How Women Can Improve Their Fertility & Hormone Health | Dr. Natalie Crawford

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 acknowledge one of our sponsors, David. David makes protein bars unlike any other. Their newest bar, the Bronze Bar, has 20 gram of protein, only 150 calories, and zero gram of sugar. I have to say, these are the best tasting protein bars I've ever had, and I've tried a lot of protein bars over the years. 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Again, to get the fifth carton for free, go to davidproin.com/huberman. Today's episode is also brought to us by BetterHelp. BetterHelp offers professional therapy with a licensed therapist carried out entirely online. Now, I've been doing therapy for a long time, and I can tell you that it's a lot like physical workouts. There are days when I want to do it, and there are days when I don't want to do it. But when I finish a therapy session, every single time I come away feeling better, knowing the time was well spent. And that's because typically I come away with a valuable insight or new perspective that I hadn't considered before. Something perhaps that I'm working through with regards to work or relationships or simply my relationship to myself. With BetterHel, they make it very easy to find an expert therapist who can help provide the benefits that come from effective therapy. They have a short questionnaire to help match you to a therapist. And while BetterHelp has an industry-leading match rate, if you aren't happy with your match, you can switch to a different therapist at any time. And it works. BetterHelp has an average rating of 4.9 out of five for its live sessions based on over 1.7 million client reviews. Also, because BetterHelp is done entirely online, it's very timeefficient. There's no driving to a therapist's office, looking for parking, etc. If you'd like to try BetterHelp, go to betterhelp.com/huberman to get 10% off your first month. Again, that's betterhelp.com/huberman. 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 before I ever had a podcast, and I've been taking it every day since. The reason I started taking it and the reason I still take it is because AG1 is, to my knowledge, the highest quality and most comprehensive of the foundational nutritional supplements on the market. It combines vitamins, minerals, prebiotics, probiotics, and adaptogens into a single scoop that's easy to drink, and it tastes great. It's 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, everyone should strive to eat nutritious whole foods. I certainly do that every 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 performance. I know this from my own experience with AG1, and I continually hear this from other people who use AG1 daily. If you would like to try AG1, you can go to drink a1.com/huberman to get a special offer. For a limited time, AG1 is giving away six free travel packs of AG1 and a bottle of vitamin D3 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 politics and I'm very disappointed in the current state of politics um on both sides and I try and go issue by issue and I realize that's itself is a controversial statement. You're supposed to take a hard stance for or against. But I think that as a biologist um I look at certain things and I go all right. And I look at other things and I go, "Oh my goodness, like like what stone age are we living in?" And so I think that um to argue uh whatever it is that one believes about it seems to me the IVF, at least to me, maybe I just I'm too uh through my own lens, but the whole notion of freezing eggs and creating embryos seems very pro-child to me. So it doesn't square with with number 10 on this list. I agree with you. I agree with you. And I think a lot of the people who are a fan of RM might actually agree with you and I, but there's definitely people who are very adamantly opposed to IVF who put number 10 in there because they have a different agenda. I'm a fertility doctor, right? I want as many people to have a family as they desire. I want you to fulfill your life's dreams of having a child as a part of it. I want to do everything I can to help you have that. I am not here to sell IVF or force IVF. I at the end of the day it impacts me zero what you individually choose to do. But I believe that across the board people deserve the tools in the toolbox. They deserve to be presented with all the choices. We could try Clomid. We could try IUI. We could try surgery. We could try IVF. Oh, you're getting older. We could freeze your eggs. They're just more tools. There's more opportunities. And in based on your circumstance, your financial, your beliefs, you should be allowed to choose. I feel very adamantly that one's own beliefs that cause you to want to put it at number 10 on the list should not be the beliefs that we enforce on everybody. Especially when we know that IVF can be so powerful to help so many people have a family. It should be something that is offered to you if indicated and you get the choice. And so back to the origin, it would be incredible to live in a world or a country where egg freezing was offered to women as we do see people are waiting longer to start their families. It would allow more people to feel less pressure, less pressure with a partnership and on their relationship, not to feel like, oh, this better work out because my clock is ticking and be able to really feel like they could chase one dream not at the expense of another. I think we're further in this country than we want to admit from that. We can't even get fertility treatments covered for patients with cancer when we know that chemotherapy is going to deplete their ovarian reserve. We have some states that we can't even get egg freezing covered for them. So this is state by state. This is state by state right now. We would we would love federal protection for everybody. We would love to be able to see. I don't know. To me, that's my litmus. What your state or your country would do for patients who have cancer, you know, are in this position. And if we're not even willing to move to help them, the idea that we could cover it for everybody, we're still ages away from that, I think. Yeah. Because uh it's not none of what we're talking about is forcing anyone to do anything. Um nor is it necessarily the destruction of an embryo. I mean it's there is a world where the embryos are created and kept frozen, right? There is there is no uh like they call that embryo banking. I mean to specify maybe for somebody who doesn't understand, right? Egg freezing, getting those eggs outside the vault to grow, taking them out of your body, and we freeze them right there at the egg state. Making an embryo is going to be thawing that egg, fertilizing it with sperm, letting it grow out to the implantation stage, which is day five or six. Not every egg will survive, fertilize, grow. There's a ton of attrition in culture. So 90% of eggs survive the freeze thaw, 75% will fertilize, 50% will make it to the implantation stage, and then not everyone will be genetically normal based on your age and other factors. And then even a genetically normal embryo only has a 65% chance of live birth. Like the science has come far, but we're not there all the way. With that being said, they do morally really feel like an embryo could be a potential life. and they do struggle with what to do if they have leftover embryos. And I have some patients who've told me every embryo we make, we're going to transfer. Okay. Well, we want to be really mindful what we do in that circumstance. And even though it's unlikely, I have a patient right now with four children and one embryo in the freezer because we froze five knowing that everyone shouldn't implant based on that 65% number, but we've gone four for four. Okay? So like we have to know that if that's what we're doing, we're prepared for how the data may fall because data just helps us guide decisions, right? Especially when it comes to live. It's zero or 100. It happens or doesn't. Now if I freeze them as eggs for some patients who have really strong beliefs and they are afraid of that number five, we might take more time or time more money, but we might say let's thaw them and only fertilize two. Let's leave everything else frozen and then whatever makes it embryo we can transfer. And yes, that's not a cost-effective way to go through the process because we might be having to pay for thawing and the fertilization and the transfer more times because there may be nothing to transfer based on that attrition. It can let some patients say, "Okay, I feel better with that process." So just freezing eggs to your point is not making embryos, right? And there's different things we can choose along the way to make an individual person feel comfortable, but we shouldn't be dictating how the field has to function. I think it would be incredible if we could encourage egg freezing earlier. I think it would open the door of opportunity and not everybody who freezes eggs will need them, but the peace of mind knowing that there's a chance is really impactful on the human mind. I'd like to take a quick break and acknowledge our sponsor 8LE makes smart mattress covers with cooling, heating, and sleep tracking capacity. One of the best ways to ensure you get a great night's sleep is to make sure that the temperature of your sleeping environment is correct. And that's because in order to fall asleep and stay deeply asleep, your body temperature actually has to drop by about 1 to 3°. And in order to wake up feeling refreshed and energized, your body temperature actually has to increase by about 1 to 3°. 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So, in insurance, I would think would want to do this because um covering all the other stuff is expensive, too. Most insurance doesn't cover IVF. You're not wrong, right? In principle, if I freeze a 25year-old's eggs, I will have three times as many eggs to work with, you know, than I would if she's going through IVF when she's 37. So, if I'm going to pay for her to do IVF at 37, it'll take so many more cycles. I'll spend so much more money. That one cycle of egg freezing is much more cost effective if I'm covering them both. But we don't even cover the ladder. So many times patients, this is such a hard stretch for everybody. And look, the technology is incredible. As somebody who has an IVF lab, as somebody who keeps embryos on site, it's I mean, it's outrageously expensive. I mean, our generator alone, it's a million dollars, right? Because if the power goes out, like what do we have to keep going? We always say if there's zombies coming, like come to the clinic. The technology to keep up with all the advancements to have trained embryologists, I mean, their micromanipulation skills, it's impressive. So it costs money to run a lab like that that will provide results. So the process and the technology is really really expensive. That being said, like I shouldn't be the one sitting here making assumptions again on what you're going to do with your money. And if somebody's in a position where they know their egg count's low and they should freeze their eggs because…

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