Realfoodology - The Truth About Egg Freezing + IVF No One Tells You | Sasha Hakman

Episode Date: February 18, 2025

233: In this episode, we take a deep dive into fertility, focusing on egg freezing and IVF. I’m joined by Dr. Sasha Hakman, a board-certified OBGYN and reproductive endocrinologist at HRC Fertility, to break down the entire process. As someone who froze my eggs at 36, I wanted to understand what comes next and what factors impact fertility, from hormone treatments to lifestyle choices.   We discuss everything from the science behind egg retrieval to the role of environmental toxins and how lifestyle changes can improve reproductive health. Whether you’re considering egg freezing, going through IVF, or just want to learn more, this episode is packed with expert insights and actionable information.   Topics Discussed:   Egg freezing vs. embryo freezing   The egg retrieval and IVF process   The impact of pesticides and endocrine disruptors on fertility     Rising infertility rates and potential causes   The connection between PCOS, insulin sensitivity, and fertility   Synthetic hormones and their effects   How age influences fertility outcomes   Sponsored By: Birch Go to Birchliving.com/realfoodology for 20% Off Sitewide + 2 Free Eco-Rest Pillows with Mattress Purchase.  Timeline Timeline is offering 10% off your order of Mitopure. Go to timeline.com/REALFOODOLOGY.  SuppCo Get 100% free access today at supp.co/REALFOODOLOGY. Qualia Go to qualialife.com/REALFOODOLOGY for up to 50% off and use code REALFOODOLOGY at checkout for an additional 15% off. Function  Skip Function’s waitlist at www.functionhealth.com/realfoodology Timestamps:  00:00:00 - Introduction   00:03:25 - What is a reproductive endocrinologist   00:05:47 - Egg freezing vs. embryo freezing   00:09:22 - Ways to improve egg quality   00:12:16 - Pesticides, endocrine disruptors, and fertility   00:16:21 - How egg retrieval works   00:18:15 - The IVF cycle explained   00:19:51 - Mature vs. immature eggs   00:20:40 - How fertilization happens   00:23:32 - From eggs to embryos   00:24:46 - The importance of sperm testing   00:27:33 - Why infertility is on the rise   00:29:50 - Phthalates and their impact on fertility   00:31:21 - How embryos are created   00:34:02 - Sperm retrieval process   00:35:45 - What happens to extra embryos   00:37:37 - How embryo transfers work   00:44:24 - Synthetic hormones and fertility   00:47:47 - Birth control and its effects   00:49:29 - PCOS, insulin sensitivity, and fertility   00:54:32 - Finding the right workout for fertility health   00:57:05 - Egg count vs. pregnancy likelihood   00:58:11 - How age impacts reproductive success   Show Links:  Realfoodology - 45: Why Fertility is Declining with Dr. Shanna Swan Check Out Sasha: HRC Fertility  Instagram https://sashahakmanmd.com Check Out Courtney: LEAVE US A VOICE MESSAGE Check Out My new FREE Grocery Guide! @realfoodology www.realfoodology.com My Immune Supplement by 2x4 Air Dr Air Purifier AquaTru Water Filter EWG Tap Water Database Produced By: Drake Peterson

On today's episode of the Real Foodology podcast in many cases when women implement these changes they tend to start cycling more predictably and Can even conceive on their own. Hello friends. Welcome back to another episode of the Real Foodology podcast on today's episode I sat down with Sasha Hockman who works for HRC fertility in California They have a lot of locations. Sasha is a board certified OBGYN. She's a board certified reproductive endocrinologist and a medical advisor. We do a deep dive into fertility, but through the lens of egg freezing and IVF. Some of y'all may remember, if you follow me on Instagram or if you've been listening to this podcast for a while,

may remember if you follow me on Instagram or if you've been listening to this podcast for a while, I froze my eggs a couple years ago at 36. And they've just been kind of chilling for the last couple years. And I didn't really know what the next steps were. I'm wondering if I'm going to have to use them. I'm hoping to be pregnant by the end of this year. So I'm on my fertility journey, as many of y'all know. And I really wanted to know what the whole process looked like as far as I already have my eggs frozen. What next? So we dive all into that, the process of egg freezing, we talk about, do you really need to take birth control while you're freezing your eggs? Because this was something that I opted not to do. We talk about how many eggs you get and is that a marker of your fertility? What it really means? What you can do about it? Things that you can do to

better your fertility. So hopefully this answers a lot of questions that you might have around IVF and egg freezing and the whole process. It helped me tremendously. So I hope it helps you and hope you enjoy the episode. As always, if you're loving it, if you would take a moment to rate and review, it means so much to me. Your support means the world and it really does help the show. So thank you so much.

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A. It works by promoting an essential cellular cleanup process that clears out dysfunctional mitochondria, aka your cells battery packs. Plus, it's shown to deliver double digit increases in muscle strength and endurance without a change in exercise. That is crazy. So if you would like to try Mitopeer today and join me in taking this every day. Timeline is offering 33% off your order of mitopera while supplies last. Go to timeline.com slash realfoodology33. Sasha, thank you so much for coming on today. Thanks for having me here. I'm excited. Me too. So I actually haven't done a podcast about this specifically because you are a

REI. What does that stand for again? Reproductive endocrinology and infertility specialist. Amazing. Smellful. Yes. So I want to talk all about egg freezing and IVF because I haven't done a podcast about this. I've done a lot of podcasts about fertility in general.

It's something that I'm personally very invested in right now because I froze my eggs when I was 36. I'm getting married in June. I just turned 40 and I'm like, holy shit, I need to get this figured out because I would love to be a mom. But I haven't talked about the IVF side at all. So a lot of my conversations just so you know have been around like optimizing your fertility, making sure you have really good high quality eggs, when to freeze your eggs and all that. So let's dive into, well first of all, explain a little bit about what that means. Like I've never even heard that term before. So what does that mean and what all does that entail? To be an REI?

Yes. Yeah. So basically we are OBGYNs by training who then subspecialize for an additional three years after the four years of residency. It takes after med school residency, fellowship, and then board certification about 15 years to get there. Wow. So we have as much training in terms of length of time as a neurosurgeon. Wow. People don't realize this.

We are trained in several different types of surgeries that are gynecologic, pelvic. But then you just really subspecialize primarily in infertility, but reproductive endocrinology involves a number of different disease processes as well, like disorders of sexual differentiation. Most private practice physicians like myself, we are really just focused on infertility, fertility preservation,

even other things like just a fertility evaluation for natural reproduction and just helping people with their family building goals. Amazing. I wish we were actually texting last night and I was telling you this, but I wish I had known you before when I was freezing my eggs. I know. I even went to the same like facility that you work out just in a different location and I'm so bummed. I know. I even went to the same facility that you work at just in a different location and I'm so bummed.

I know. I would have loved that. I know because there's so much. I feel like, so we hear a lot of stuff on the surface about this, like, okay, freeze your eggs as early as you can. And then like IVF, there's a lot of conversation about IVF, but to be honest, I feel pretty undereducated in all of this. And I even went through the egg freezing process.

So maybe we can talk about that. Because we were even talking about it last night where I was like, I felt like I didn't even fully understand the scope of everything I needed to know when I went through it. Because one, I think it's kind of a wild process. You're also emotional. You have to have a major surgery.

It was kind of uncomfortable. And then looking back on it, I'm like, oh, I don't, there was so much I didn't even know, you know? Like, first of all, okay, so let's talk about this. So when you freeze your eggs, you have two different options, which is like freezing your eggs, or if you already have a partner, you can freeze your embryos. Yeah, we call that embryo banking. Okay.

And what would be the benefit of freezing embryos over freezing your eggs? Great question. So, there's actually this misconception that freezing embryos is better than freezing eggs because the embryos are more viable. There's like somewhat some truth to that, but the biggest difference is when you go to freeze eggs, you have some advantages and disadvantages. The advantage of simply freezing eggs that are not fertilized is that you have full autonomy on what happens to these eggs.

Should something happen in a relationship and you created embryos, most of the time the resolution to that dispute is discarding the embryos. And it really sucks for the female partner because then if they're much older, they have nothing preserved. And their options are a lot more limited or things may be a lot more difficult, especially if they're past their 40s. So that's sort of the biggest disadvantage of creating embryos with someone, even if you feel like that is your lifelong partner, especially if you're going to really hold off on using them for a very long time. The other thing about eggs is that they nowadays with our technology, we do something called

vitrification, which is flash freezing of the eggs. So a slow freeze process because it's filled with so much fluid, you can end up getting these ice crystals. And then when you go to thaw them, it just really damages the eggs. So when you hear about people who froze their eggs back in the day when it was still considered experimental, they'll often say it's really not that successful, it's not that good, they don't do as well as embryos.

So before vitrification, that is true, but now the way that we freeze them, it's basically like freezing time. And so they're in this glass-like state because we put the embryos in these straws, they go in liquid nitrogen, and it's essentially frozen in like a fraction of a second. Wow. So it's yeah, it's pretty impressive. So with that, the thaw survival rates are so much better, but you still expect to lose maybe a certain percentage of eggs.

If we look at the national averages for women under 37, the average survival rate of eggs that are being thawed is 95%. If you're over that age, so over 37, then you're looking at about 85% survival rate on average. And is that because as we age, are they just like, are they more like fragile or what is that? Yeah, it's probably correlating to egg quality, which we expect that that does decline with age.

I would say the biggest or the sharpest decline in egg quality, which we expect that that does decline with age. I would say the biggest or the sharpest decline in egg quality really starts to happen around 37, 38. Okay. And then it just sort of accelerates after that. And I'm curious from your lens and what you've seen, do you think that there is any correlation with, because I've had a lot of podcasts where we talk about nutrients and how well those can improve your egg quality, or like if you focus on mitochondrial health, things like that.

Have you ever seen a difference in like if somebody's actively working on nutrients, lifestyle, maybe toxin exposures, and maybe that has a different effect on the egg quality? Anecdotally, I have not. I know that there are conflicting studies. So some studies are pretty impressive where they show that if you do certain supplementation with antioxidants, for example, CoQ10 being the most commonly used supplementation that we recommend, in addition to things like NAC or N-acetylcycline, there's pretty good evidence backing

how it can improve egg quality. That being said, it's a little more nuanced because it depends on the person's overall health status, their prognosis, their age. And I truly believe that there's always this genetic underlying component to how well your eggs are going to perform. And it's not necessarily something that's inherited, but it could just be like some random variant. And there's no data to prove this. This is just my theory. It's something I would love to see researched is just how our genetics can really impact or how specific genetic variants could impact your egg quality and how they perform.

So I mean, that's really the biggest thing. I think that if you're in a certain age category, like if you're in your 30s and you want to postpone, say, for three to six months to really improve egg quality, especially if you're someone who has an unhealthy lifestyle, nutritionally, lack of exercise, you have insane exposure to environmental toxins. We know that that truly negatively impacts things. So possibly by supplementation and improving overall lifestyle, we can see an improvement in egg quality.

And maybe in a handful of cases I have seen that happen. Now being in LA, it's kind of hard to gauge that because I feel like the majority of my patients are very conscientious of this and most of them really work hard to take care of their health. So it's tough to gauge with this particular population. I think that when you're seeing a more unhealthy population then it's easier to have more actionable things that they can do to improve that equality but if you're already someone who's really on top of your game it it's a little bit harder to fix that. For sure see this is where I feel like the and we don't have to spend a lot of time talking about this but

just the insidious nature of like the pesticides that are being sprayed on our food It's not that's ending up in our air and water that I'm just like there's no way It's not having an effect on us and that's the kind of stuff Yeah, like we like we don't really we can't control it, right? We know it has an effect on us Yeah, I mean, it's it's been well established in our field now that Even if you look at endocrine society or the American Society for Reproductive Medicine, it's often talked about how there are endocrine disrupting chemicals everywhere that they're really affecting our overall health, our reproductive

health, our risk for cancer long term. So it's really tough because all you can do is reduce exposure by eliminating certain things like perfumes. We know are super toxic. Yeah, that's a big one. It's a big one. Honestly, that makes me feel so much better. I'm so happy to hear that that is a topic of conversation and something that they're

recognizing because that is a really big one. Also, that's a really easy one. It's an easy one. That's an easy one to take out. Yeah. Just stop spraying the perfume if you want to wear something like find an essential oil or something natural. Obviously not when you're in the OR, but in your everyday life.

No, but it's funny even as an OBGYN I didn't know that until I started my fellowship and then I happened to find this out my first week and after I got scolded, but rightfully so. But now after eliminating all fragrances I can smell fragrances from a mile away and I hate it. It just gives you a headache, it makes you feel awful, which says a lot. Yes and I just yeah I have such a pet peeve with like the scented deodorant or the not deodorants the laundry detergent where you can smell people from a mile away with their clothes. It's just so bad yeah. Because I just think about their endocrine the laundry detergent,

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And I was, one, I was horrified. I was embarrassed. I debated even if I was going to share it on the podcast because I was like, it feels like it's like a marker of like your fertility and your worth. And I could go into all the things that we judge ourselves for as women, right. But let's talk about that a little bit because you brought up a really good point that I'd never thought about before. And you said that, you know, sometimes you'll see in other cases where you'll see someone

who gets a lot of eggs, but they don't actually have that many that are viable. And I think at the end of the day, it really does matter about the quality over the quantity, of course, right? Yeah. But where is that kind of like, is that a marker of like how good your fertility is? Or can we talk about that a little bit? Yeah, of course. So yeah, that's another misconception.

Oh, I have a lot of eggs. That's really reassuring for my fertility. Now, like I said before, the disadvantage of egg freezing is that you have no idea what the potential of that egg is. We haven't fertilized it yet. We don't know what it's going to do. And if you've never tried to get pregnant in the past and you're electively choosing to freeze your eggs because you're single and you're getting older

or whatever it is, then we just have no clue what the journey it will take is. Now we use data from previously frozen eggs that are thawed and fertilized to help predict the likelihood of having a child or a live birth from the number of eggs that are retrieved. But those are averages. Some people do much better and some people do much worse. So that's just what we have to work on, but it's not the be all end all, right? So oftentimes what we see in an IVF cycle, very different than egg freezing. We actually see the whole journey.

So if I walk you through an IVF cycle, the biggest difference is first to get your eggs, we give you injectable medications typically in order to help stimulate your ovaries. Your ovaries are comprised of follicles. Now you have follicles in the resting stage which is where the majority of your eggs lie. A follicle is a sac that contains an egg. Every egg has its own follicle and most of them are in the resting stage. Some of them have left the resting stage and they are now antral follicles. That's what we call them. A normal number, what's considered normal is about six to eight per ovary,

could be as much as 14 per ovary, and that's now considered normal. And those are the follicles that are available for stimulation. We cannot tap into future follicles. They're in the resting stage. They are not there. They will not respond to medications. It is just the bigger follicles, which are fluid-filled sacs that can be seen on ultrasound that are available for that stimulation. Once we start the injections, which takes an average of two weeks to really get those follicles ready, then we prepare to get you ready for an egg retrieval. And that egg retrieval is the procedure that you underwent where you go in with a needle into every single follicle, you suction the content, it goes into a tube and it's handed

to the embryologist who then kind of dumps it in a dish and looks under the microscope and is able to count the eggs out loud so that by the time the patient even wakes up, we know how many eggs there are. Now when you're freezing your eggs, we just freeze the mature eggs. And so that the listeners understand the difference between an immature egg and a mature egg. Immature eggs have both copies of the chromosomes. A mature egg has sort of ejected out one of the copies so it could accept a copy from sperm. Got it.

Those are the only eggs that we can actually fertilize in a lab. The immature eggs cannot be fertilized. It's got too much DNA. So when we are able to see which ones are mature, those get frozen and then that's the end, right? But for IVF, it doesn't end there. During the egg retrieval, we're getting the male sperm, whether it's partner sperm or donor sperm,

it is basically they're preparing it by cleaning it out and then you go to fertilize the eggs. There's two main ways of doing that. There's something called ICSI, which stands for intracytoplasmic Sperm Injection. This is where it's a mouthful. But you're basically looking for the best-looking sperm. You inject it directly into the egg to try to... The goal is to try to attempt a higher fertilization rate. There are specific medical indications for doing ICSI. And then

for like male factor infertility, for example, or previously frozen eggs as another indication. But I'd say 90% of IVF clinics are just using it for everybody. The other type of fertilization is conventional. You put sperm and egg in a dish, and then you look the next day to see what happens. Oh, wow. Like so, I guess a more natural way to fertilize it. It's kind of fallen out of favor mostly because in about 10 to 15% of cases, you will have total fertilization failure and nobody wants to be in that situation.

That's a really hard phone call to have with a patient. So that's primarily why most clinics just do ICSI because you know nobody wants to call a patient and say, yeah, almost none or none have fertilized. After that, you culture the fertilized eggs for a duration of about five to seven days. I would say most big labs will culture until seven days. Some will just stop at six. Usually by day five or six, you should have what's called a blastocyst. So that's a day five embryo. Some take a little bit longer.

But there have been babies born from day seven embryos, which is why a lot of labs will culture to day seven. Because even if it only gives us a handful of babies every year, that's a big deal. That's many lives. Yeah, especially when you think about that one individual couple that's really waiting on that. Right, it changed their life, right? Exactly. So we, like, at our practice, we do it for everybody.

Yeah. And from there, the ones that do develop into blastocysts, you have the option to then biopsy some of the outer cells and send them out for genetic testing, which is known as pre-implantation genetic testing. So we're testing the embryo before we transfer it back to the uterus and it implants. And that gives us an idea of is this embryo chromosomally normal or not? And based on that, we have prognostic indicators of what is the likelihood of that embryo becoming a baby. So PGT is not perfect.

It does not exclude a lot of things like small deletions or duplications. And this is why it doesn't yield 100% pregnancy rates. In fact, a chromosomely normal embryo gives you a 65% chance on average. So that's sort of the process, right? So when you're doing IVF, when you get to that final euploid embryo number, now you really know what you're working with. I have had patients where we only get three to four eggs and they end up with two euploid embryos. Amazing.

I mean, they really defied all odds because if we look at the national averages for statistics of fertilization, on average, 70% of eggs will get fertilized. And of those fertilized eggs, only half of them are expected to become embryos. Of the embryos, the percentage that are chromosomally normal depends on age. So if you're under 35, you should have 50 to 60% that are normal. But as you get older, that percentage naturally drops. But I have seen patients where they have a ton of eggs retrieved, 30 plus, and we end up with no normal embryos. And when that happens, sometimes I'm like, this one cycle might be a fluke, let's try

again and see what happens. And when it happens again, that's when you know, okay, there's something seriously wrong, either with egg quality or sperm. But there are ways to sort of test to see, is this aneuploidy source from the sperm or from the egg? So I'm curious, because I had another podcast where we were talking about this, where we don't really talk about men a lot

in this whole process and how much the sperm actually plays a role in the overall infertility if you're struggling. It's always put on the woman, right? So when y'all are doing this process, is there testing of the sperm too to make sure that it's viable before? I mean, I'm assuming they have to be, right?

Yeah, so what we do is we always start with a semen analysis. So what we're looking at are different parameters from the sperm in that sperm sample. So what is the volume of semen to start with? It should be at least 1.5 ml. And then we look at the concentration of sperm and, you know, typical concentrations that we like to seize above 15 million, 1.5 million per ml. And then you look at the motility, which is the swimmers, you know, what percentage of the sperm that's there are swimmers should be should be at least 40% motility, but a more important marker of motility is something called progressive motility because motility

just indicates that they're moving, but we want to know which ones are the straight shooters and how many of them are there. And so in most andrology labs, you want to see at least 32% of progressive motility. That's really important. And then finally, the morphology, which is the percentage of normal shaped sperm. But if you're using really strict criteria of how the sperm looks like, we only expect to see 4% or more appearing normal. Really? Because the majority of sperm is just vastly abnormal. Is that, is that, has that always been the case?

Is that normal? It's always been the case? Is that normal? It's always been the case. Okay. So human reproduction is actually quite inefficient. You all may remember that I had Mark Hyman on the podcast last year and we talked about Function which is a company that he helped found and it's an all-in-one health platform that starts with over 100 advanced lab tests covering your entire body, heart, hormones, liver, kidneys, thyroid, autoimmunity, cancer signals, toxins, nutrients. They also have some new tests now outside of the 100

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If you want to skip Function's wait list, go to www.functionhealth.com slash real foodology. That is functionhealth.com slash real foodology. Which is so weird. It's so weird. Yeah. It's really inefficient. I mean, if you look at the most fertile couples, the chance of conception in a given month, if you're under 25, is at most 25%. That's so wild. To me, I just have to believe, I'm like, it has to be because of what's happening

in our environment. There's no way that we have always been like that. Well, in my opinion. The infertility rates are rising for sure. I think it's multifactorial. I do think our environment plays a huge role. Yeah. I also, I mean, I know for a fact that a big part of it is we're waiting

longer to have babies, right? So that's a huge variable, but if you control for age and you still look at younger women, the infertility rates are significantly higher than they used to be. The biggest question I sometimes ask myself is, well, is it because we're more educated and people are seeking out treatment as opposed to just suffering in silence? Or is it, I think it's probably a combination of many things. I definitely do believe

that our environment plays a massive role. We just have so many environmental toxins. There are many different researchers who are looking at the different pesticides, for example, and how that's affecting sperm. And we know that sperm parameters have declined quite significantly in the last 50 years, particularly from men who live close to sort of big farms that spray pesticides and that are exposed to things like glyphosate. Yeah, that's a big one that I like to talk about a lot.

That's, I mean, well, it doesn't give me joy, but it's just, I think it's a really, it's an invisible insidious one. Yes. And that's the hardest part. It's kind of like an invisible disease. You don't see it. You think, okay, well, I'm mostly eating vegetables, fruits, Whole foods as much as possible in terms of my protein sources. I'm not, you know, my carb choices are really healthy, low glycemic index, high fiber, and yet here we are.

And it's the most frustrating thing for patients that are stuck doing all these repeat IVF cycles and they're just like, what? I've done everything in my life to stay as healthy as possible. So that's definitely a big part of it for sure. There's also the phthalates piece too. Have you heard of Dr. Shanna Swan? Yes. Yeah, yeah.

At the countdown, I had her on my podcast a couple years ago and she was talking about, I mean, it's, yeah, The countdown. I had her on my podcast a couple years ago and she was talking about, I mean, it's, yeah, it's horrifying. The phthalates and what she's seeing with dropping sperm rates and also like, even when the babies, they're being born with smaller. She talks about the anal genital distance. That's what it is. I was like, what's the word for it?

Yeah. Yeah, really interesting study. I read about it too and I've heard her on many podcasts as well and her work's amazing. It's also kind of depressing. I know, I know. It is. It's one of those things that like I say this often where I'm like, if your house is on fire, wouldn't you want somebody to tell you? It's like if we know this is happening, we've got to sound the alarm so that we can start creating policies. The more that we know about this, then we can start creating policies and not allow these companies to maybe use plastic anymore.

And we need to create other options outside of plastic if now we know what it's doing to our body. But until that, I mean, it's up to us to, I mean, I buy all my water and glass. Like, I try the best I can. And then, you know, there's only so much we can do to we can't just right. Live in a bubble. Right. Right. And and that's the hardest part. And I try to always reinforce like, I don't want you to become paranoid. Exactly. I want you to be knowledgeable and then make the best choices

you can when it's feasible. Yeah, for sure. You know. So, OK, so let's go back to. So I obviously I froze my eggs when I was 36. Now you were telling me that I could actually turn those into embryos, which I never knew that. I thought I was going to have to go back through another IVF or not IVF, whatever, like an egg freezing through the whole thing, the hormones and the retrieval and all that to

create the embryos. So what does that process look like? Because I think I want to do that. Yeah, so it's so much easier on you this time because really all it involves is basically getting a semen analysis, making sure that sperm looks good. If for whatever reason it doesn't, this is where additional testing really happens for the guys.

So the guys have it fairly easy in the beginning where they just do the semen analysis. If it comes back normal, their job is done. Meanwhile, the women are getting all the pelvic imaging, the tube testing with the x-ray, and that is not a fun test, the HSG. In addition to- I have a friend that just did that

and she said it was really painful. Oh yeah, it can be. There are ways to make it less painful, but that is not universally done, unfortunately. Yeah. So yeah, the women have to go through a lot. And then, of course, the ovarian stimulation, if you're going to go freeze your eggs, plus the egg retrieval,

all the things. But once we make sure that sperm looks good, then you basically just schedule a time to thaw the eggs and you go to fertilize them that day. So once the eggs get thawed, you essentially every patient has some sort of barcode on the straw and in the chart it's labeled which canister and so the embryologists are able to easily locate exactly where they are when you have, you know, thousands plus samples. You go to get it out, and then there's a whole thaw process.

And basically, then you look under the microscope to see which one's actually survived the thaw. And that looks good. Then you go to inject the sperm directly into the egg. And most practices, most embryology labs will have these bench top incubators. They're teeny tiny. They're incredible. You basically culture the egg in there and you check the next day and you're able to tell which ones fertilized and which ones didn't. Okay. So you're physically doing nothing aside from just coordinating dates with the clinic. Okay.

So I'm gonna ask you a question that I might regret but I'm curious because Hector asked me this one time and I'm so curious what is how do they actually go about getting the sperm? Is it literally like in the movies when you go to a doctor's office and they have magazines or like can he do that at home? You don't have to give like major details but like what is the process look like for that? Do they go into the office to do that? So you can actually drop it off. Okay so you can do it at home. You can do it at home. We were very curious about that. You just have to get a sterile cup from the clinic beforehand. Yeah, that's what I assume.

And then usually you'll get like a whole sheet of instructions. You need two to three days of abstinence. Do not use any saliva, lotions, anything that will affect the sperm. And for guys that have a really hard time with that, sometimes the lab will provide mineral oil that they use in the lab that's safe for the sperm. That's so amazing. I just love to know all of this. Because literally Hector was asking me, he's like, what's the process for that? And I was like, I have no idea. And you see movies and they make it in this whole thing where they're like awkwardly at the doctor's office and they're giving them magazines. And I'm like, surely they're not doing that

still. Some places do. Really? Yeah, some places do. They will still have the guys come during the egg retrieval and they will put them in a room in the ejaculation room. And you know, usually like it's a screen now, but the feedback I got from my husband is that room's disgusting. Like I'm not touching anything in there.

Literally, though. That's why I'm like, that's just yeah, that's really funny. After we did IVF, he was like, nobody asked me how my part was. No offense, I don't think anyone cares. No, literally, like, babe, you're fine. Like, that's so funny. Okay, so Okay, I'm so happy to know that I wouldn't have to go through the hormones and all that again because when I froze my eggs I thought because they did give me the option

They're like would you want to do embryos and I was like well at the time I didn't have a partner and so I just Didn't want to do that and I thought at the time it was one or the other that you couldn't go do the embryos later Yeah, I mean the whole point of freezing the eggs is that they're there and they're available for when you need them. And depending on the number of eggs you have, if it's a smaller number, I always recommend my patients thaw all of them to fertilize.

Don't split it. But if you have, people who have a ridiculous number of eggs, I'm just like, yeah, if you wanna split it and keep some back up just in case that makes sense. Because you just never know where life takes you. And then there's also like the ethical considerations for couples where they feel very strongly about not discarding embryos. So a lot of people do feel very attached to their embryos. And then once they're done having their kids, if they have extras, they're kind of like well What do I do now? I don't want to just discard them because I saw

The the result of these embryos which is like the people I love most in this world How can I go and discard these other embryos? So? For those who really feel very attached or they you know, I I would say probably my more religious couples, I say, let's just start more conservative. We just saw a certain number that makes sense based on your age and then go from there. So that there isn't this like crazy abundance of embryos that you don't know what to do with. I mean, that's fascinating. I'd never even really thought about that before. Yeah, it's tough predicament. And sometimes you don't even think you're going to feel that way until you have your

first child from an embryo. And you're like, wow, wow, yeah, I kind of love these other embryos. Oh, okay. So let's say that I do the embryos, and then I decide to move forward with wanting to actually turn one into a viable pregnancy. What does that process look like? do the embryos and then I decide to move forward with wanting to actually turn one into a viable pregnancy, what does that process look like? Do I have to take hormones in order to do to finish that process off in order to get pregnant? So there are different ways of doing this. So this is the embryo transfer

process and oftentimes people will sort of clump that with an IVF cycle and call that IVF, but this is an FET, a frozen embryo transfer, totally different than IVF. It is the continuation of it. So once the embryos are made and they are cryopreserved, and I'd say the majority of people now are probably doing genetic testing on their embryos, although many do opt not to do that. Once you have those results and they're still cryopreserved, those embryos, although many do opt not to do that. Once you have those results and they're still cryopreserved, those embryos are just waiting for you,

you sort of pick a time. I'd say the most common time that people will pick is immediately after the embryos are created, especially for couples dealing with infertility. But for those who are doing fertility preservation or let's say in your case, you're like well I want to wait until after my wedding So then you just sort of like set this date where once you get your period You start the process of prepping for an embryo transfer and this is after additional evaluation of the uterine cavities is done So is that the HSG test and that's one of them is done. And is that the HSG test?

That's one of them. Okay. The probably most common option that doctors will use is called a saline sonogram. So it's a similar process where you place a catheter in the uterus. Not very fun. Yeah, that sounds awful. Yeah. You should take meds before to really help with the cramping.

And then sterile water is pushed into the uterus under ultrasound guidance. And then this is where you get nice images of the uterine cavity to make sure that there aren't any polyps, which are benign tissue growths inside the cavity, or fibroids, which are benign tumors of the uterine muscle that can grow in the cavity, scar tissue, or an abnormally shaped uterus that some women are born with that may need to be corrected. So these are all things that can negatively impact the success rate of an embryo transfer or result in a miscarriage. So these things are done first in the cycle prior to getting ready for an FET, frozen embryo transfer.

Sometimes additional testing will also occur like an endometrial biopsy if it's indicated. When you start the process of actually prepping for the transfer, what you're trying to do is mimic the post-ovulatory stage because five to six days post-ovulation is where you have that implantation window. So you need to mimic that hormonally or you do it naturally. So the two most common protocols that we use is one is a medicated one, which is called a programmed FET protocol. This is where you get estrogen pills or patches or shots, and then you come in for monitoring the ultrasound is to see how your lining is responding to the estrogen.

Estrogen helps to thicken the endometrial lining. So we need it to be nice and thick prior to any progesterone exposure. Then once that lining looks good, you start progesterone and then the progesterone is really what starts the clock. So in a programmed protocol, you're getting estrogen. Once the lining is ready, you start progesterone. And then five days after that start is when you have your transfer. Sometimes there will be variations in the timing

depending on specific scenarios for patients. And that's a whole different conversation, super complicated, so I won't get into that, but that's sort of the timing of it, takes an average of about two and a half to three weeks to get to that point of transfer. So usually the clinic will say, okay, you're gonna start your progesterone

and on this day, on this time is your transfer. And the embryo transfer is a painless process, this is where you have a catheter with the embryo loaded in it. It's placed in the uterus. You should not feel cramping with it. So I always tell my patients, if you are feeling anything, I need you to tell me because it should be a very painless process. I would say the most uncomfortable part of it is you need a full bladder and everyone

just really wants to pee. So that's probably the most uncomfortable part. The natural FET method is my personal favorite. I'm all about keeping it as natural as possible. I just think that the body does it better. Statistically speaking, in our data, they seem to have the same pregnancy rates. I do think that as more practices do natural cycles more frequently, we're going to start seeing a little bit of a shift where I think the pregnancy rates will be improved. But you know verdict is still out. So with the natural cycle it basically relies on you ovulating. So you come in, we track your

ovulation, and once I see that your follicle is ready, then the large majority of us will do, I guess, what's called a modified natural cycle where we give a trigger shot. So you probably remember taking this trigger shot right before your retrieval to mature your eggs. In this case, the trigger shot is to actually help ovulate. And then typically a week after that is where you'll have your transfer. I have had patients who say, I want absolutely no medications whatsoever. The only thing I'm willing to take is the progesterone suppository just to make sure that I'm giving that extra support for my baby. And in those cases, we've done it successfully. So it's

a pretty nice protocol. It just requires a little bit more monitoring sometimes, especially if it's completely natural. And then it also depends on age. So someone who's perimenopausal obviously can't really do that because they're really high likelihood. Yeah, yeah. They're probably going to get canceled and it's probably not going to be as successful. The uterus does not age. So if you're older and having an embryo transfer or programmed, FET is probably the way to go. Okay. Wow, this is really fascinating. I always thought that I was going to have to go through an actual IVF process if I wanted to use my embryos.

No. But it sounds like I could do the all natural way, which makes me feel so much better. Yeah. Like so much better. No. But it sounds like I could do the all-natural way, which makes me feel so much better. Yeah. Like so much better. Yeah. If you ovulate regularly, then you're a great candidate for it. Yeah. And like clockwork. I'm like clockwork every month. Like very, because I track everything with my natural cycles and all that. And yeah, I'm like clockwork. That's great. So, oh my gosh, that makes me so happy because I was texting you last night. So another reason, so the reason why I went to this doctor that I went to to freeze my eggs was because I was asking around and I don't even remember now who referred me, but

I was really scared to do the egg freezing process because I have a very like volatile reaction to doing synthetic hormones. My whole life, like, the first time I ever tried synthetic birth control was when I was 21. I couldn't even finish the pack. I was an insane person. I just did not like the way that I felt. And then another time I took them for like a couple weeks, I had the exact same reaction. It changed my period for literally like 10 years. Like I'd never had a heavy period and these hormones like literally messed up my cycle.

Like I just, my body is so sensitive. And so I was worried that I was gonna have to do that. But after I got my egg retrieval and I didn't get as many, I was concerned that like, oh fuck, should I have just like, just done it? Like sucked it up and done the birth control anyways? Do you think the birth control makes that much of a difference before when you retrieve the eggs? So, yeah, this is...

And you can be honest, it's okay. No, this is the part that's called priming. So, it's actually quite controversial whether priming is really even necessary or not, especially with birth control pills specifically. So, some data shows it makes absolutely no difference, and then some shows it does. Now, the advantage of taking birth control pills prior to starting is that the theory behind it is you're kind of keeping the follicles small, similar in size, and the hope is when you stop the pill, the follicles will grow more in synchrony so that you have more mature eggs available

all at the same time, maximizing the egg count. That being said, I have had plenty of patients not wanting the pill who have been very successful in their cycles as well. And I know many doctors who don't do it, and they have really great outcomes. I would say my favorite type of priming is starting in the luteal phase, so one week after you ovulate, and with an estrogen pill in particular. I don't do this for women

with really high ovarian reserve because the concern with them is that they're going to hyperstimulate, but with the estrogen pill, this is called an estrous prime, that has been shown to improve the response to the injectable medications and potentially yielding to a higher number of eggs retrieved. So that is my preferred method. That being said, there have been many cases where I do what's called just like a straight start, so at the beginning of the menstrual cycle, but you can really tell on ultrasound when the follicles are all various sizes,

this is where I tell those patients, like, listen, you have a good number of follicles, but some are way bigger than the others. I don't think they're gonna grow in synchrony and we're not gonna get a high number of eggs. If you want reconsider, we don't start today. And with the next cycle, we start priming you, we do the birth control, we do the estrous prime, and then we start in hopes of getting a higher yield.

Yeah, which I wonder now looking back, because that was never a conversation that was had with me, and I wonder now if that was, yeah, like if I had been told that, I probably would have been like, okay, I'm just going to suck this up and just do it. It could also be the type of birth control pills that you've been taking too, because sometimes, and we talked about this too last night where I said, well, S-Trace has a lot of side effects, the most common one being just really intense nausea,

and that was my personal experience with it too, but if you administer it vaginally, then you're bypassing that first pass effect of it being metabolized by the liver, which leads to a lot of the side effects. So if you place it vaginally, it has really great absorption, you're bypassing some of the side effects,

and you're only on it for a week. Yeah, okay, in a week, that's like pretty manageable. I just was, I was so, I like joked that I like pretty manageable. Yeah, I just was I was so I Like joke that I like PTSD from my experiences on synthetic hormones that I just like I was it's a thing I like almost didn't freeze my eggs because I didn't want to take the birth control. It really it did it like scarred me I really like did not have great experiences on birth control. Yeah, it's it's really interesting with the birth control pill how Two women can feel vastly. Oh, it's wild. Yeah the birth control pill how two women can feel vastly different. Oh, it's wild. Yeah, for me it's the opposite. I feel like I'm my best when I'm on it. And then I've had many patients who are like,

I will not do it. I literally go nuts. Yes. And I say, okay, no problem. We'll, we do something else. Yeah, I'm like, I will not be getting married in June if I get put on these synthetic hormones because I turn into a monster. Like I'm I don't recognize myself. So it just is like not but it's interesting because I have another girlfriend who same thing as you. It's like she thrives on she's like, I have never felt better. Like, wow, we have had vastly different experiences. It's crazy. And we're all just we're also bio individual, you know, that it's like, man.

Okay, this is so fascinating. God, I have so many questions for you. Okay, so this is really interesting and I hope you don't mind that I'm like bringing this up, but I think you've talked about this before, but you have or had or have PCOS? Yeah, so it's a really funny story. Okay, and you were able to have kids too. Yeah, yeah I was. There's a big concern for that for women.

So let's talk about that. PCOS does not mean that you can't get pregnant. A lot of people think that with PCOS it's really just an ovulation issue. PCOS is actually a diagnosis of exclusion and it involves two out of three of the following things. So that's like the primary diagnostic criteria, which is you have irregular periods or no periods at all. You have signs of hyperandrogenism, whether it is high testosterone levels on blood draw, or you're dealing with really bad cystic acne, hair loss on your head, hair growth on body

areas that are just more male pattern, as well as polycystic appearing ovaries on ultrasound, which are not cysts by the way. So polycystic ovary syndrome has nothing to do with cysts. It just is a lot of follicles in the ovaries. So I kind of hate the name of it. I wish we would rename it. It's an endocrine disorder, a metabolic disorder that really the true cause is not fully understood, but we're starting to understand that there's obviously a disconnect

between the brain communicating with the ovaries. The ovaries are producing lots of androgens and that is due to preferential release of luteinizing hormone, LH, which is more commonly known as your ovulation hormone. You get that LH surge before you ovulate, but what LH really does is it helps rev up androgen and testosterone because that's a precursor to estrogen. But when you have too much LH, you get too much testosterone. No FSH, which is follicle-stimulating hormone, you don't get stimulation of the follicles. So they never really grow a follicle to then release an egg. So you have all of these follicles that are hanging out in the ovary,

and they're just not doing anything. Yeah. And it presents really, really differently from woman to woman. And I always thought that I had PCOS because I met the criteria and other endocrine tests came back normal and negative and I had polycystic ovaries and appearance, high ovarian reserve. Not that it ended up changing management, but I just recently did an expanded genetic carrier screen. And it turns out that I have something very uncommon called congenital adrenal hyperplasia. So it acts like PCOS, but it's more of a genetic disorder.

So this was inherited from my parents. Yeah. I don't know if it's two from one. Yeah, it's really rare. But if you pass it on to your children, you can have a child that's really ill. So lucky for me, my husband's negative. And so we don't have any affected kids. But that is, it's likely why I was also able to conceive on my own as I got older.

But in general with PCOS, you definitely can get pregnant without treatment, but I always tell women who are an ovulatory, if you're actively trying to get pregnant, don't wait for the random ovulatory event. You should be on meds that will help you ovulate in a more predictable manner. There should be additional workup like testing for pre-diabetes or insulin resistance because other metabolic disorders that happen with PCOS, they should be managed before pregnancy occurs. For sure. Yeah. Well, because oftentimes when you manage that, you also are able to lessen the symptoms of

like the PCOS because they usually come hand in hand. Not always, but like... But it is like a really high association. So if you improve insulin sensitivity, and this is where also lifestyle plays a massive, massive role. So I always tell these patients, like, you have to lift weights. You just have to. You do, you got to do resistance training, build muscle mass. It's going to help improve your metabolism,

all other metabolic parameters. And then, of course, nutrition is a really key part of all of it too. And you know, that's a whole separate topic. But yeah, there's a lot of different lifestyle things that are important. Supplementation that's important for PCOS. But in many cases when women implement these changes, they tend to start cycling more predictably and can even conceive on their own. That's amazing.

It's so funny, I was talking about this on my podcast earlier that I've started doing all these little things that feel like it was almost subconscious that I wasn't consciously being like, this is gonna be good for my fertility and I've been doing all this stuff lately. One of them being weight training and I've been hearing for years.

I mean, we all, you know, like I've been, I've had all these guests on my podcast that say like, you need to be weight training. And I just was so resistant to it for so long. I don't even know why I just don't, I'm not a huge, like I just don't love like gym culture. Yeah, the intimidation factor in the gym. Yeah.

The bro culture, like meatheads, so to speak. Yes, and if I'm being honest, I just, I love walking. Walking is my favorite form of exercise. It's meditative for me. I have dogs. It's like a great time for me to bond with my dogs. I just love it so much. And there's something about like the actual act

of lifting weights that I just don't really enjoy it that much. But I found this gym near my house a couple months ago because I have the flattest butt ever. And I was like, I need to get this under control. I was like, I need to work on my butt. And they had this class, a boot camp class that I started going to.

And then I became friends with one of the trainers there and I decided to start doing personal training with her. And I'm actually really starting to enjoy it. I'm actually really starting to enjoy it. I'm actually really starting to enjoy it. It's fun, isn't it? It is. I used to really hate it, but now I look forward to it. I see this trainer a couple of times a week

and I've also been going to the booty camp. And like, you know, we're doing like smaller weights but she's helping me kind of move up. But like she's been helping with my form. And it's just so interesting because I've had all these conversations recently about how much weight training can really improve your fertility too and just your overall health, right? And like with things like PCOS and yeah, and I know you're a big proponent for weight training.

Yeah, I'm obsessed. I thought pre-kids, God, I lived in the gym. Like when I wasn't at work, I was in the gym and I would be there for two to three hours at a time. I don't know how people do that. Yeah, I just, it was really my happy place. That's amazing. And yeah, I mean, I think it's great. Obviously, I can't afford anywhere close to that time anymore. So it's got to be really efficient. But you know, you just get in there, you do the thing.

And I would say like for people who are tight on time, even just two to three sessions a week is really something. I think people always often feel like, okay, well, if I am not as consistent as humanly possible, there's no point in going today because I haven't gotten a week. And that's the worst mentality. Even if you just get one session in a week, that's way better than nothing. Well, and let me tell you that I started out only doing two sessions a week. I was just doing boot camp on like Tuesdays and Thursdays. And after like two months, my fiance was like, holy shit, Court, like I can see a difference in your butt. Like I was only going twice a week.

And so it really has made me feel like, OK, I only need to do this like two or three times a week. I don't need to be going every single day. No, you don't. I wanted to go back to one two or three times a week. I don't need to be going every single day. No, you don't. I wanted to go back to one thing that you asked me before. And I think we kind of got sidetracked. But when you asked about the number of eggs and the likelihood of pregnancy. Oh, yes. This is a really important thing that people need to know that your egg reserve does not predict likelihood of pregnancy.

Amazing. So anti-malarion hormone levels does not not predict likelihood of pregnancy. Amazing. So anti-malarion hormone levels does not correlate to likelihood of pregnancy. You could have diminished ovarian reserve and still have the same likelihood as someone your age who has very high egg reserves. So having high ovarian reserve is really cost effective for egg freezing, but is not like it could be falsely reassuring. Yeah. And on the other hand, a diminished ovarian reserve can lead someone to feel like they're never going to get pregnant and there's no way that they're going to get pregnant naturally. When in reality, there's probably a lot of women out there with diminished ovarian

reserve getting pregnant on their own and they have no idea because they've never tested their fertility because they just get pregnant. Yeah. So. Oh my gosh. Thank you so much for saying that too. I'm sure everyone listening is probably feeling better. I'm feeling better and I'm glad that you brought that up. I guess before we wrap up, is there anything else that you feel like women need to know that we didn't cover in any of this area?

I guess the other big takeaway is that female age is the number one predictor of reproductive success. So if you are younger and you're even thinking about it, just go for the consultation. It doesn't commit you to anything. Yeah. But just like go see a fertility specialist, see what it's all about, understand your numbers, what things look like for you, and then make a plan accordingly. The most common thing that I see in women that come to see me,

the number one regret is, I wish I froze my eggs or I wish I froze more eggs. And the people who have that, that have the eggs, they never regret it. There are people who end up having leftover embryos and they're like, you know, I did what I needed to and now I have the family I wanted. But the worst is seeing the regret.

And I hate to see that for women to go through when they want a specific family size and it becomes a lot more difficult, especially as you start to increase in your 40s. So it's important to talk with your doctor. How many kids do you see yourself having? What does that look like for you? Just get in and have a consult.

Yeah, I think that's really important. I wish I know I can say, and I think I told you this last night that at 36, I wish I had not waited that long, but it was. It was not even something that was like that was crossing my mind before then. Right. I always knew that I wanted to be a mom and I always just felt like, oh, this is just going to happen someday. And of course it did.

It happened later than I had hoped and that I had expected for it to, you know? And thank God I found my person. But I just, I wish that I had started thinking about this when I was like 28, 29 and maybe did it when I was like 32. And look, I don't live in regret. I don't believe in living regret because you're just, you're gonna like torture yourself. But just if you're younger, I think it's just like you said, going for a console, just like poke around if that's something that you want to do. Just look into it earlier than you think you would because also it comes in a blink of an eye. It does. I feel like I'm 29. Like I can't believe that I'm 40 and so I just look back at all those

years where I'm like I just like all of a sudden I blinked and I'm 40 and I'm like okay should have been focused on this a little bit more but it's fine. Yeah. It's working out the way that it's supposed to and you know, yeah and And 40 isn't the end for most people it just some for some women It just takes a little more work, but plenty of women get pregnant in their 40s. Yeah But you know, but you know, it's it's really interesting I would say that almost every fertility doctor I know has frozen her eggs or has frozen embryos. There's very few that I know. I think I can only think of one person who didn't do fertility preservation.

And this is because we understand it so well. So all of us in our early 30s were like, all right, it's time. Egg freezing, embryo banking, whatever it looks like. Some people who are married did embryo banking. I was one of those people and we ended up needing to use an embryo in order to get pregnant. So yeah, you know, it worked out. So yeah, it's just, it's always a good idea to just understand it. I agree. I agree. Well, thank you so much for coming on today. Please let everyone know

where they can find you. Yeah. So you can find me on Instagram at Sasha Hackman MD or my website, SashaHackman.com. Am I allowed to say where I work? Yeah, of course. Yeah, it's all up to you. You can find me at HRC Fertility in Beverly Hills. Amazing. Thank you so much.

This was awesome. I learned so much from this. Yay! I'm so glad. Thank you so much for listening to the Real Foodology podcast. This is a Wellness Loud production produced by Drake Peterson and mixed by Mike Fry. Theme song is by Georgie. You can watch the full video version of this podcast inside the Spotify app or on YouTube.

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