for

you to get pregnant. So, if

microplastics can accumulate inside the

ovary, that's obviously detrimental

towards fertility or ovarian function.

On a greater scale, we know that some of

the endocrine disrupting chemicals that

are in plastics have been associated

with worse IVF outcomes, lower live

birth rates, longer time to pregnancy,

and these are population-based cohort

studies. So, there's no randomized

control trial. So, we have to limit it.

And there's some truth to the fact that

people who might be more exposed to

plastics may have other lifestyle

factors such as we know plastics can

also be in food wrappers, right? So

maybe they have more of an ultrarocessed

food diet. So it's never one specific

thing, but I look at all of these

lifestyle factors and I include toxins

as one of them. These are all either

contributing to your inflammatory burden

or they're helping you. And when we

start thinking about optimal hormonal

health and fertility, it is your

decision every single day. Am I drinking

water out of this cup or out of a

plastic bottle? Am I going to lift

weights, do nothing? Am I going to run?

How much sleep am I going to get? What

foods am I going to eat? How do I deal

with stress? And these choices, even

though one single one's not going to

make it or break it, together, they can

add up to that inflammatory burden or

they can help decrease it. And that

chronic inflammation does in fact matter

to your fertility and does worry me. I

realize I'm jumping jumping around here

a bit, but um in just thinking about

what seems to be on a lot of people's

mind. I took a informal poll of some

people heading into this because

obviously I I only know my own

experience as as a male. So, uh to a

number of

>> women, I asked the question um you know

what are you wondering about? And a

common question was um it seems that for

some women if they've been pregnant once

before

uh they have it in mind that it's going

to be easy for them to get pregnant

again later or easier. And of course

they understand the logic that they were

younger before by definition even if

it's a year, right? Um and that

fertility drops off with time. But there

seems to be this um kind of belief uh

that if one was pregnant before that

it's going to be possible to get

pregnant again within the normal windows

of biological windows for getting

pregnant.

>> Is there any evidence that having been

pregnant before makes it easier to get

pregnant again that's separate from the

fact that obviously they were pregnant

before? I realize that it's a convoluted

question but it's it's not a perfect

experiment, right? Because they've been

pregnant before. Obviously, they can get

pregnant if they haven't. The control

group is not a very

>> uh it's not a good control group for an

experiment. But for within the person,

if they've been pregnant before, can

they exhale a little bit that yes, they

can get pregnant?

>> I did fellowship research with the

primary investigator on a large cohort

study, one of the biggest ones we have

on natural fertility. And this study was

called Time to Conceive. And it was

looking at women who did not have a

history of infertility, who were trying

to get pregnant, who were 30 and older.

And then we looked at different

variables of them. And one of the most

startling pieces of data is that there's

a huge age related impact of fertility.

Right? This data set set the standards

for the numbers that we quote. Meaning

if I will sit here and say if you're

trying to get pregnant with your first

child and you're 30, you'll have a 20%

chance per month. Right? The finest

point we look at in natural fertility

studies is called fakundability. The

probability of pregnancy per month. But

as you age, when you're 35 to 36, that

number will be 11 to 12% per month. At

age 38, it'll be 5% per month. And at 40

and beyond, it'll be 3% per month.

Importantly, for the person hearing

this, none of those numbers are zero.

And so, by no means do we mean you can't

get pregnant. But in the group who had a

child before and were trying to conceive

with the same partner, that number

stayed between 18 to 20% up till age 37

and then it dropped.

>> So, we do see that

There is this protective benefit for a

multitude of reasons, right? You

conceived with that person, so they had

sperm, right? Sometimes I find out some

patients, the male partner has no sperm.

And we didn't know all that time they

were trying.

>> Oh my goodness.

>> Right. Oh, I've had patients try for

years, be dismissed by their doctor

>> because men and women mistakenly think

that because there's semen, there's

sperm.

>> Exactly. There's ejaculate, so there

must be sperm inside of it.

>> And then when we find out there's none,

it's it's heartbreaking. And it's a big

reason why we can segue and say one of

the things I really hate the most right

now about my field is that by definition

infertility is a failure and we don't

even recommend testing or screening or

talk about a preventive approach at all

until you have failed. Yet if we look at

the population say okay the definition

of infertility is trying to get pregnant

for 12 months and then once you've

reached that point well now we'll check

a semen analysis now we'll do an

anatomical investigation now we'll check

your ovarian reserve now we will discuss

if you're ovulating so we're making you

go through this period of time where

you're trying and yes maybe the majority

of people will get pregnant but most

people who do will get pregnant the

first six months. So 72% of people will

get pregnant in that first six months of

trying and only 13% will get pregnant in

the next six months of trying. That's

why if you're 35 and older, we will

shorten that testing interval down to 6

months. But sitting across from so many

people who've tried and tried, went to

their doctor, their doctor said, "Oh,

you're fine. You're young. You're this.

You're that." Forced them to try longer

and fail. And then to find out fallopian

tubes were blocked. They had a birth

defect of the uterus. He had no sperm.

She had low ovarian reserve. And they

would have intervened differently back

at time period A had they had that data.

Really makes me feel like we have to

switch how we approach infertility in

the world where infertility rates are

rising. Women are waiting later to get

pregnant. It doesn't really make sense

to make people fail first before we'll

even do an investigation. We should test

things and if it's all normal, maybe you

do just go try your six or 12 months. we

would capture people who don't get

pregnant and be able to help them at a

sooner time period which is so valuable.

So to your origin question there is data

that having a child previously puts you

statistically at a higher chance of

getting pregnant again. But secondary

infertility is real. This is where

you've gotten pregnant before and now

you're having a hard time conceiving

your second child. I want to acknowledge

that it's really hard for people who

walk it because they weren't expecting

it. They're a little underprepared for

it because they said, "I got pregnant so

fast before." They come into it just

assuming it will be as easy.

They watch their children have a longer

age gap, a bigger age gap than they

wanted. But also, they don't really fit

into the community, meaning there's a

really robust infertility community and

they support each other. And so many

patients who have secondary infertility

say they feel caught in between feeling

guilty that their child's not enough for

wanting more. Of course, they're

thankful for their child, but not really

fitting into that category yet also

simultaneously feeling left behind their

friend group or their family group or

watching their family start to look

differently. And so even in women who've

had a prior child, age does become

impactful. It's not the only variable.

We also see that you know sperm counts

change with age. So your partner sperm

count will change with age. We see egg

quality starts to change with age

largely because metabolic health changes

with age as well. And then we see things

like endometriosis and adnomiiosis which

are tincture of time diseases. It's

simply you've had more time. So there's

a higher probability that these dis

diseases could be present. So I think

it's important to say yes you can

probably take a sigh of relief that most

likely you won't have trouble again. But

if you've been trying those six months

after and you're not pregnant, I would

say kind of at the longest, go and get

an evaluation. And if you're a little

bit older, maybe started your journey a

little bit later, it's never too early

to get an evaluation for anybody at any

time cuz you can't make decisions on

data you don't know.

>> I'm a big fan of knowing the data and

then making the choice that's right for

you and your circumstance versus taking

population-based data and just applying

it to every single person.

>> Yeah. All excellent points. And um with

respect to the sperm testing since

clearly there are men who think they're

making uh sperm and they're not. Um

there are at home tests of that as well.

So once again men have it a bit easier.

They can do it at home. Although I don't

know how high quality the at home tests

are.

>> There are some that are just telling you

almost like a pregnancy test plus minus

are sperm present are sperm not. Of

course that's not really telling you the

full picture. There are though some

mailin tests that go to a true lab that

we would even take as valid. So, it's a

it's called a CLEA certified lab, CL L I

A for somebody listening and you can

find some of these online mail and sperm

test and collect a sample. They send you

the whole kit. You mail it off. It's

very valid and you get all the sperm

parameters that we would then look for.

So, that's a great way to get data

yourself and not have to have your

doctor tell you no or go to a fertility

clinic. I mean, we'll do a semen

analysis for anybody who calls and most

clinics will. It's usually earlier that

patients are getting roadblocked,

whether it's their PCP or their regular

OB/GYN. They're getting dismissed and

just, oh, just try first. It's probably

fine.

>> You mentioned that if a woman has had a

successful pregnancy, that the

probability of getting pregnant again is

significantly higher, although with the

caveats you mentioned, is there any data

about if someone has been pregnant and

either terminated or lost the pregnancy,

whether or not that's related to ability

to get pregnant again later?

>> It's a good question. And most of the

data that exists is looking at prior

life birth. So I think there's a couple

things. If you've gotten pregnant,

regardless of the outcome of that

pregnancy, if it's with the same

partner, we can feel confident that they

had sperm present. So that's already one

leg up over never getting pregnant. If

it was an intrauterine pregnancy, we

know at least one fallopian tube was

functioning. So that's also in the camp

of we're checking some mental boxes of

some of the things that we think about.

And we know your body could accept an

embryo implanting at least to some

degree. The top cause of pregnancy loss

is going to be random genetic

abnormality. This wasn't the right

embryo or the embryo didn't have the

right capacity or capability to truly

implant. So I think that should give you

some sigh of relief that it's probably

going to be a little bit easier because

certain boxes are checked. I think it's

also really important to say I mean I

had four pregnancy losses myself. I

don't know if you know this. So I had

four pregnancy losses. Yeah. I mean, and

and by the way, could I really

appreciate the personal story uh sharing

in the book because it um it really

clearly was in service to your patients

and to the to the reader and even as a

male who can't relate certainly to

certain aspects of all this. Um, it was

it was not only very moving, but it was

it was really a testament to just how

that sort of thing lands and then the

process of trying to sort out what's

real and it just made me even more

grateful for the the other information

because otherwise I mean it would sort

of be like if I'm talking about ovarian

health, right, which I've I've talked

about on podcast

with all the caveats, you know, that

that how but of course how could I

possibly know? So the your personal

experience well while the reader and I

you know feel feel and felt for you in

in reading it. It is it is super

impactful because people there's a level

of trust that just comes from somebody

who's been through that whole jungle.

>> Thank you. I'll try not to cry on the

show about it which is funny because

it's so long ago, right? I have two

children now had them after this journey

and it was terrible for so many

different reasons. Of course going

through pregnancy loss is an emotional

roller coaster. I started to have a lot

of self-lame against myself. Felt like

it was my own body. Something was wrong.

And professionally, what I was

unprepared for is I was this was the end

of OBGYn and then the beginning of my

reproductive endocrinology fellowship.

So I felt like how am I going to be a

fertility doctor, Andrew, if I can't

even get myself pregnant, right? The

professional impact of how it made me

view myself in my space, I was so

unprepared for. Right? We especially in

an era where you separate your personal

and professional life, which is, you

know, what was 100% accepted back then.

You know, my last pregnancy loss was an

ectopic pregnancy. My fertility nurse

had to give me my methtoresate shot. I

mean, everybody knew about it and I felt

like a really big failure. And when I

sought help to say it'll happen, just

relax. there's nothing you can do or

even just do IVF felt so dismissive of

what I felt like was true as the patient

experience say well what about this

symptom or what about this question and

just really really pushed aside and I'll

be honest it made my whole career is

different because of it which isn't that

interesting how sometimes things happen

to us that are not ideal and that can be

really terrible I have the two kids I'm

meant to have but also I have forever

viewed fertility differently. In fact,

all my fellowship research was on

natural fertility because of it. Cuz I

said at the core, I want to know why

some people get pregnant naturally and

why other people don't. Like, I really

want to know that. I want to do

epidemiologic research. I got a masters

in clinical research because that

research is very complicated to

understand and most fellows do an IVF

lab project, which is great, but it's a

lot more of a controlled environment.

And then I've been so passionate about

talking about it since then. And so I

think to walk back, what I wanted to say

though is if you've gone through

pregnancy loss, I don't want to ever

dismiss how terrible that experience is.

And sometimes it can feel that way by me

sitting here as a professional and

saying, "Oh, you had a pregnancy loss,

so that could be a good sign for the

future."

>> And I don't want anybody to ever feel

that hearing it. But it does tell us

that certain systems are intact. On the

other hand, after two pregnancy losses,

you need an evaluation. The evaluation

is for certain blood tests, a semen

analysis, a sperm fragmentation, and a

uterine and tubal evaluation. That can

be moved up to one if you had heavy

blood loss, you know, needed a DNC

procedure. If your periods have changed

afterward, if anything was really off,

you can always get tested. And we never

want to be in the world where we used to

make women go through three pregnancy

losses before they would get an

evaluation. And I fell into that camp

after two. I said, "Shouldn't we do

tests? I'm starting to fall off the

curve here. Isn't something wrong?" And

I was told, "You need to have another

pregnancy loss before we'll do those

tests." It was the worst thing, the

worst feeling that I had to fail again

to a certain degree and lose a pregnancy

before they would even investigate why.

>> Yeah. That this theme it seems of like

it's only menopause when you haven't had

a period for a year. you have to have

two pregnancy losses and then we can put

you into this category of

>> like amendable for treatment. I mean

it's so it's um something really

backwards about all of that. I I imagine

with your book and um you being public

facing with health information and

hopefully others

>> um with you in your field that

eventually this will change.

>> I mean if I were to draw the parallel to

psychiatry which isn't a fair one. I

mean, should someone really have to um

be waking up at 3:00 in the morning for

an entire year and have no uh hope for

the future and be near suicidal before

they get whatever the adequate treatment

is.

>> We'll treat them for depression or

whatever is going on. It doesn't

>> it doesn't make sense. I don't think it

serves us. And I will say this too,

>> we're starting to see a change.

>> My big lofty hope for the book is that

it changes the entire field of

fertility. like I understand why OBGYn

used to take care of this and then at

some point they said some people have

infertility let's draw a line in the

sand and have some people specialize in

this right and I did three years of

training in that after OBGYn but at the

same point it doesn't make sense to

practice that way it doesn't make sense

to force people to fail and I might tell

you hey the greatest likelihood is all

the tests will come back normal but we

should do them because sometimes it

doesn't Right? If I look across somebody

who has recurrent pregnancy loss and I

say 80% of the time every test will come

back normal. But 20% is is a big number.

That's a lot of people who maybe it's a

simple medication, maybe it's a

procedure, something can marketkedly

change what they're going through. And

in the same breath, the 80% really need

specialized care because what's really

going on if we don't have an easy test

for it. So I agree with you. I think the

whole field needs to change. I think we

need to change how we define terms, how

we address women, how we approach

reproductive health and hormones and

fertility and really in a more proactive

patient centric approach and women and

men are driving this really by talking

about it. 10 years ago when I started on

social media, nobody talked about

fertility. And patients who did had

nameless, faceless accounts and now you

see celebrities talking about IVF,

talking about endometriosis, talking

about their termination for genetic

reasons or whatever happened. And those

stories are so powerful to drop the

stigma, but also highlight how wrong it

is that we force women to fail before

we'll even evaluate what's going on, let

alone treat.

>> As many of you know, I've been taking

AG1 for nearly 15 years now. I

discovered it way back in 2012, long

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been taking it every day since. The

reason I started taking it and the

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designed to support things like gut

health, immune health, and overall

energy. And it does so by helping to

fill any gaps you might have in your

daily nutrition. Now, of course,

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day. But I'm often asked if you could

take just one supplement, what would

that supplement be? And my answer is

always AG1 because it has just been oh

so critical to supporting all aspects of

my physical health, mental health, and

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K2 with your subscription. Again, that's

drink AG1 with the numeral1.com/huberman

to get six free travel packs and a

bottle of vitamin D3 K2 with your

subscription. One theme that I heard uh

over and over again um was um women

would say, okay, they thought that they

might have been pregnant before or they

knew they had been pregnant once before.

Circumstances varied, but they sort of

had it in mind that they could get

pregnant at one point

>> and that their mom had one either them

or a sibling um let's say at like age 42

or 43 and they're in good health

themselves. Um and so they had it kind

of in mind that there's time. I think

this is not uncommon. Um and given that

uh life is very expensive. Um most

people in the world seem to be underpaid

nowadays. Um and

uh people are waiting longer to get

married and have children. Um, and the

other common narrative that I was

hearing was that there are

>> people that want kids, but that it's

under the, "Well, if I found the right

person, I would do it, but otherwise I

wouldn't do it on my own." That's not

always the case, but it's it's pretty

true statement. It's it's a it's a

common theme, right?

>> So, for those women, which I think is

quite a few, whether or not they're in

their 20s or their 30s or their 40s, um,

what sorts of things do you recommend

they would add to that? Uh, rather just

kind of real life analysis. Those are

not meaningless metrics like how old

would one's mother had a child or for

instance

>> but things have changed microplastics

maybe certain things have gotten better

right we're no longer eating margarine

I'm not trying to be facicious here I

think that there's so many variables

people are living longer yet they're

more environmental toxins perhaps I mean

people are smoking less so it the

>> are they though

>> are they we'll talk about nicotine for

sure um so

for those women um in their let's say

20s30s and early 40s.

>> Yeah.

>> What's the level of urgency that they

get certain things checked out and what

should they get checked out? Oh, and I

should say that um they'll say that

they're having regular periods.

>> I'd love to answer it and I'm going to,

but for the person who's maybe coming to

this discussion,

>> let me let's explain egg quality really

quickly because it really is going to

tie into what we can test and what we

cannot. As you know, well, women are

born with all the eggs they're ever

going to have. The eggs are kept I like

to think about it as in a vault inside

your ovary. And so they're stored there.

You have the most eggs when you're five

months old inside your mom. You have six

to seven million eggs. By the time that

you're born, you have 1 to two million.

By the time you start your first period,

you have half a million. So you lose

eggs over time. A lot of the

determination of that starting number

will be influenced some by genetics and

some from your mom's health while she's

pregnant with you, things she is exposed

to, her current disease state. What I

want people to think about is every

single month you are losing eggs. So I

like to imagine and describe to my

patients a group of eggs is coming out

of the vault. Each egg grows inside a

small fluid fil structure called a

follicle. The brain sends out follicle

stimulating hormone or FSH well named

gets a follicle to grow. As the follicle

grows, it makes estrogen. This is called

the follicular phase. Estrogen levels

talk back to the brain. Remember that

the brain does not see what's happening

anywhere in the body. It is simply

waiting for the hormone signal. That's

what hormones are. They're communication

signals. I like to think about it like

text messages between friends. When

estrogen is high enough for long enough,

200 picoggrams for 50 hours. And that's

the level it'll tell the brain it's time

to ovulate. The brain will send out a

surge of LH. A follicle will then

rupture. Egg will be released. It only

has 24 hours to be fertilized. But that

follicle will actually reform and become

the corpus ludium. Now we're entering to

the back half of the cycle called the

ludial phase. The corpus ludium makes

progesterone stimulated from LH pulses

from the brain. So then it makes

progesterone pulses throughout the ludal

phase. Can only live for about two weeks

unless a pregnancy occurs. When you have

an embryo come in and implant, it makes

hcg the pregnancy hormone we check in a

pregnancy test. Fun nerdy fact, hCG and

LH share a receptor. So HCG comes into

the corpus ludium and now stimulates a

constant production of progesterone. But

if that doesn't happen, corpus ludium

will die, progesterone will drop, and

you'll get a period. Okay? Also, back to

the vault, you have a different number

of eggs that come out every month. That

is proportional to how many remain. So,

when you are younger, when you have more

eggs, more eggs come out of the vault

every month. As you get older and you

have fewer eggs, fewer come out every

month. That explains why you go from 6

to 7 million to 1 to 2 million. And why

you go from 1 to 2 million to half a

million, because you had more, you're

losing more.

At some point, everybody will be out of

eggs, right? We're going to call that

ovarian failure and not menopause for

the sake of our discussion. But so,

everybody will go into ovarian failure.

Now, the timeline once you have your

your clock is now up because at that

point, there's no more eggs. You cannot

get pregnant with your own genetic

child. You still have a functioning

uterus. It's just not being stimulated.

So, importantly, those women can get

pregnant with donor eggs or donor

embryos. they can still carry a

pregnancy. That's sometime a myth that

people think about, but once you're out

of eggs, that's kind of the end of your

clock. Now, two things are happening

with time that are really important

because your eggs are inside that vault

inside your ovary is that they absorb

the wear and tear of your life. And your

egg has many different functions. It has

to respond to hormone signals and make

estrogen, make progesterone, and

ovulate. The mitochondria inside the

egg, which everybody knows the

mitochondria, the powerhouse of the

cell, gets exclusively passed on to the

embryo. It's completely controls embryo

growth and development. In fact, the

male genome doesn't even kick in until

day three after fertilization. Oh, those

first few days are 100% maternal.

The egg also has to hold the chromosomes

in correct position. So, an interesting

fact is that inside the egg, it is

frozen in metaphase of meiosis 2 for

whatever reason. And so the chromosomes

have met in the middle and they're held

apart by those myotic spindles and they

do not separate until you ovulate. And

so then you get your egg that has what

we think about as your 23X and the other

part goes into a polar body. Okay, this

means that when you're 25, your eggs

have only been held in metaphase for 25

years. Your chromosomes are for the most

part still in the right position. Your

proteins are strong that are holding

them apart. Most people have better

generalized metabolic health. Their

mitochondria are stronger. When you are

40,

40 years have passed. We've asked those

chromosomes to hold there longer. I

always say if I have a line of

kindergarteners and I ask them to stand

for 40 years, like somebody's going to

get out of line. So tincture of time

adds up. But the other thing that

happens as we get older is as a

population we get more metabolically

unhealthy. So we see more chronic

inflammation, more insulin resistance,

more obesity. And all of those factors

influence oxidative stress,

mitochondrial health, DNA damage. They

can damage the myotic spindles holding

those chromosomes apart. So we also see

more genetic abnormalities as we age but

that is worsening as metabolic health

worsens too. Okay. We don't have a

direct test for egg quality. That's what

we call egg quality. Genetic normaly and

egg competency. How good are the

mitochondria? Can it do its job? We

approximate it to age which has some

fault because not all 40-year-olds are

created equal.

When we think about ovarian reserve,

this is how many eggs you have

remaining. So this is how many eggs are

inside the vault. And we can approximate

it with a blood test called AMH. AMH

stands for antimmalarian hormone. It's

made from the granulosis cells that

surround each follicle. So in its purest

form, more eggs inside the vault, more

come out, more AMH. Fewer eggs in the

vault, fewer come out, lower AMH. Not a

perfect test. The vault also is not

perfect. So there's some month-to-month

variability in how many exactly get sent

out. And in prolonged periods of not

ovulating, AMH can be suppressed,

whether it's from birth control pills,

pregnancy, postpartum, whatever the

reason is. So AMH is imperfect, but it

is something. And it's a very simple

blood test. It's not telling us if you

can get pregnant or not, but it is

telling us how many eggs do we have

outside the vault. And the way I like to

frame this is that every woman who wants

to have children or understand her own

reproductive timeline should get an AMH

checked. That is against medical advice.

Meaning the American College of OBGYn

says that women should not get an AMH

checked unless they have infertility.

Okay. This is wild to me. Right.

>> I mean to me as well. I mean it just

seems like like this failure criteria.

It just seems so it seems just very

extreme and unnecessary.

Unless there's some uh hidden agenda to

try and prevent people from maintaining

fertility or sense or having children

because and that doesn't square with at

least my assumptions.

>> The idea here is that it can be really

stressful. This is what they say in

their document American College of

OBGYn. It can be very stressful for a

woman to find out she has a low AMH and

that it doesn't predict fertility. And

there's some truth to that. So let's

think about real I have two

30-year-olds. one has 20 eggs outside

the vault, which would be age- related

norm and one has five eggs outside the

vault. Well, if every single other

factor is the same and they each are

ovulating one egg, they have the same

chance of getting pregnant, right? So,

that's not a faulty statement. However,

the person who has five eggs will not

have as long to grow her family. She

will not get as many eggs if we're doing

advanced treatment like egg freezing or

IVF because I can only get the eggs

outside the vault to grow. So, it's

hugely impactful for what your journey

may look like in treatment. But more so

than that, Andrew, so many of the causes

of a low AMH directly contribute to

infertility, things like autoimmune

disease, insulin resistance,

endometriosis, smoking cigarettes. So,

if there are factors, some of which you

can control, some of which you can

treat, if I have a woman who has a low

AMH, I'm not going to sit here and say,

"Okay, well, you can still get pregnant.

No worries." I'm going to say I don't

know that you'll have infertility, but

some of the reasons your AMH is low can

cause infertility. You will get fewer

eggs if we're freezing your eggs or

doing IVF. You will go into menopause

earlier. So, we need not wait, right? To

your point, the woman who's 20, 30, 40,

thinking about this,

she might make a very different decision

when she knows she's really faced with a

timeline that is less than ideal. And

why should we allow time to be making

that decision for us instead of at least

playing an active role? I sit across

from women every day, find out they have

a low AMH. And I say this, like, let's

do the investigation to see if we can

find out why. Probably 50% of the time

we find an autoimmune disease. I can't

reverse the clock, but I can slow down

the rate of inflammation, right? If say

if it's Hashimoto's, suddenly we can do

thyroid replacement. We can work on

decreasing inflammation. And if

inflammation harms our ovary, maybe we

can slow down that rate of egg loss. At

least she's being treated and probably

feeling better and we'll have improved

fertility outcomes because her

Hashimoto's is treated. So, we should

look at why. Why is it low? And treating

that why very well may impact fertility.

We also might say, what should we do

about this? You know, I have a lot of

couples who are partnered who are just

waiting for the right time to get

pregnant. So sometimes we say, well, we

could get pregnant, but I'm in medical

training. I'm going to law school. I'm

doing XYZ. It's not a good time. Well,

when faced with their perfect time, they

may not have eggs anymore. Suddenly, we

reevaluate where we are. And there's no

one right answer. We might choose to try

to get pregnant now. If we don't have a

partner, we might buy donor sperm and

try to get pregnant. Maybe we freeze

eggs. Maybe we freeze embryos. Maybe we

do none of those things. But we made the

active choice, right? Sitting here

saying, "I chose not to pursue treatment

knowing my AMH was low and that I might

be an ovarian failure at the point when

I was planning to have a family and I

know that makes the journey so much

easier to walk because you made that

active choice from a place of

knowledge." That was your autonomous

decision versus saying, "I asked my

doctor for an AMH test 5 years ago. They

told me it wasn't medically recommended

because I don't have infertility. And

had I known that information, then I

might have done something different.

That was the longest discussion to say

everybody should get an AMH. I think

it's a very important marker. It's a

newerish test. We've only been checking

it for about the past 10 years. It's not

a perfect test. I don't have the

nomogram for exactly how it should drop

over time. And I like to think about it

as categories.

Normal, above average, below average,

critically low. And based on your

category, we should probably talk and do

different things. If you are listening

to this and you want kids one day, ask

your doctor for this test. If they say

no, you can order it yourself at a lab

core request. Many of the online

platforms like function health. You can

have an AMH checked through them. You

can ask your doctor for it and say,

"Well, if it's low, I know I'll talk to

a fertility doctor to find out more

information or call a fertility clinic

and just say you want fertility

testing." The end. Okay. I think it's

such an important marker. It is not a

test of egg quality. Again, we talked

about what egg quality is, right?

Genetics and egg competency, but it is a

check of how many eggs you have. And

that knowledge can be really impactful

for how you view your future and your

plan. So, I think everybody should get

an AMH. I think we've got to learn to

track our cycle. And I know you said in

the vignette that these women have

regular cycles.

Having a regular period is really good.

It's much better than having an

irregular period. But knowing when you

ovulate and tracking ovulation is a much

more sensitive health marker than simply

when you bleed or when you have a period

because tracking ovulation is going to

allow us to know how long is your ludial

phase and how long is your follicular

phase. And ovulation disorders progress

through a very predictable pattern. And

we know this well. The first stage of an

ovulation disorder is a ludalphase

defect meaning a shortening of your

ludal phase. So, you're ovulating, but

the brain and ovary have a

miscommunication

and we don't make progesterone long

enough to sustain the ludal phase. Less

than 11 days is a short ludal phase, but

you'll still have regular cycles. So, if

I sit across from somebody and I just

say, "Are your cycles regular?" And they

say yes and we carry on. I've missed the

fact that they actually have a shortened

ludial phase and that warrants further

investigation. prolactin, thyroid, AMH,

PCOS, looking at different causes. The

second stage of ovulation disorder is a

long glutial phase. Takes the ovary

longer to actually respond to the FSH

stimulus from the brain. And then from

there, we'll progress into irregularity

and true amenorhea or absence of

periods. But those first stages, you

might miss the little red flag warning

sign that something's wrong inside your

body because you just tracking when your

bleed is and it's every 34 days, so you

think it's normal. But if we were

looking at when you actually ovulated,

we have more data. So learning to track

ovulation as opposed to just cycle

tracking, I think, is one of the most

important skills a woman can have for

learning to listen to her own hormonal

cues. Amazing. Um, just, and I don't say

that lightly, you just explained egg

quality, the biology of the of the, uh,

ovulation cycle and how it links to the

actionables and, um, I'm just struck.

It's, uh, awesome. Um, and

>> it has me asking a couple of practical

questions. Um, some people will have

insurance, some won't. Uh, what's the

cost of an AMH test? Let's assume

insurance doesn't cover it.

>> Um, and they just have to go completely

out of pocket. Um, and before you

answer, I will say uh whatever it is, I

think it should probably be compared

against what it would be to try and um I

don't want to say rescue, but but sort

of not take the test and then you know 3

years later you're trying to harvest

eggs. It could be multiple cycles

because you you realize it was only five

eggs per uh

>> you know per month as opposed to age

match, right? 15, right? Exactly. So um

so are we talking hundreds of dollars,

thousands?

>> 79.

>> $79. Yeah, we're withholding a $79 test.

And I I feel really strongly about this.

I do not view myself as the gatekeeper

of information about your body. Do you

want hormone levels checked? Do you want

an AMH? I do not think that is the role

of a physician. And now I can say your

insurance doesn't cover it. You can make

the decision if $79 is worth it to you.

But in the age of information where

that's an easy test to do, every lab

runs it and it's relatively inexpensive

compared to freezing your eggs or I IVF.

I mean, right, multitudes. $79. We're

throwing a fit over a $79 test.

>> Wow. Um,

I'm going to make sure that message goes

far and wide. Um, because I, you know, I

thought you were going to say maybe in

the high hundreds or thousands, which

for some people is going to be, you

know, prohibitively expensive. Yes. I so

get AMH checked. I think I'll avoid

going into too much editorializing here

because I'm really just interested in in

how you view this, but how you describe

the sort of the the way your field has

originated and where it's headed reminds

me a little bit of I remember in the 80s

there was a a genetic testing was

starting to become possible and a lot of

it was happening at Stanford having

happened to grow up near campus and I

remember hearing you could get tested

for like Huntington's disease which

>> is can be a devastating disease. Um, and

the idea was people don't want to know.

People don't want to know. I think

everything I've I've observed, I can't

speak for everyone, but everything I've

observed about people's interest in

their own health and genetics and what

genetics does and doesn't mean tells me

that people are actually much more

interested and they're much smarter

than, let's just call it the traditional

medical field, certainly medical genetic

testing gave them credit for.

>> It's like people aren't idiots. You can

sit someone down and say, "Hey, listen.

you have this gene, there's an X

probability. Here are the things you can

do to protect yourself. And but there

was this assumption like people don't

want to know because now they're going

to live in dread and their life is going

to be destroyed if they know they're

going to get full-blown Huntingtons or

something like that.

>> It's so paternalistic.

>> It's actually um I mean it borders on

unethical. Um people are smart. People

can take in information and they can

make decisions that don't necessarily

crater them on the basis of just

knowledge. I mean it feels like we sort

of treat people like children like

little children and even little children

would probably want to know certain

things. Um although you don't want to

give them genetic information but

certain things like hey you have a

challenge with X Y and Z and you can

overcome it in the following ways.

>> Technology is advanced. It has how we

counsel and how we approach health care

needs to advance also. Meaning

>> we don't live in a universal healthare

system. We don't have only X dollars to

spend on every single patient. And in

certain circumstances when that's the

case or a patient has limited money, we

do have to make very judicious decisions

about the best use of those dollars. But

for the majority of people who will be

listening to this, they are willing to

spend money on their health. And it

shouldn't be a society or a physician or

somebody standing in the way of getting

data that can dramatically impact your

life. And because you mentioned

Huntington's, I should say, right?

Autotoomal dominant disorder. People

have very strong feelings on if they

want to know they have it or not. And

I've had patients because we can test

for this with IVF. So we do genetic

testing of embryos and we often do

screening to see if the chromosomes are

in the right position which we talked

about for age. That can be really

beneficial. But we can do single gene

testing as well. PGTM for monogenetic

diseases and Huntington's is one of

them. And I've had some patients say I

my mom had Huntington's. It was the

worst experience to watch her go through

that. I would love to test my embryos,

but I I've committed to myself that I

don't want to know if I have it or not.

Okay. And I think it's really important

just to mention that disease to say we

can blind test you. You know, we can you

can make a probe to see if you carry it

or not. You don't have to know and we

can still test the embryos. And I've had

a few patients who them themselves did

not want to know, but we went through

the steps to make a probe in case they

did. In both cases, the patient did

carry it, didn't find out that they did,

but they could assuredly transfer an

embryo that did not have it because

often they these people have felt so

strongly watching a family member die

from a terrible progressive disease.

They've said children are not in the C

cards for me

>> or I'm not going to have genetic kids or

sometimes they'll come to me and saying

we have to use an egg donor or sperm

donor because I might carry this and

don't want to know. So again, it's the

idea that that should be your own

individual choice whether you want to

know or not, but it shouldn't be the

society or somebody else putting this

roadblock up and it's such an antiquated

approach in the era of technology and

access where you really can get so many

data points. Why should somebody be

making the decision on if that

information is valuable to you?

>> Yeah. And I think with blood testing,

the price coming down, um it seems to

me, maybe it's just the circles I run in

that people want more information as

opposed to less. But I'm glad that you

raised this um these cases where people

don't want to know certain certain

amounts of information. Um

one thing that Well, I'll just pose this

as a question. How many women out there

um do you think know

if I have to be careful how I word this

if doing a egg harvest cycle um

decreases their ovarian reserve or not.

>> The majority of patients that I sit

across from will tell me I'm afraid to

freeze my eggs or do IVF because I don't

want to go into menopause earlier. So,

the myth that doing that is going to tap

into the vault and pull out eggs is

inaccurate and a fear that really does

need to be busted because it doesn't.

It's a limitation of the science that I

can only get the eggs outside the vault

to grow. If I could tap into the vault,

it would change the game. But right now,

I am limited by the eggs you give me,

the number of them controlled by

whatever's outside the vault. We in IVF,

we just give FSH, same hormone your

brain makes trying to stimulate more

than one egg to grow. Your body doesn't

want to have five kids or 12 kids or 20

kids. So, it has checks and balances to

prevent that from happening. I, however,

would like every egg outside the vault

to grow because in nature, you will

ovulate one and everything else will

die. You are constantly losing eggs no

matter what. when you're pregnant, when

you're breastfeeding, when you're on

birth control before you start your

first period, constantly losing them. I

cannot change that right now. So, doing

IVF or egg freezing is not going to

decrease your ovarian reserve. It is

simply going to influence one month in

time trying to not have all those eggs

die.

>> And I think the myth is that um by doing

a cycle of of egg freezing that you're

taking more eggs from your reserve. Um,

but as you pointed out, women are losing

the same number of eggs each month or

follicles each month regardless. You're

maximizing on that process by just

maturing more and taking them as opposed

to letting them die.

>> Exactly. We are not running out of eggs

early. I think it's just based on,

again, nobody understands basic biology.

So, we think in our brain, I'm just

losing that one egg since I'm ovulating.

We're not thinking about all of the ones

that were sent out of the vault who

weren't chosen.

>> Yeah. And I think people will also

assume um because they haven't been told

that if you do an egg, you know, if you

stimulate for more to mature that you're

somehow

>> um taking away from eggs that you would

have had,

>> you know, stuck around somehow. So we're

hitting we're saying the same thing

three different ways.

>> So you're giving I mean it's fascinating

to me if you think about it because we

are allowing the possibility for you to

have children in your family that likely

you would not, right? Because if you

were to get pregnant naturally that

month, the greatest probabilities it

would just be one that you would

ovulate. Yeah. For IVF, we can sometimes

take one month's group of eggs in time

and have a couple different embryos and

those become a couple children for you

that you have from this one exact

cohort. I think it's so fascinating, you

know, early IVF days. I mean, IVF's not

that old. It's only been around like 46

years. I think the oldest IVF babies,

we didn't have gonadotropens. We didn't

have FSH. um that was you know synthetic

or purified and so we couldn't get

multiple eggs to grow. So original IVF

patients had to go live at their IVF

clinic and they had urinary based

hormone measurements done every day so

they could try to gauge when as

estradiol was rising when they were

getting closer to ovulation and in those

days this is just science they went and

they did abdominal surgery to aspirate

the egg. Now we do a vaginal egg

retrieval where we take a needle

attached to a vaginal ultrasound. just a

minimally invasive procedure. But back

in the origin IVF studies, they had to

go and do an abdominal incision to put a

needle in the one single follicle to get

the follicular fluid and the egg out. So

it was very low odds of working. It was

crazy to even think of. But the advent

of gonadotropins, the ability to first

started by purifying FSH and LH and be

able to give that to people to stimulate

more than one egg. understanding this

concept that there's so many more eggs

that you have outside the vault every

month that has changed the game and it's

such an amazing advancement in science

that we can leverage that physiology for

egg freezing or IVF.

>> Very practical uh question. Um it's

clear that the younger that a woman is

the the more eggs that uh could be uh

frozen in a given cycle. But I think

it's fair to say that many people either

because of finances or life

circumstances that could be not having a

partner and wanting a partner before

having kids, this sort of thing, um are

waiting, right?

>> They're just waiting. What stands

between um us now in the United States

and egg freezing being covered by

insurance 100%. I don't hold any

superpowers, but there are, you know,

there are pretty powerful ways to lobby

um all the administrations regardless of

who happens to be in office when that

actually happens. I mean, it is

possible, right? That the the phone is a

powerful tool. Advocacy is a powerful

tool. I do think that um things can

happen um if there's a lot of advocacy.

So, um first question is, you know, what

would that require and um is that a good

idea?

I am a fan of knowledge and options and

egg freezing is not a guarantee. So you

know how I pose it to patients is we are

going to keep the door of opportunity

open longer for you and that is our goal

if we want to compartmentalize it as

some people will falsely sit across from

me and say oh egg freezing is an

insurance policy for my fertility and

it's not because an insurance policy

always pays off but it's an investment

in my fertility like investing in the

stock market like probably will pay off

but depends on external factors that we

don't have yet right so the ROI is yet

to be determined but in general general

considered to be a good thing. I think

it would be absolutely incredible to be

in a place where egg freezing could be

covered and you know there's definitely

countries where it is that they have

said well the birth rate is dropping we

want to keep the reproductive lifespan

open for some patients we want to offer

this I think to be honest and

transparent the number one restriction

against that that we see as a field

right now is the camp of people who are

ethically or morally opposed to IVF for

reasons of embryo disposition

Embryo disposition.

>> Yeah. Like the personhood of an embryo.

Is an embryo a person?

>> I see. Because embryos that are not used

are going to be either kept frozen or

discarded. And to those people, that's

seen as essentially killing a baby.

>> Correct.

>> Right. That's their that's their view.

>> Yeah. And we should acknowledge that I

have many patients right now who are

donating embryos, you know, when they

are done with their family, which is an

amazing way to kind of pass forward the

opportunity and for other couples to

have a family. And I also just want to

say at the top of this is that IVF is

incredible. 17 million babies have been

born in this world because of IVF. So I

think this technology is great. Does

that mean everybody has to do IVF? No.

You are allowed to have your own

feelings and decisions about anything

that you do, IVF included. And there's

often things we can do within the

procedure for patients who might have

religious or ethical concerns to limit

the number of embryos that we make or

only transfer embryos that are created.

And that's important to know to bring

that up if that's your line in the sand

is that we can often do things

differently based on your beliefs. It

might be less efficient. It might cost

more money. It might have a lower rate

of success, but I've had patients walk

that road and that's the way it felt

comfortable to them. In this country,

there's a camp, but not to get too

political, um they're really pushing

something called restorative

reproductive medicine, and they're

opposing a lot of the American Society

for Reproductive Medicine's um attempt

to get fertility treatment and fertility

preservation covered. And their

rationale, even though a lot of RRM I'm

a huge fan of, it's about teaching women

cycle tracking and getting to the root

cause and really supporting

understanding your fertility, like

bullet point 10 on their list is that

IVF is unethical. But these people are

ostensibly pro-child. So that I'm not my

political stance. People often speculate

like I'll be really honest. I don't like