Relatable with Allie Beth Stuckey - Ep 1018 | Former IVF Doctor Blows the Whistle | Guest: Dr. Lauren Rubal

Starting point is 00:00:00 Dr. Lauren Rubal is a double board certified integrative medicine doctor in OBGYN. She spent years as a reproductive intercronology and infertility physician working with patients through the IVF process. Eventually, she woke up to the ethical and moral issues with IVF and she opened up her own practice that helps couples from a holistic standpoint. get pregnant naturally. And today she is going to tell us all of the scientific medical ins and out of the IVF process. She is going to tell us things that you probably did not know, goes into the entire procedure, the risks associated with it. There is a lot that she told me that I did not know about this whole process and what we should be thinking about when it comes to fertility and pregnancy. This episode is brought to you by our friends at Goode Ranchers. Go to Good Ranchers.com.

Starting point is 00:01:02 Use Code Alley at checkout. That's good ranchers.com code Alley. Dr. Rubal, thanks so much for taking the time to join us. If you could just tell everyone who you are and what you do. Absolutely. Thank you for having me. I am an OBJUYN who did a fellowship in reproductive endocrinology and infertility, which is a three-year subspecialty after the four years of OBGYN residency.

Starting point is 00:01:35 practiced as a full scope REI for a number of years. And as I tell everyone, my biggest career achievement was leaving all of that behind, opening my own practice dedicated to a more restorative reproductive medicine model. And also in the meanwhile, completing my integrative medicine to your fellowship. So I'm now double board certified in that plus I be Joanne. Yes. And your story is so fascinating. We talk a lot about IVF on this podcast and that's because it's in the news really more than ever. I feel like a lot of Christians are thinking about reproductive technology in a way that we didn't really think about even five years ago, surrogacy, IVF, the ethics behind this. And so I'm so excited to get to talk to

Starting point is 00:02:24 you, someone who is such an expert in this, but you worked in the IVF industry, if you will, or specialty for a long time. And I'm so excited to get to talk to you, someone who is such an expert in this, but you worked in the IVF industry, And of course, then you didn't have any qualms with it. And so tell us what that was like and what your thinking was then. Yeah, that's a great question. I mean, I think that it goes without being said that infertility is a profound and unique suffering. And couples who are undergoing it, I just have so much empathy for. So I think that first and foremost is so important to always remember.

Starting point is 00:02:59 With that being said, I know from my experience, I was so focused at the beginning on just trying to help those in that suffering, help those who were trying to conceive or were having recurrent miscarriages, for example. And I was also focused on the end goal, which was the child. But as I practiced the tasks of my profession, I really began to question a number of things. But the first part of this was, well, is this really the best approach? Is this the panacea that we've all... been told it is number one. Number two, are we actually getting to the root cause? So I felt like I was just starting to treat women as though they were just, I was really only treating like them as

Starting point is 00:03:48 ovaries in a vacuum. And I wasn't focused on the whole person, body, mind, soul. And so I felt there was this incompleteness in my approach to identify what was going on in healing it. Okay? So that was the second part. And then the third part was really seeing the sequelae of what couples and women went through as they went through all of these aggressive procedures. And there are many layers to this. There's obviously a moral and ethical component, but there's also the physical. It's very difficult to be injecting yourself with multiple medications daily on average for weeks. There's an emotional component, obviously. There are side effects that you're battling against and procedures that you're undergoing. And then, of course, the continued waiting game from fertility. And so

Starting point is 00:04:34 all of these factors really coalesced into, again, my decision to stop and have a more holistic approach. And I think that also speaks to women's health in general. So much of women's health, we're told our fertility needs to be suppressed, that we need to be on pharmaceuticals for a myriad of different conditions that all have one very similar band-aid. And so I questioned why I was doing that. I didn't feel like it was as tailored as it should be. And before we get into your kind of like awakening and transition professionally, I want you to answer some just basic medical questions that a lot of people have about IVF

Starting point is 00:05:20 because what I found and what was true for me is that there is a lot of ignorance and not to try to use a pejorative turn, but there's just a lack of knowledge about what IVF actually is. And when we think about it, big picture, without thinking about it too hard, it's easy to just be supportive of it in every case because having a baby is great. Where I'm pro-life, and so I'm pro-baby. I understand the desire to have a child, and I want someone who desires to have a child to be able to do that. And if IVF is the means by which they get to have a child, then I think it's easy for people to celebrate. but not everyone knows everything that goes into the in vitro fertilization process. So let's, I want to start from the beginning.

Starting point is 00:06:05 A 32 year old married woman walks into your office or, you know, not anymore, but back when it was just this kind of IVF approach or the old fertility methods that you were focused on until more recently. And she said, okay, you know, we've been trying to have a baby for two years. we can't do it, we want to go through IVF, like, what does that process look like from there? Yes, absolutely. And so the conventional process would be, of course, to try to diagnose the reason why they were unable to conceive to that point.

Starting point is 00:06:42 And so that couple will undergo a slew of testing, which, of course, they still perform, whereby we're looking at both the factors within the woman's body, such as issues regarding her eggs, whether they're being released from the o'clock. ovary, the number of eggs, the hormone balances that exist within her body, such as thyroid, for example. We'd also look at the structural components of her reproductive tract, which include the uterus, the fallopian tubes, which are where the sperm and the egg meet within to form baby. And then finally, we'd look at the male partner, and we'd assess his sperm through a semen analysis. And so that would be the very standard infertility workup that a couple would

Starting point is 00:07:29 first undergo. Again, knowing now what I know with the breadth of further knowledge that I've gleaned in these last several years, I would say that at least for myself, I can only speak for myself that I overlooked a lot of factors that may still contribute to infertility, which is why this unexplained diagnosis, meaning the woman's ovulating, at least one tubes open, the sperm overall looks normal. We give that couple, okay, well, this is unexplained. That diagnosis ranges from anywhere between 10 to almost 50% of the time, depending on what study you're looking at. And it's interesting looking now when we actually get to the root cause of this, we can get that diagnosis down to certainly less than 5%. So that's just one example of why conventional treatment

Starting point is 00:08:26 versus this restorative reproductive approach is quite different. Okay. So when someone walks in and basically everything kind of looks good and it looks normal, that's when they're given unexplained infertility because I've heard that a lot. You even see it in like the Instagram bios of some people who are chronicling their IVF process. say they have unexplained infertility. So that's basically what they mean, that for whatever reason they can't make a baby, but the doctors can't pinpoint why. And is that typically the diagnosis that someone is given before IVF has recommended to them? Well, there's a variety of different diagnoses, which makes sense because there are a couple involved. A third of the time, it's

Starting point is 00:09:10 based on what we call a female factor. There's so something going on within the woman's body. a third of the time it's a male factor, even up to half, it's both. There are several diagnoses that we're making. So there is a variety of reasons, common reasons why people go to IVF immediately include issues with the sperm, issues with the tube, such as the tube being closed, or low number of eggs, which is called diminished ovarian reserve. Okay, gotcha. And then say that woman who walks into your office, that's what she falls into one of those categories.

Starting point is 00:09:49 And so they move forward with IVF. What does it look like from there? Yes. So from that point, what would happen is a woman typically starts an IVF cycle with her period, with that bleed. Although many times women will also be given birth control pills for varying reasons or be given injections before that. projected start date of the IVF cycle for even a couple of weeks in order for the physician to in a way become the exogenous brain is the way that I kind of think of it because typically what happens in our endocrine system, which is just our hormones talking to each other.

Starting point is 00:10:27 Our endocrine system is comprised of hormone messengers so that the brain can talk to whatever organ it needs to and the organ can talk back. Okay. And in a woman's natural cycle, there is what I think of as a race, to ovulation every month, meaning there's a group of eggs that lines up, but only one egg at the end of the month, at the end of the cycle, can be released, can be the winner of that race, okay? It can be ovulated. In IVF, the goals are different.

Starting point is 00:10:59 In IVF, everyone's a winner. So every follicle that contains an egg is ideally will become a mature egg. And so how does that happen? How it happens is that a woman's given daily injections for on average a couple of weeks in order to cause those eggs to mature. But before those eggs can be released, again, a couple of weeks later, they'll undergo a procedure called an egg retrieval. This comes after multiple visits every other day almost, on average four to five visits

Starting point is 00:11:36 with the fertility doctor, at which point she's going to undergo a vaginal ultrasound to measure the size of the follicles because as the follicle grows in size, the egg inside is maturing. And so that's being monitored very closely. The lining of the uterus is being monitored. And then finally, the day of that egg retrieval comes. The woman is typically given conscious sedation, meaning medicines through an IV. So she has a twilight sleep. And then while she's asleep, there is a needle that's placed through the vagina under ultrasound guidance and into each of those eggs and the, into each of the follicles, which is where the eggs are contained, and then the eggs are suctioned out, and that's done with every egg in both ovaries. The eggs are then handed

Starting point is 00:12:23 off to an embryologist in a lab, and then the embryologist looks at the eggs, determines that they're mature, and at that point, they'll place the egg in a dish, either surrounded by a lot of sperm, or they will take a sperm, they'll select a sperm that ideally is moving forward, that ideally is normally shaped, and they'll physically place that sperm into the egg in a process called Xeer intracidoplasmic sperm injection. And so then they leave those dishes overnight, and the next day the dishes are checked again, and 80% of the time on average, they'll then contain an embryo, a fertilized egg. Okay, gotcha. And can I ask, this is an uncomfortable question that we have actually never talked about. So we hear, okay, the sperm, you use the sperm and you put it in the dish or you put it on the egg. But something that is overlooked is how you actually get the sperm. I feel like we don't really think about that or talk about that. But that has its own, like, ethical questions, right? So are you able to talk about that? Like, how does.

Starting point is 00:13:36 the father then give his sperm to then fertilize the egg? How is that collected? Well, the vast majority of the time, it's done through masturbation. And so I think that I've certainly talked to a lot of male patients who have said what an uncomfortable and embarrassing process that is because there are specific collection rooms whereby they'll go and collect and then hand off the sample to the embryology lab. And is pornography a part of that? Yes. Okay, so a man very often is watching or looking at porn in order to masturbate to give the sperm to then that is used in IVF. And you would say that's the majority of cases of IVF? I would say that's the vast majority. I mean, I think the other way of collecting would be to do it through the process of intercourse. And I know for certain

Starting point is 00:14:33 for some of my couples who don't want to interrupt that unitive and procreative act, you can use a perforated condom. So that way, that act is still licit in that regard. But that is not the majority. That is absolutely the minority at the time. Okay. So you said that after the, which by the way, just to like pause there, I feel like that is not talked about very much at all when it comes to the ethics and the morality of this. So I just want everyone to kind of like take that in if they didn't already know that that was part of the process. But once that egg is fertilized, you said that there is an 80% chance that after waiting, once they're in the petri dish, that there will be an embryo. Well, how many eggs are typically collected, would you say, in a typical egg retrieval?

Starting point is 00:15:23 You know, it depends, Allie. It depends on the woman's egg number, and it depends on the type of stimulation that's employed, okay? So I'll give you a range, okay? What we would call a good prognosis patient would typically have eight to ten follicles, each of which would contain an egg in each ovary. Okay? And so the average number for good prognosis would be anywhere from about 20 follicles

Starting point is 00:15:51 being seen on ultrasound and measured. I would say from those, maybe perhaps there would be about 15 mature eggs retrieved. Out of those, if we assume an 80% chance of fertilization, that's 12 embryos. Okay. And we contrast that to someone who has something like, for example, polycystic ovary syndrome, which is a condition whereby women have an imbalance in their meal and female hormones. And they also have irregular cycles, irregular ovulation. but those women may have many more follicles.

Starting point is 00:16:23 So I can remember reading or hearing about even up to 50 plus eggs being retrieved in women, such as a PCOS patient. On the flip side of women who has that low egg number, they may be, there may be only three eggs retrieved in that case. So there's a wide range. Okay. So say a woman has a dozen eggs that are retrieved, all of those eggs are then fertilized? Great question. I would say, again, the majority of the time, yes, all those eggs, all those mature eggs would be attempted to be fertilized, correct?

Starting point is 00:17:14 There are cases, especially with higher egg number, whereby the eggs. the eggs themselves could be frozen in order not to create so many excess embryos. But that is not necessarily performed. I mean, again, I don't know if there's a statistic on that. But I would say the majority of the time that those would be attempted to be fertilized, yes. Okay. And then you said, I know I'm kind of bouncing around a little bit as the questions come to my mind. but then you said there's an 80% chance that an embryo will form from those fertilized eggs.

Starting point is 00:17:53 And so then what happens from there? So then that embryo has one of three fates at that point. The first is for, well, I mean, regardless, let me actually back up. Because what happens from there, even before the determination of what happens ultimately with the embryo is that the embryos are then watched. They're kept in those dishes for a period of days. and in an incubator in order to simulate the temperature, the humidity, all the conditions whereby they would naturally be within the mother's tubes, fallopian tubes. And we watch as those embryos grow and divide.

Starting point is 00:18:36 And it's actually remarkable. They're dividing so rapidly they go from one cell to hundreds of cells just days later. And we can watch that process happen. happen. They actually mature and the process of maturation means they actually, the embryo forms an inner cell mass. So they're beginning to grow and develop into, again, what becomes the baby and then what becomes the placenta. And this is all happening naturally in the fallopian tube or in these dishes. Okay. And so they may be graded at this point. And so an embryologist is checking on them throughout this process. They're being potentially manipulated because in the case of, you know,

Starting point is 00:19:16 for example, embryo biopsy, they would, an embryologist would actually place a needle into the embryo, suction out some of the cells, and then send that off to a lab to screen the chromosomes within those cells, okay? Okay. They may undergo, yeah, so there's a lot of potential options, but that brings us to, again, the one of three fates. One fate is that a few days after their life, they will be transferred back into a, woman's uterus in order to see if implantation if pregnancy occurs.

Starting point is 00:19:52 Okay? That's one. The second fate is that they will be biopsyed, as I mentioned, in order to undergo chromosome screening. The third fate is that they will be frozen. And they will be frozen in liquid nitrogen-containing canisters as well. They'll be stored. Okay.

Starting point is 00:20:09 And you said that the embryos are graded. Are all the embryos graded, and what does that mean? So what it means is there's, well, what is grading mean? There are different ways for the embryologist to determine the morphology of the embryo. So that's a, let me unpack that. What that means is an embryologist knows that there's a very typically precise set of growth and symmetry of the cells, for example, lack of debris within the embryo. him or herself.

Starting point is 00:20:49 And those will correspond to certain grades that have been spelled out in different systems that have been validated. But the ultimate reason for grading is because there's been data supporting the fact that embryos that look more symmetric that achieve a certain number of cells or a certain stage in development at the time that they should may have a higher chance of of leading to a live-born baby. Right. Okay.

Starting point is 00:21:21 And you said that there's the biopsy possibility. Do all parents choose to get that kind of testing? Because you said that that looks at the chromosomes. Is that how gender is determined or what is being looked at there? Yes, that is how gender may be determined. And the reason for that is because all chromosomes are screened. And so they'd be called either uploid, which means, screened chromosomally normal. So a 46X, X, X, X, Y, okay, they can be checked for specific genetic disorders.

Starting point is 00:21:58 The majority of the time, though, again, the embryos are screened for just chromosome number, right? And so, again, that 46X, 46X, 46x, would be typically looked at very commonly. And to answer your question about how common that is, I would say the most recent data nationwide of IVF clinics in 2021, it was the last year that they've been able to publish that data show that at least half of all cycles are PGT, which is pre-implantation genetic testing, which is what that biopsy is for PGT cycles. So it's very common now, and the number is increased. Well, because I hear very often, especially when it comes to say like two men that are using an egg cellar and then also a surrogate is that. And even with Paris Hilton, like Paris Hilton used a surrogate.

Starting point is 00:22:54 And she knew the gender of all of the embryos that she had on ice. She was like, I have like 12 boys and I'm still trying for a girl, whatever it is. So I guess I thought that all IVF patients know the gender of the baby before it's even transferred. But I guess that's not the case. they'd have to undergo that biopsy process in order to get the chromosomes from that embryo because that embryo has a unique set of chromosomes right from the mother the father and so therefore that embryo would him or herself have to be biopsy in order to understand what that's embryos chromosomes reveal how often would you say there might not be an exact

Starting point is 00:23:53 statistic on this. But for those who do undergo or their embryos undergo that genetic testing, how many then decide, okay, if the baby has Down syndrome, for example, that's a chromosomal disorder, do they decide, okay, we're not going to move forward with transferring that embryo? We're going to try again for a healthier embryo. Like, how often are decisions made based on any kind of chromosomal signs of some kind of disability or disorder? Very often, Allie. I mean, the standard typically is that if that embryo is deemed, screened, chromosomally abnormal, that embryo will not be transferred back into the uterus.

Starting point is 00:24:40 There has been a move more and more towards some centers being open to attempting that transfer. And I'll tell you the reason why that is. It's because, again, no technology is perfect. And that also goes for pre-imputation genetic testing for the screening process. And so these embryos, it's very interesting. I liken it almost to, this embryo is almost like a lots of different cells, almost like a soccer ball, if you will, sometimes. That there are white areas of abnormal cells, but also black. black areas of normal cells, for example. And if you biopsy the wrong area, you might erroneously

Starting point is 00:25:28 conclude that that embryo is not chromosomally uploid and therefore would not have that embryo eligible to be transferred. Again, the data is very new in this regard. But there is, there are case reports in the literature showing that some of these embryos that that, that, then, you know, of course, informed consent obtained. Everyone agrees that we're going to go ahead and transfer this embryo into the uterus. And there have been reports of chromosomally normal babies born to these abnormal, allegedly screened embryos. Okay.

Starting point is 00:26:12 So do parents even have, because you mentioned or alluded to the fact that some centers won't even consider transferring a chromosomally abnormal embryo. And that could mean like a baby with Down syndrome. And of course, we know that people with Down syndrome can have like fulfilled and very joyful lives. But that could be like the kind of baby that we're talking about that they deem almost, I don't want to, you didn't use the term incompatible with life,

Starting point is 00:26:41 but it seems like that is almost the judgment being made by saying, okay, this embryo is going to be discarded. Like, do the parents in that case, Do they have the choice? Are they ever told, hey, this baby has Down syndrome? What do you want to do? Or are they not even informed about what happens to those embryos that the doctor decides are not healthy? I would say that typically I can only speak for myself.

Starting point is 00:27:12 Okay. And so I will tell you that in my prior practice, you know, I had such a blindness, Allie, that and there's a lot of reasons for that. But with that being said, you kind of just think, okay, this is this an aneuploid. And it's true. There are plenty of situations, not just Down syndrome. I think trisomy 18 is another one that there are children with trisone 18. I personally know of one that are able to lead lives that are, it's not, it is compatible of life this diagnosis. There are plenty of others like Turner syndrome. And, but there's this blanket thought that, oh, anuploid means not transferable. Yeah. Okay. So for the embryos that are deemed healthy or the ones who don't

Starting point is 00:28:04 go through genetic testing, well, how many healthy embryos would you say someone typically ends up with? I know there's so many factors that go into that, as you've already explained with the number of eggs and the age and all of that. But what is like the average number of embryos created in the IVF process? So let's use that kind of middle of the road, good prognosis patient example again, right? And so remember there were 12 embryos that were created, right? Out of those, they'll be watched. Not every one of them will continue to mature.

Starting point is 00:28:39 And so about six embryos, I would say, on average, will make it to blast us a stage, which is typically day five of their life and is what we consider a mature embryo. And so, again, out of those, if that couple chooses to have chromosome screening performed, perhaps about half of those will yield euclid chromosome screen normal embryos. Okay. And so that would be then three embryos if biopsy was done. If it's not, then there would be about six embryos of which, depending on the woman's age, anywhere from one to even potentially up to three or more would be transferred back at a time.

Starting point is 00:29:26 Okay, so at a time. So she could have three of those embryos transferred simultaneously? Potentially. And that has a set of criteria depending on the woman's age and different prognos. diagnostic variables. But what's interesting is that they actually published again in this most recent CDC report of U.S. clinics, the average number of retrievals of egg retrievals needed to achieve a live-born baby. And Ali, even in the best prognosis age group, which we consider less than 35 years of age, the average number of egg retrievals. Remember all that whole process that that couple and that

Starting point is 00:30:04 woman have to undergo, the average is two. And in a woman who's over 40, the average is, I believe, over nine and perhaps even 12, but definitely over nine, which is just, just you think about these women, really, it, again, it takes, it can take a toll on many couples and women as they're undergoing this for many reasons. On the woman's side of this, you said before the ag retrieval, she has to inject herself with, what is it that she's injecting herself with? There's different type of, first of all, hormones that are used. okay, as well as other injections designed to prevent premature ovulation.

Starting point is 00:31:00 And then, so those are the main type of injections used. Okay. So she's injecting herself typically at home with these shots. And I've seen pictures and videos of that. As you said, she's got the multiple doctor's appointments to make sure that the eggs are maturing. She goes through the egg retrieval and she's kind of put under, like you said, a twilight sleep for that. There was that, I don't know if you saw that. I think it was New York Times podcast.

Starting point is 00:31:23 this horrible story of these women who were being told that they were being put under or being told that they were given fentanyl and they actually weren't and the nurse was stealing the fentanyl and putting something else in there and they were completely awake for all the egg retrievals. So that was like a whole big story. There's just so much that happens in this reproductive industry that a lot of people don't know. But anyway, so they get the egg retrievals. Then they start the fertilization process as you just explained. but what does the woman do while that fertilization process, that growing process into the blastocyst is happening?

Starting point is 00:32:01 Yes, it depends again on what the plan is. If there is what we call a fresh embryo transfer to be performed, meaning five days later, for example, the embryo is going to be placed back into that woman's uterus, then the woman will undergo just preparation of her uterus is what it's called. and that's by giving hormones as well in different ways. And so that might include more injections that will include pills as well as potentially antibiotics. So that would be her preparation and then more scans to make sure that the uterus is prepared to receive the embryo.

Starting point is 00:32:42 Okay. So getting the uterus ready to receive that embryo so that it's hospitable for the embryo to implant for the placenta to grow and all of that. And what is the transfer process like both for this embryo and for the woman? And so the transfer process, I'll start with the embryo. So what will happen is it depends as well again. If embryo, if the transfer is happening with a embryo that has not been frozen, then what will happen is the embryologist will take the embryo and what it's called is load, place that embryo into a long transfer catheter. And then at the same time, what the woman is experiencing is that she'll be on a table. There will be typically an

Starting point is 00:33:36 ultrasound on her abdomen in order to watch as the catheter is placed through the vagina, through the cervix, and into the uterine cavity. And then you actually can see the air bubble surrounding the embryo being placed into the uterine cavity. Afterwards, the embryologist will then take the catheter to ensure that the embryo was indeed placed within the cavity or is no longer in the catheter. But typically that transfer process is done while the woman's wake. The couple is together in the room and is quite comfortable typically. Okay.

Starting point is 00:34:18 Not always the case. Sometimes if it's difficult to enter the uterus, then it can be uncomfortable for that woman. I would not think that that's. So the cervix doesn't have to be dilated at all? It just not. Okay. Not typically, but sometimes, yes. And in those cases, that could be very uncomfortable.

Starting point is 00:34:40 Okay. So at that point, though, she doesn't really know if she, yes, there is a living embryo, which as you've already said is scientifically, it's. own individual. That is inside her uterus, but we haven't gone to implantation yet, correct? That's just the transfer. So she wouldn't necessarily get a positive read on a pregnancy test yet, right? No. She wouldn't at all because, yes, you're correct. Implantation still has to happen. And during that process of implantation, that's when the embryo actually and the placenta and the uterus, it's actually quite beautiful because there's a very specific window of implantation that occurs,

Starting point is 00:35:23 whereby there are these special called peanut pods. They're almost these suction cups from the endometrium. And there's a cross talk between the embryo and the endometrium in any time, you know, spontaneous or through this process. And that the embryo is then drawn up into the endometrium. And this starts the process of implantation. after that the hormone HCG or human corionic and atotropin begins to be produced. And that's the pregnancy hormone that you can measure in the urine or in the blood.

Starting point is 00:35:53 Yeah. As you're explaining all of this, it just makes me like wonder at God about how he created the human body and the female body. Really like pregnancy and natural conception and childbirth is all such a miracle. Like all of the mechanisms and all of the effort that has to go into if you're doing it through this process to create a child. It's really just the fact that anyone is here is really just beautiful and miraculous and speaks to God's design. Go ahead. Yes.

Starting point is 00:36:26 I have to tell you one other part that I just love hearing because it just always makes me think of God as well. It's so interesting when couples are having intercourse and the woman's almost going to ovulate. Okay. And so she's a few days before ovulation. In fact, there's only a six-day period of time where a woman can become pregnant that cycle, whereby men are always fertile. Women are not necessarily always fertile even within that month. But anyway, when they're having intercourse during the time of her fertile window, they've done these very interesting studies looking at labeled particles that get deposited into the upper vagina. And they'll see that. like sperm within minutes, within two minutes, those particles along with the sperm are in the fallopian tube already after ejaculation. And it's so interesting is that they're on the side that the egg is on. Wow. And so there's like, isn't that own? Yes. I know. Yes. There's a, there's a lot of chemotactic signaling. There's a cross talk going on that, you know, is just so amazing. Yes. So amazing. And okay, so back to the transfer.

Starting point is 00:37:40 process. How, what, what is the percentage? I forget the number. I'm pretty sure it was lower than I realized. What is the percentage of transfers that will end in a successful implantation? Well, okay, so let, I just want to set the stage for this because I think that it's hard to parse apart the numbers. And the reason for that is because there were several factors. The first part of this is just to understand what is the baseline chance of pregnancy per cycle, right? And that's kind of the baseline we should be comparing things to regardless. And so when we think about couples in their 20s, which I think of as almost like best prognosis, right? High, egg quality and quantity.

Starting point is 00:38:28 No fertility issues, just trying for the first time. Their average chance of pregnancy per cycle is about 25 to 30%. So just FYI, that's just important to kind of set that stage, okay? With that being said, the way that the data is presented that I think is helpful to understand it better is how many of intended retrievals are going to yield a live birth? Because that's actually what we care about is the baby, you know, being born and not born ideally, right? And so when we think about best, again, best prognosis, there, or even all, Let's just talk about all comers. All comers, it's about a 37% chance of live birth.

Starting point is 00:39:14 And so again, it's not quite as high. I know that that can feel surprising, right? So that's just the live birth rate. When we compare that to just, there's different ways of looking at the data, but you can compare it to, again, some restorative reproductive medicine measures. There's an interesting study looking at couples who were, by all accounts, what we would call, hate using these terms in some ways, but poor prognosis, meaning the woman was advanced maternal age. I think the average age was

Starting point is 00:39:49 37 years of age. They've been trying for over five years. And when they looked at a series of a thousand couples who then went into, again, this deeper dive by these restorative reproductive of medicine approaches, they found that the cumulative live birth rate was over 15%, which is pretty amazing. So again, there's other options available. To answer your question, that's a look at some of the numbers. I think that people assume that IVF is like the guarantee that you're going to have the baby, that that's just what you do if you're 37 or you're 45 even, that you just go through

Starting point is 00:40:45 IVF and you're guaranteed to have a live birth out of that. And that's just not the case. There are some embryos that don't, they don't survive the transfer process. Of course, there are some embryos that won't implant. And that's true in natural conception too. And then, of course, there is the risk of a miscarriage, which, again, is also a risk, whether you naturally conceived. Is the risk of miscarriage higher in the IVF process? Well, you're asking compared to spontaneous conceptions is what I'm assuming, right? I would say that's a hard, that's a little bit hard to evaluate. And the reason for that is because we think of women who, it's a different population as the kind of term we use, meaning that those women who are experiencing

Starting point is 00:41:34 difficulty consumer, that couple may have different risk factors that might change that risk of miscarriage. Okay, that's the first part. And so the second part is, is that if they do proceed, with pre-implantation genetic testing with that chromosome screening, you can imagine that that's going to, again, decrease the number of embryos, like I said to you, that will even be used or tried, you know, attempted to be transferred. But then it does have a decrease in miscarriage rate is what the studies show, which makes sense because the vast majority of first trimester miscarriages are due to just random chromosome errors on the part of the embryo.

Starting point is 00:42:18 Okay, gotcha. Is it true that this is common? I know that this happens. I just don't know if it's common, that I've talked to women who really wanted to go about IVF in a way that is more ethical in the sense that they only wanted to create the number of embryos that they knew they were willing to implant or transfer, rather. And that some doctors are very hesitant to do that, to only create like fertilized three eggs, for example, just because the chances of then a successful life birth from that can be lower if you had, say, you know, fertilized six eggs.

Starting point is 00:43:02 Like is that, have you seen that at all? Like, is that the case that some doctors are hesitant to fertilize a lower number of eggs? Yes. I mean, I think that there are certain, what I've heard is that there are certain centers who, for example, won't even consider moving forward with fertility treatments if the PGT, if that chromosome screening isn't performed, for example. And so I've certainly heard of that. Yeah. And I also have listeners, because I talk about this a lot. And so I get a lot of stories from a lot of moms who have gone through IVF. They have regrets. about it. They love their children, but they realize, wow, there was just so much I just didn't know. And then some who went through IVF, they didn't actually end up getting pregnant that way. They got pregnant later. They adopted later. So many different stories, even on this podcast that I've had. And one story that I've gotten is a woman who got pregnant with triplets. And she was

Starting point is 00:44:01 encouraged by her doctor. This was after the IVF process to reduce. It does seem like it's more likely to be pregnant with multiples in the IVF process because you could be transferring more than one embryo at once. Is that something that happens that you have heard of of doctors saying, hey, if you get pregnant with twins or get pregnant with multiples, we can always do a selective reduction, which is aborting one of the babies in the hopes that it will lower the risk to the mom. Yes, Ali. So I think that the reason why is because in IVF, remember the baseline chance of twins, for example, in the general population is about 2%. In IVF, there's about a 30% chance of multiple pregnancies, okay? If this is another reason why there's such a push for that

Starting point is 00:44:52 chromosome screening is because with chromosome screening, one embryos transferred back at a time, thus decreasing number of multiple or just chance of multiple pregnancies, okay? But in those patients who do have triplets or more, the standard would be absolutely to say that due to the risks to the mother and to the children, which I know sounds very ironic, that selective reduction would be recommended. I think that's something that a lot of people just don't think about. I've actually seen, I saw recently an Instagram post from someone saying that she did this, that she went through selective reduction and that it was something that she was happy about that, you know, she said kind of like that it saved her life but also saved the life of her other children potentially

Starting point is 00:45:47 and you just kind of choose the baby that's easiest to get to and then abort the baby that way. And that is also sometimes an unforeseen consequence of purposely transferring multiple embryos at once is that you could end up with triplets or, I mean, oh, it's not probably often, but you could end up with quadruplets or something like that and then have further pressure after that. And so there's just a lot there. Go ahead. No, I agree. And I think that's what's so hard is that couples are then faced with these excruciating choices, maybe not for everyone, as you mentioned, but I would say for many couples that either at that moment or even in the future, right, after it's already occurred.

Starting point is 00:46:35 And I think another common one that many couples are dealing with these days are when they've completed their family, right? But they still have embryos frozen. Yes. There's over one million embryos estimated to be frozen in the United States right now, indefinitely, potentially. And they, I think these couples struggle so much with what to do with these embryos. And I think that's because inherently, for me, I think that it's because they inherently

Starting point is 00:47:06 realize that this is my child. And so I don't know if I feel comfortable, you know, giving away this embryo for adoption, for example, or donating this embryo to research where the embryo will be destroyed. Or just undergoing frank destruction. So a lot of very profound and difficult moral and ethical situations that people are placed in. and we just aren't talking about it enough. Yes. So I imagine that all of these questions played a role in you quitting your IVF practice.

Starting point is 00:47:40 So can you talk about that transition? Oh, absolutely. I mean, for me, yes, like I said to you, I love what I do. I think it's such a honor to be able to walk alongside the couples that I care for. I always knew I wanted to be a doctor. It was kind of one of those callings. And so I just love my job. With that being said, once my eyes were opened, once I finally started again, I was so involved in everything.

Starting point is 00:48:15 And I said to myself, like, this is, I'm dreading going back into work. I was dreading going into work. And that's why I decided, again, to stop, to leave it all behind. I just felt like for me, my soul was at stake. And I say that. Explain that. Like your eyes were opened kind of in what way? That this embryo is a human being and that human being deserve has inherent dignity and should

Starting point is 00:48:46 be protected as the most vulnerable of all. Again, this is, it makes sense. It just makes sense scientifically. There's no question about that. Number one, number two, is that all of these technologies, just because we can do something, doesn't mean we should. And what's the ultimate, we're seeing this now almost, it just feels like it's snowballing more and more, is the fertility industry, again, there's a lot, there's just not a lot of regulation compared to, for example, the adoption industry where you really have to undergo a very rigorous, screening process to understandably become the parents of this of this child and I don't think that that's present and I also think that this is starting to be used in ways again that are have

Starting point is 00:49:45 significant ethical and moral questions surrounding them so that was one big part of it for me and then I would say also that I just felt as I told you before, that we're putting these very expensive band-aids on these issues that are going to persist. And is that actually the best way to do medicine? Shouldn't we instead try to identify the root cause and heal it? And then we're going to be having healthier mothers with healthier babies and helping them in the long ones so they can have the longest life possible to care for their family. And we haven't even touched upon that. But there are risks to moms and children that are conceived with IVF.

Starting point is 00:50:30 And thankfully, in the overall scheme of things, these risks are rare, but there are relative increases in risk that, again, I don't know if there's enough attention put on those. And in my opinion... Oh, yes. So for moms, the maternal risks include an increased risk of 26% of preterm birth,

Starting point is 00:50:51 which can be devastating because if the babies are born early, they can have problems with every organ system, including cerebral palsy or even death. It includes an overdubling of the risk of hypertensive issues in pregnancy, as well as what we call severe maternal morbidity, which is basically a condition that's where the woman gets, the mom gets so sick, she may die. She's close to death, and that could be life-threatening hemorrhage,

Starting point is 00:51:18 or what's called preeclamps, which is high blood pressure of pregnancy, where they can even have acclampic seizures or sepsis, which is an infection of, the body. These things can increase significantly. There's an over five times increased risk of placental problems, again, which can lead to life-threatening hemorrhage at delivery. That's the mom. For the babies, there is an up to 40% increase in non-chromosomal birth defects that may be present. There is an increase in autism, as well as a four-time increased risk of stillbirth. I mean, that is awful. Again, thankfully, these numbers are.

Starting point is 00:51:57 are overall low. But I do believe that that may play a role in couples deciding what to do. And like I said, my personal opinion is that part of that is because we need to do a better job, again, understanding the reasons why people are struggling with this and healing that. And like you said, it's a very expensive, costly in more ways than one, as you just said, costly financially, but also can be costly for your health, can be costly for the child's health. There are women who go through rounds and rounds of IVF. I mean, that can really wear on your body and on your emotional state. I mean, what you described for IVF, it's very invasive.

Starting point is 00:52:43 I've had three kids myself and even just like the like ultrasound and then then when you deliver like the cervical check process like all of that is invasive and like leaves a mark on your brain that you're like that was not fun. So glad I have this baby, but that was not fun. I would love to never have another cervical check in my life. And so but you I listen to IVF and I'm like, well, that's a lot of that. Like, that's a lot of very invasive stuff that someone is going through potentially many months in a row. That's not nothing. That can really wear on your body and mind and your heart, too. Absolutely.

Starting point is 00:53:26 Yes. And even for, again, the finances, there was an interesting study that showed that the average cost to have a live-born baby was anywhere from $60,000 to $72,000 with IVF or the higher end was with donor egg. So this is a, it's just a, it's a crazy, exhaustive process in so many levels. So for you, these revelations, these realizations about, you know, everything that wasn't being talked about and was kind of just like pushed to the side as far as the ethics and morality of how we treat these women and how we treat these little children at the earliest ages of their life. I'm guessing your faith had something to do with this kind of awakening, right? Yes, absolutely it did. I like to talk about it in both ways because, again, I think there's a clear medical and scientific argument for this.

Starting point is 00:54:36 But for me as well personally, of course, I, the Holy Spirit for me, just he, God is so good. Thanks be to God that he did not give up on me. And I felt best his call more and more and more. And to me, I really, it was, it was, I talked about being blind and I think sin blinds. Your heart gets so hardened. Yeah. And to have that, my heart really just broke open.

Starting point is 00:55:02 And the, you know, I always think of that verse of, of being washed away and realizing. Yeah. What I was involved in. So, yes, I, I'm so grateful to God for his mercy. Yes. Absolutely. That goes without being sad. Yeah. And now talk about, you already have a little bit, but more about what you do now, this holistic approach to fertility is someone who, for whatever reason, it took three to four months for us to get pregnant every time. We didn't have any kind of medical intervention or health. But I remember the first time. I was 26 when I got pregnant. I guess we probably started trying when I was 25.

Starting point is 00:55:44 And I remember my doctor telling me, oh, if you don't get pregnant, you know, y'all are in your 20s, you're healthy. If you don't get pregnant within six months, then we probably need to see about getting you some kind of, you know, just seeing what's going on. I don't know if you would agree with that or not, but that kind of scared me. I remember thinking, oh, my gosh, if I don't get pregnant in six months, something's wrong with me. And we did, we did get pregnant within six months. But I have friends who it took them longer than six months. And they didn't really have anything wrong with them. It just, I don't know, whatever it is.

Starting point is 00:56:17 I think people don't realize there's not, you can't get pregnant every single day of the month. And so there's just a lot of misunderstandings and a lot of scary talk when it comes to trying to get pregnant. And I think some people think that if they don't get pregnant the first time, because everyone also has a friend like that who gets pregnant as soon as they have unprotected sex, you think there's something wrong with you. And that's just not always the case, right? Not at all. I know I always kind of say that the people who get pregnant the first time are the only ones that talk about it very openly it seems like. But, you know, first of all, I would say that knowledge is power. It's one of my mantras. And so if you're concerned, whether you've been trying for three months or certainly the technical definition of subfertility is trying to conceive without being able to for 12 months. It can be earlier with risk factors. But I always tell my patients, if there is something that you are concerned about, it's always an opportunity to go in and speak to a professional because they may have some insights.

Starting point is 00:57:25 You be able to do some testing, whatever you want and feel comfortable with and you decide together, that will allow you to optimize your health. Okay, so that's very first and foremost. The second point, I would say, which kind of speaks to the misconceptions, is that goodness, we just aren't taught, we aren't taught about our bodies. I feel like I would have no idea about any of this unless I did what I did. And I'll tell you, Allie, as the purported expert in women's health, I realized after I started digging deeper into fertility awareness-based methods, that I was learning some things for the first time. And this is actually supported by literature. In fact, only I believe about 6% of OBGYNs and family medicine physicians were able to answer correctly regarding fertility awareness-based methods and their efficacy in both achieving pregnancy and avoiding this. And so even though patients are clamoring for a more natural and empowered approach to understanding their own bodies, their own

Starting point is 00:58:28 fertility as a couple as well, you know, again, I think the data shows that anywhere from 23 to 60% of patients want to use a more natural approach, these fertility awareness-based methods to either achieve or avoid pregnancy, only 1% end up doing so because they didn't feel like they understood it well enough or received proper counseling to do so from their medical providers. And so there is a gap right now. And I think that there are gaps on multiple levels, but that's exciting because that means we can address this, right? And so what it means to me is that a basic education of, again, in middle schools, right? I feel like the system, when we think about sex ed, there could be, in my opinion, a much more comprehensive way of understanding what a woman's

Starting point is 00:59:24 body is doing and why, and that it all makes sense. And it's part of this beautiful, again, miracle and in complexity that works so perfectly. And if it's not working, you can seek help for that. And it will give you, again, the empowerment to understand that. That's one level. The second level is educating those of us who care for others. And so facts about fertility is a wonderful program by my dear friend, Dr. Margaret Dwayne, who seeks to help medical students and residents nationwide to understand different

Starting point is 00:59:58 fertility awareness-based methods and their efficacy. And then finally, I think that, you know, there needs to be continued calls from patients themselves. And so I always tell my patients, I love when they're proactive. I love when they come. Someone was telling me the other day, she said, oh, I don't want to come with the big notebook. And I said, no way, I love it. I have learned so much for my patients, quite honestly, because people do great research. And that's how you should be. You should be proactive. Be your own best advocate. It is so important. speak up if there's something you don't understand or something else you want to consider, make sure that this is your life, right?

Starting point is 01:00:35 It's how I always tell people. You have to be able to feel at ease and comfortable and at peace with the path that you are going on. And that alone, I think, sets you apart as a doctor because so many of us have had that experience with the doctor who just makes you feel like you can't ask questions. And if you do ask questions or you question their authority at all or if you say, I did research, then they look at you like you're an. idiot and then you're like, okay, well, I guess I'll just do whatever you say. So even a doctor saying, no, I want you to come in with your questions and with your research, I think that's great.

Starting point is 01:01:07 And because you're right. Like it took me probably until my third pregnancy and third birth to realize, no, I can speak up. And like I, at this point, I feel kind of confident that I know what I'm talking about, not about everything, but when it comes to my own body. And so, yes, I totally encourage women to feel confident in that. So you help women with normalized cycles, optimize fertility and miscarriage prevention, hormone transition, integrative tools that a lot of people just don't think about, including like mood issues, heart health, like the body really just works together and everything affects something else. And so often we have such an isolated approach to medicine today that we just don't realize how all of these little things work together, right?

Starting point is 01:02:03 That's exactly right. And that's part of the principles of the integrated fertility that I am honored to be able to practice, is that we are whole people, right? As I mentioned before, their mental, emotional, physical, and spiritual parts of us. And that it's a whole system's approach. And so the interconnectedness of organs, exactly, the importance of our microbiome. for example, the importance of lifestyle changes and how that can truly make an impact. And this has been well studied, as well as the role of inflammation. And again, seeking to understand those hormone balances and correcting them. I've seen just, it's been so fulfilling.

Starting point is 01:02:45 And again, my career has been very fulfilling in different ways throughout its 20-year course or whatnot. But this current chapter has been really exciting because I, truly feel, again, that I'm healing, helping heal these issues and women are reporting just such market improvements and how they're feeling. And then, of course, we see the fruit of that. It's very, it's just wonderful. Yes. And praise God. And it's just, I mean, God created our body so purposely and with such intention. And there's so much that we can learn about them. And I love it. Like, I'm so fascinated by everything that you do and everything that you've

Starting point is 01:03:27 talked about today, even as someone who opposes IVF, I'm fascinated by that process because, you know, like we already mentioned, it just shows how intricate the design of our reproductive systems is and how miraculous bringing life into the world is. And so the fact that you are giving couples that power and that knowledge and also just helping us get healthy in the process really is amazing. Yes, absolutely. Absolutely. Is there a place where people can, maybe they're in your area, but where they can hear more from you or learn more about what you do? Where would, where would they go? I think the best place right now would be at my website, which is Lauren Rubelmd.com. And so that is a great way to reach out to me. There's a contact page there.

Starting point is 01:04:21 Perfect. Gosh, there's just, there's so much more. Even I could ask you. There's so much. much more that we can talk about. We'll have to have you back on, but I just so appreciate you. Thank you for using your testimony for good. Yes, all glory to God, but I love how he uses people's callings, people's passions, people's own revelations about medicine, the body, the ethics of it all for his glory and to help other people. So thank you so much, Dr. Rubal. I really appreciate you. Oh, thank you, Allie, for having me. And I appreciate you and your hard work as well. It's just, again, all for God's glory, but it's good to be an instrument of. his will. Yes and amen. Thank you so much. You're welcome.

Relatable with Allie Beth Stuckey - Ep 1018 | Former IVF Doctor Blows the Whistle | Guest: Dr. Lauren Rubal

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