The Diary Of A CEO with Steven Bartlett - The Pregnancy Doctor: Pregnancy Halves Every Year After 32! If You Want 2+ Children, You Need To Know This! If You Experience This Pain, Go See A Doctor!

Episode Date: June 3, 2024

Where have all the babies gone? Dr Natalie breaks down everything you need to know about fertility.  Dr Natalie Crawford is a double board-certified fertility doctor. She is also the co-founder of Fora Fertility clinic and Pinnacle Conference, a leadership conference for women in medicine. In this conversation, Dr Natalie and Steven discuss topics such as, how plastic and pollution affect your fertility, the surprising condition that’s affecting 1 in 4 women, the best time to have sex for pregnancy, and the impact of phones and hot baths on sperm count.  00:00 Intro 02:05 You Need To Look After Your Fertility Even Before You Want Children 04:31 We're Struggling More Than Ever To Have Children 07:00 Are We Having Less Sex? 07:47 Sperm Count Is Declining At Scary Risk 10:38 I Had 4 Pregnancy Losses And It's Devastating 13:36 The Stigma Of Infertility 16:15 Infertility Is Not Just A Female Issue, Men Are Affected Too 18:49 Understanding The Basics Of Fertility 22:26 Environmental Factors Affecting Male And Female Fertility 26:32 Are Phones And Laptops Bad For Fertility? 29:40 Heat And Infertility 30:15 What Testosterone Replacement Therapy Does To Your Sperm 31:45 The Egg Vault 35:25 Egg Production And Anomalies 42:41 Regret, Hindsight Of Patients And What You Can Do 47:16 What Has Changed Since Our Parents 49:06 The Effects Of An Unhealthy Lifestyle 54:07 Sleep Is Crucial In Your Reproductive Hormone System 55:07 How Stress Impacts Fertility 57:14 The Best Diets For Good Fertility 59:11 How Dairy Impacts Your Fertility 01:01:05 You Need To Understand The Reproductive Cycle To Know How Exercise Impacts It 01:10:58 Menstrual Irregularities And What's Normal 01:16:57 How Long Does It Take To Get Pregnant? 01:17:50 When Trying To Have Children Sex Can Become A Chore 01:21:43 Purchasing Sperm From The Black Market 01:24:48 PCOS Explained 01:30:59 PCOS Diagnosis 01:33:50 Link Between PCOS & Endometrial Cancer 01:37:02 What Is Endometriosis & How Do You Know You Have It 01:43:55 What Happens When You Come Off The Pill And Want To Have Children 01:46:25 Advice For People With Endometriosis And PCOS, If They Want To Have Children 01:49:36 Getting Started With Freezing Eggs And Embryos And Success Rate 01:55:15 The Cost Of Fertility Procedures 01:56:40 IVF Stigma 01:58:42 Ads 01:59:32 When To Think About Fertility Treatment 02:01:54 Dummies Guide To IVF 02:06:38 Myths Of Conception 02:08:54 Best Sex Position To Get Pregnant 02:10:33 Is Birth Control Healthy? 02:13:36 What Can People Do If They Struggle With Infertility? 02:15:40 Last Guest Question Follow Natalie:  Instagram - https://bit.ly/3yIQJ9L  Twitter - https://bit.ly/3wLxtb6  YouTube - https://bit.ly/4551ZZY  Watch the episodes on Youtube - https://g2ul0.app.link/3kxINCANKsb My new book! 'The 33 Laws Of Business & Life' is out now - https://smarturl.it/DOACbook Follow me: https://beacons.ai/diaryofaceo   Sponsors: Colgate: https://www.colgate.com/en-gb/colgate-total Shopify: http://shopify.com/bartlett

Quick one. Just wanted to say a big thank you to three people very quickly. First people I want to say thank you to is all of you that listen to the show. Never in my wildest dreams is all I can say. Never in my wildest dreams did I think I'd start a podcast in my kitchen and that it would expand all over the world as it has done. And we've now opened our first studio in America, thanks to my very helpful team led by Jack on the production side of things. So thank you to Jack and the team for building out the new American studio. And thirdly to to Amazon Music, who when they heard that we were expanding to the United States, and I'd be recording a lot more over in the States, they put a massive billboard in Times Square for the show. So thank you so much, Amazon Music. Thank you to our team. And

thank you to all of you that listened to this show. Let's continue. People are waiting longer to get pregnant. But if we imagine that there is a vault of your eggs, by the time you're born, you have one to two million. In your reproductive years, 300,000. This means if you and your partner wait till 35, your chances of getting pregnant are going to be approximately... I feel like I better get a move on. But there are things that we can do to improve your reproduction.

And this is information that nobody talks about. So let's get into it. Let's do it. Dr. Natalie Crawford is a double certified practicing fertility doctor helping people to optimize their lifestyle to improve fertility. Rates of infertility are increasing. One out of every eight women would have infertility and now it's one out of every five. And there's multiple factors that are contributing, including irregular or lack of having a period. There's more auto immune disease, obesity, chronic stress. People are waiting. But at 40, your chance of miscarriage

is 50%. And suddenly, you're left behind. And I know that because I had four pregnancy losses. And I'm going to cry now. Lots of people will be struggling with a variety of the things that you've talked about. What would you tell them? You can't control everything, but you should be able to control the factors you can. So what would my daily habits look like? I love that question. So what about the misconceptions around how to increase our odds of getting pregnant?

Yes, there's so many myths. If a female orgasms, does that increase the chance of fertility? This is super interesting. And then what is the number one thing that people don't do that impacts their reproductive system? It seems so straightforward. It's not a pill that you take for a major change of behavior. It is simply... Congratulations, Dario Vecchio gang.

We've made some progress. 63% of you that listen to this podcast regularly don't subscribe, which is down from 69%. Our goal is 50%. So if you've ever liked any of the videos we've posted, if you like this channel, can you do me a quick favor and hit the subscribe button? It helps this channel more than you know, and the bigger the channel gets, as you've seen, the bigger the guests get. Thank you and enjoy this episode. Natalie, who are you and what is the mission that you're on? Hi, Stephen. I am a fertility doctor, which means that I help people grow their family or plan for their family, no matter what that looks like.

But my mission started because early in my career, I realized I was seeing people when they were already behind the game. They didn't have the basic knowledge about how their body worked, their hormones, their reproductive system. And I had to bring them up to speed. And every time somebody said, I wish I'd known this earlier. I can't believe I wasn't taught this. Why isn't this the stuff that we're taught? Because I might have made different decisions earlier in my life. And that was a pivotal moment for me about eight years ago when I started wondering if I could reach people earlier in their journey, before they had infertility, before they were in my office, if maybe that could change the trajectory of their course, if they could be more empowered

with that education to make the decisions that are right for them versus just letting time pass, which ultimately makes some decisions for people. And when we talk about getting started earlier and thinking about this earlier, when we hear the topic of fertility, I think most of us think it's something that people over the age of 35 need to start worrying about. Or, you know, once we get up until close to our 40s, then we need to start thinking about our fertility more consciously. But what you're saying is that fertility or infertility starts much earlier in the decisions we make. 100%. If we view fertility as the ability to get pregnant, and infertility is a disease.

In the World Health Organization, the CDC, everybody defines infertility is a disease. In the World Health Organization, the CDC, everybody defines infertility as a disease, the inability to get pregnant. So then we can view fertility as more of the health, the wellness state. And just like we're trying to prevent disease and other aspects when it comes to cancer, Alzheimer's, many other diseases, we need to be approaching our fertility as a preventative action, taking steps to make sure that if having kids is one of your life goals, you're not making choices that is going to make that impossible or extremely difficult when you get to that stage. And what is the sort of macro social cultural backdrop to this? Because the conversation around

fertility and infertility to me and this might just be a sort of perspective bias seems to have suddenly increased over the last couple of years and I don't know whether that's because I'm in that age range now where my friends are having the conversations or that I think socially we're starting to think more about it because there is some pretty alarming data that's emerged around people struggling more than ever to conceive children. Because there's like social factors at play. Exactly.

What is that social backdrop? So it's very interesting when you try to put the whole picture together. One, because we are more aware of fertility. We have social media. People are sharing their stories. 20 years ago, you didn't know somebody might have infertility or be struggling. Similarly, there was less access to reproductive technology. Things like egg freezing didn't exist.

You couldn't do IVF unless you traveled to a city that had a big enough program. And so when there were limited ways to treat something, there was less access to get in to care to even be evaluated. So one, we do have people more aware about their fertility, getting diagnosed earlier and easier, finding out problems sooner. And some of that is, well, I think all of that's wonderful. Socially, yes, rates of infertility are increasing. We used to say one out of every eight women would have infertility. And now in the U.S., it's one out of every five who's just trying to conceive for the first time will have infertility. So that's a huge increase. It stays even when you confound studies for age. So the number one thing everybody says is, well, people are waiting longer to get pregnant, which

is absolutely true. I think only 5% of people started their family over age 30 back in the 70s. And now it's 25 to 30%. So we see a huge increase in the number of people who are waiting to start their family. I did. You are. Especially as women are being empowered to chase other dreams, go to professional school. They're delaying entry into childbearing. So part of this is that people are waiting later, diseases develop later,

but then also as a society, people are less healthy. We see more obesity. We see more diabetes. We see more environmental toxins than we ever have. So I really think this is something where there are multiple factors that are all contributing to this alarming rise of infertility that we're seeing. And are we having less sex than we used to? I think people are having less sex, yes, especially as they age. In the reproductive age range, it depends. People, when they get married, tend to be having less sex. But interestingly, there's been a really good study looking at marijuana. So we'll use it for example. People who smoke marijuana tend to get pregnant less, even though they're having more sex than people who don't. So when you say this group's not smoking marijuana and they're getting

pregnant, even though they're having less sex than this other group, it's showing us that it's not just timing or not having intercourse. There really are other factors at play that are very socially acceptable that are influencing the ability to get pregnant. I was reading through some research earlier about fertility and the sort of global trends. And I read this one stat that said the global fertility rate has decreased from 4.84 live births per woman in 1950 to 2.23 in 2021. And it is expected

to drop to 1.59 births per woman by 2100, which means that there's clearly a trajectory. I mean, if this is true, then there's a trajectory. To having less kids. Yeah. In the US, it's 1.3 is the average right now for a single woman or one person will have on average 1.3 children. That's very alarming when you start thinking about is that number just people are waiting or what about all the people who just can't get pregnant? And I see those people in my office over and over and over again that are not able to get pregnant, even if they're starting young. So I think that we really have two factors going into that statistic you saw.

When it comes to sperm, you know, a study came out last year looking at sperm counts, and they've decreased 50% in 50 years. What's most alarming about the sperm count decrease in men is that in the past 10 years, it's decreased at double the rate that it did the 40 years prior. So when we start looking at more recently, the rate of decline is accelerating. And that's got to be the world around us. And you in 2020 founded the Fora Fertility Clinic, which is based over in Austin. How many couples, women, people have you seen since you've opened that clinic? And what is the typical sort of case study of why someone will come to you in that clinic? What are they searching for?

What are they struggling with? I love that question. So, yes, I started Fora in 2020 with my partner, Amanda Skiller, and she and I have been practicing for quite a while at this time and realized that there wasn't an approach, at least in Austin, for personalized care. Because of that, probably the number one type of patient that we see is coming in who's already had lack of success somewhere else, meaning went to a clinic, has been trying the average patient is going to be over age 36, has been trying for one to two years, learned about their cycles, tracking their cycles,

relatively normal evaluation, trying to do IVF, and now is not getting the result they wanted. What I find the hardest thing for people is the isolation. You're suddenly being left behind in your friend and your peer group when you're trying to have a child and those in your world have succeeded. And suddenly you're left behind. And the stress and the isolation that causes really makes the entire process so much harder than many other medical diagnosis that somebody might get. Can you give me some more color on how that feels? Because you know how that feels. I do know how that feels. So I had four pregnancy losses before I have my two children. And this was a long time ago, and I was in the middle of training. So I was a resident and a fellow.

Definitely was not taking care of myself very well because that was the lifestyle of a doctor in training. And I didn't tell anybody I was pregnant minus my husband for the first three pregnancies because people weren't sharing about their pregnancies. I had this idea. I need to wait till I'm in the safe zone. I'm out of that first trimester. And so when I started losing those pregnancies, nobody knew I was pregnant. So it was so hard to come and tell somebody that I was losing the pregnancy when I hadn't even opened that door to trust them with the first piece of information. It was very hard to come in with that subsequent request for support or help. And I just felt like that wasn't what people

were sharing or talking about. My fourth pregnancy loss was an ectopic pregnancy, which is a tubal pregnancy. So this is a pregnancy that implants in the fallopian tube instead of in the uterus. Those pregnancies cannot grow. The fallopian tube doesn't have the blood supply to support a placenta. And the fallopian tube can rupture and it can become a surgical emergency and be very scary. That was diagnosed for me when my husband was off in a bachelor trip in Las Vegas and I had to receive a medication in order to try to stop the pregnancy from growing, but there was still a risk of the tube rupturing. And I was forced to call friends, have somebody come with me, be with me. And sharing it, there was so much support given that I realized that was such a mistake of mine. Not that you need to post every pregnancy announcement on the internet or tell

everybody at your job, but there are people in your life who want to support you and they can't show up if you don't let them know what's going on. And that's one of the things that I tell my patients is that give the people in your world the opportunity to show up for you. Tell the people who are asking, who you turn to in other times of crisis, tell them that you're struggling with this. Let them show up and support you because most of the time people will. They care about you. And that is going to lessen the burden because that isolating piece, the doubt and the fear, especially if you're a goal-oriented person, I have set so many goals. I'm going to do this. And here's my path to do it. So to feel like I was failing at becoming a mother when I didn't fail at anything and now my body was failing me felt so shameful, so much guilt.

And I had nobody to share that with or to help alleviate that burden from me. You used the word guilt there. There's a complex set of emotions that I've heard described when someone finds out that their pregnancy or even their sort of their sexual organs more broadly are struggling with something. And I've got lots of friends that have been diagnosed with a variety of different conditions in that sort of, with their sort of sexual health. And you almost observe a feeling that they can often feel like they are broken in some way, like they're not, you know, working. They're like a broken person. And I say that to try and highlight the fact that there's so many people going through that exact same thing

and that all of these conditions are very, a lot of people are struggling in silence with that feeling of inadequacy. You're so right. There's so much stigma to infertility. There's so much misinformation and uncertainty when it comes to reproductive health together that makes it difficult for people to talk about or ask questions. And when you feel like one of the things that you always thought was certain about your future, if you are a child and you envisioned your life 30 years from there, something, if you envisioned having children and suddenly you're faced with the potential reality that that might not happen or it might not happen without intervention, that really crashes down a piece of your own identity and who you saw yourself to be, who you wanted to be. And trying to struggle with that true identity crisis at that moment

really brings out so many emotions. It's what so many of the people who sit across from me every day say, I just, I don't feel like myself. I feel like I'm stuck while everybody else is moving on because I'm broken. My body is failing me. It's so hard to watch somebody go through it. And even if I can't get everybody pregnant or control the outcome, the thing that I always say is that at a minimum, you need to understand how your body works. At a minimum, you can know that you're making the choices that are right for you. You can feel good that you did everything that you could and that there wasn't education you needed or choices you would have made looking back in the rearview mirror. And even when somebody is deep in the midst of failed IVF cycles or sitting across from me, I say the same thing.

That's our minimum. You deserve to understand why we're making the choices so that this can be a process where you can advocate for your care and we can collaboratively do everything we can to try to achieve this goal for you? I had got a good friend who's just, because obviously I'm at the age now where my friendship circle is starting to go and get fertility tests done and such, and they're trying for kids. Many of them have been very successful. But I've got one particular friend who has been trying for some time. They're struggling. So they went and got the tests done. And it turns out that one of them in that relationship has some issues which are complicating their chances of getting pregnant. And when I heard that, yeah, God, I can't imagine how that person feels in that relationship. Because I can imagine in your head how you can start to overthink and you can feel that word,

again, that word guilt towards your partner. And you can start thinking, oh my God, this person's going to leave me because I can't give them what they want and all of that sort of complex, those complex, slightly irrational, but completely understandable thoughts. The relationship aspect is so hard, even going through it myself, because my husband wanted to support me and of course he did, but I felt like I was the one failing, not him, right? I'm the one who's not bringing my A-game to the table. This is a me problem. And even though it's an us problem, it felt like a me problem to the point where I really try to level the playing field to all of my patients, at least when I see them, and say, it's the two of you. You're a team. This is a team. It doesn't

matter whose diagnosis comes back as what. We are trying to get us pregnant and really reframe everything that way. I have a patient story from the past who had been going through infertility, been going through IVF because she found out she was running out of eggs early. And she had taken a lot of blame for not freezing her eggs earlier, for waiting longer. And going through IVF, her husband, turns out his sperm wasn't functioning the way that it should. And we didn't know that until you fertilize the eggs with it and really see how embryos grow in the lab. And she said to me at our follow-up visit, even though the outcome of that cycle was devastating to have no embryos develop because they found this sperm issue, it improved their marriage so much because for the first time, her partner and her, they felt like they were on even playing field,

that they were both part of the reason they were in this situation. And whether it was imposed by him or not, she had carried that guilt, that shame, that broken feeling alone, like it was just her. So let's get into it then. Let's do it. Let's talk about fertility. Where do we need to start? I was going to assume where I need to start here, but I'm an absolute muggle and idiot as it relates to fertility and female and male reproductive health. So where do we start if we want to understand fertility? I always like to start with the ovary and understanding the difference in eggs and sperm. So we'll do sperm first and we'll do eggs. Do you know how many sperm you make in a day? Do I know? How about how many you make in a second? No, I have no idea.

The average man makes 200 to 300 million sperm in a day and 1,500 sperm a second. So men, 1,500 a second, you're just like. So men and their testes have germ cells, meaning they can just produce brand new sperm at very high rates every single day. And in the ovary for women, it's so different because you are born with all the eggs you're ever going to have and you run out of them over time. And this means that one, the number of eggs you have remaining is a part of the picture. And two, your eggs sit inside your body and they absorb the wear and the tear and the world around you your whole life, where your sperm lifespan is 90 days. It takes 72 days for sperm to grow across the testicle and then 18 days to get out the

ejaculatory system. So you have three months. So you could change your life and change your sperm counts in three months. Why does it take 18 days? In my little idiot head, I thought that I make my sperm today and then if I ejaculate, that's the sperm out. No, yeah, those sperm were made a couple months ago. Really?

Yeah, they're like in storage lockers so that you have some for every day. So they kind of get put in line so that you can send them out at that right time period. Okay. So, but if you ejaculate multiple times, eventually you can't keep producing more. So let's imagine that you have lockers and we'll just pretend that there's 200 million sperm in each one. If you ejaculate every single day, you're ejaculating 200 million sperm each time. Now, if you're saving up for a couple days, you're going to ejaculate 400 million. And now if you've waited three days, 600 million. The catch here is sperm are so fragile.

They're so fragile. They like to die. They get tadpoles. Oh get- Tadpoles. Oh, those little tadpoles. So if you wait too long, you're just going to have a bunch of dead guys. And then they're going to impair the ability of the better sperm to even function. And I use the analogy of imagining that this is a highway and the dead sperm are stalled cars all over the freeway. Even if your sperm counts normal, if you're having very long abstinence periods in between your intercourse times, you're going to have a sample that has so much debris and dead sperm in it that it's going to make it hard for

the good guys to do their job. Okay. So you do need to keep ejaculating to remain, to optimize your chances of fertilizing an egg? Yes. Oh, I didn't know that. And how often? Do you know? I always say it's going to, there's a fine balance here. Somewhere between every day to every three to four days is going to be the best, whether that is ejaculation in any form, whatever suits your fancy. We see that longer than seven days for most people will severely increase the amount of debris that you see and the proportion of the ejaculate that is dead sperm. Super interesting. So let's go, we'll stay at the foundations. We're talking about sperm and eggs.

So is that sperm covered off? So that's sperm. Okay. And sperm counts, as you said earlier, have been reducing over the last 50 years by 50%, which is horrifying. Why? Is there something in particular in our environment that's causing that? It's all the things.

And some of them are changeable and some of them are not. So we have to view the world as it is. Certainly we see we've got more men who are unhealthy, who are overweight, who have other medical comorbidities that are also impacting their ability to make sperm. Like if you have high cholesterol, if you have diabetes, some of those things are going to impact your overall health and the production of sperm. So this goes for sperm or egg. The hormone axis from the brain to your gonad.

Your gonads are either your testes or your ovaries. Your brain is constantly interpreting signals from your whole body and is trying to determine, can Steven have a kid right now? And if you become very stressed. Now, back in the day, what was that? There was a bear attacking you. There was a famine. So you had no food.

There was a plague going around, then it'd say, this is not a good time to have a child right now. Because you can't support your own body or the world around you. Your adrenal glands are making cortisol because it's so stressful or your calorie intake went down. So your brain says, this is too difficult. I am going to shut off the system to make reproductive hormones. And that happens in both men and it can happen in women. So the brain is constantly interpreting the world around you and then sending out signals to make eggs or sperm, like to make eggs grow or to be making sperm, and the hormones that are associated with them. So estrogen and progesterone for women and testosterone for men. And so one, we have

anything that interferes with this pathway. People are more ill. There's more autoimmune disease, more inflammation. There's more stress, chronic stress. There's more obesity. But then we also see the environmental impact as well. So certainly there's so many toxins in our world from the foods we eat, from the air we breathe, from the type of, you know, kitchenware that we use, what we put in and on our body. All of it makes a little bit of a difference. And we know some people, if you live in an area with high pollution, you're going to have lower sperm counts and a reduced fertility rate. But that might not be something you can change because that's where you live. But it might be even more important for that person to understand it and then want to not also smoke marijuana or drink out of plastics or do other things that might be adding to that

burden. So smoking marijuana and smoking cigarettes are no-nos if I'm right. Absolute no-nos. So I think cigarettes, most people are pretty aware cigarettes are pretty bad for your health. If we talk about reproductive health in general, cigarettes smoking for women and your eggs are going to decrease your egg count, your egg quality, and the rate of miscarriage. Significantly. Significantly. For men, what we see is it decreases your sperm count, your sperm motility, and the quality, the shape of the sperm, also increasing miscarriage. Marijuana does this as well. If you smoke marijuana, even if your partner does not and is never around you when you're using

it, she has a higher chance of a miscarriage just because you're smoking marijuana. How? Because of DNA damage inside the sperm's head. Okay. I'm giving out bad sperm. You're giving out bad sperm. What about vaping? We don't know as much about vaping, but it appears in all the preliminary studies to be similarly very bad.

That what is in what you're breathing with vaping might even be more harmful than cigarettes, potentially. What about phones and laptops? Oh, I love this one. Okay, so that's a great question, and people ask about it. Two ways to look at it. There was a study that was published last year that actually looked at this. And we'll talk about just having your phone, using your phone, and then location of the phone.

In the study, what they looked at is phone usage from 2005 to 2018. So we have to remember in 2005, phones were different. It wasn't quite the same, but they had a much higher radiation emitted from them. So modern phones actually emit much less radiation. So even though we keep them on our person, they're ultimately safer than what we saw as origin phones from 2005 to 2010. In this study that they looked at, the number of times that you used your phone, which is wild to us because we use our phone constantly now, but the number of times you used your phone, the more you used it, the less sperm you made. Okay. However, that was most impactful for the early generation phones from 2005 to 2010. So when they stratified and

looked at some of the phones we have now, we're not seeing that same impact. And I think that is because there's less radiation. And also everybody uses their phone more than 20 times per day, right? You're using it all the time. Location didn't matter. There was no difference of location, whether you kept your phone in your pocket, your back pocket, the counter, off your body, there was no difference. So I think that helps us understand some of the radiation aspect of the phone and if that is impacting sperm. Heat of the testicle is, of course, something very, very different. I do think you talked to Rena about this. So when it comes to the testicles, they live outside your body for a reason. We know that men who have an undescended testicle, even if it's surgically removed.

Sorry, what's an undescended testicle? You can be born with one of your testicles in your abdomen instead of in your scrotum. And that's usually surgically corrected before the age of one. Because if it stays internally, the heat of the body is too hot and it destroys the cells, the inability to make sperm, inability to make testosterone. So the testicle is outside the body in the scrotum so that it can be kept at a lower body temperature. We know that things that increase the temperature of the scrotum do impact sperm production and testosterone production. Testosterone and sperm are made together. So one thing is going to influence one, it will influence the other. This is sauna use every day, hot tub use every day,

laptop in your lap. If you are putting your phone exactly by your scrotum every single day, then it might be having an impact if it's heating up and it's the heat that's causing the problem, not the radiation that's being emitted from it. So we always are asking if I see somebody for infertility, I'm going through any behaviors that are significantly increasing the temperature of the scrotum to see if that is a modifiable factor. What about hot baths? If we're having lots of hot baths? If it's daily and you sit in there for, you know, more than 15 minutes, then I would cut that down to not be daily. I see this a lot in Austin from people who love to cycle. So they're on a bike,

they're outside, they want to go ride for two to three hours at a time, numerous times a week. That's a lot of heat contained right to the scrotum area. And we often see significantly lower sperm counts in men who cycle at that intense level. Interesting, right? Very interesting. What about TRT? You talked about the correlation and the relationship between sperm and testosterone levels. If men start taking TRT, which is hormone replacement therapies, testosterone replacement therapy, does that impact the quality of my sperm and my chances of fertility? Stephen, at least one time per week, I will see a couple who comes into my office who has been trying to get pregnant. And the male partner went to a hormone clinic, a men's health, and he was put on TRT for

libido or fatigue or something. And essentially, that is male birth control. Because taking testosterone yourself is telling your brain that there is testosterone present because naturally testosterone is made as sperm is made. If your brain thinks there's a lot of testosterone, it says, hey, we don't need to make much more. We're doing really good. So the hormones from your brain stop being sent out and no longer tell your testicle to make any more testosterone or any more sperm. So TRT use makes men azoospermic, meaning having no sperm in the ejaculate. You still have an ejaculate.

It looks the same to you. But when we go look at it under the microscope, there's no sperm in it. Sometimes that is irreversible. The longer you've taken TRT for, there's a chance that I might not be able to get sperm to return to your ejaculate. It might be permanent. Let's talk about eggs.

Let's talk about eggs. You have this wonderful example where, I guess it's a bit of an analogy called the vault. Yes. I've got some marbles over here in a jar, which I thought would help us to visualize this idea of a vault. So I've put about, I don't know, it looks like there's about, how many marbles do you reckon are in there? If you get it right, you win the whole lot. 200 marbles.

200. I'm going to say, we'll count after. Well, now you're counting. That's different than guessing. No, no, no. I'm not, just go on, have a guess at how many marbles are in there. We'll count after. We'll see who's right. Okay, I said 200. Okay. Anyone in the comment section below, you guys can also guess.

Don't cheat, don't skip to the end. I think there's about... He is counting. That is not called guessing. I can't count them all, can I? Because I can't see them all. Seven times, 70. Nobody else can see them all and count them?

140. Okay. This is the analogy. I'm going to pass them over to you. I'd love you to use this as a visual aid to explain to me this idea of the vault as a way to understand how many eggs women have and how that changes over the course of our lives. Love it. All right. So I like to think about the ovary as inside your ovary, if we can imagine that there is a vault of your eggs. So that is what this jar is representing. So again,

in contrast, in men, testes are making brand new sperm every single day. In women, when you are a five-month baby inside your mother's womb, you have the most eggs you're ever going to have. You have six to seven million eggs. By the time you're born, you have one to two million. By the time you start puberty, you have half a million. Your reproductive years, you're going to start with about 300,000. And by the time you go into menopause, you'll have less than a thousand left. So you still have a few eggs left. Women only ovulate about 400 to 500 eggs over the course of their lifetime. So if you're born with one to two million and you only ovulate 400 to 500, that seems like confusing math. So the way that I think about it is that every single month you are losing eggs from this vault. And what is happening

is that the eggs are coming out in proportion to how many are inside. So when the vault is more full, more eggs come out that month. And when the vault is less full, less eggs come out. So if we can imagine one month, you're going to have a group of eggs all come out of the vault. And so if this is our ovary, what we would imagine is that the vault sent out all of these small eggs, and each egg grows inside a follicle. The brain is going to send out follicle-stimulating hormone once you start puberty. So before puberty, all of these eggs are just going to die after that month is over. But once you've started puberty, FSH, so follicle-stimulating hormone from the brain, will come and stimulate one of these eggs. Why only one?

Because humans are not meant to have litters. You can only carry one child at a time in our uterus. So this is the protective mechanism by which humans don't have multiple children most of the time. So each egg grows inside what we call a small follicle. So the brain sends out follicle stimulating hormone. This is one of the rare times where in medicine, hormones are named for what they do in women, not men, because you have FSH and LH2. FSH controls the production of sperm for you and LH, the production of testosterone.

But for women, FSH controls the stimulation of one follicle. So this follicle will grow and this one will ovulate and the rest of them will die. So that's one of the 400 that I'm going to lose. These just go away. I want to make sure I understand this. So in the jar is the vault that's inside the woman. Yep. At every month? This is what's available this month. Okay. She produces quite a few. When you're younger, yeah. because there's more in my jar.

Proportionately, there's like 20 or 30 in there proportionally to a jar that has 200. These numbers aren't obviously ratioed. And then one of them is basically selected. To ovulate. At random. At random. It's one of the great mysteries. If we could control which one, because it doesn't have any more likelihood to be genetically normal or good just because it responds. So what is interesting when we think

about this vault is, as we said, when we have less eggs, less are coming out every month. So you're going to start to dump out less eggs and the jar gets emptier. What age was I then and what age am I now? So we can say that you, you know, we're 30 at one point and now we're starting to get to about age 34 at this point. Okay. Okay. What starts to happen just for numbers? So at age 30, you're going to have about 20 eggs come out of the vault every month. One egg will ovulate, 19 will die. Next month, another group. Okay. When you get to about 35, you're going to have about 14 to 15. So still pretty close. When you get to about 35, you're going to have about 14 to 15. So still pretty close. When you get to 40, it'll be about 8 to 10 per month. 44, closer to 3 to 4 per month.

So you start to see that after age 37 specifically, a more rapid decline in how many eggs are remaining, therefore less are coming out every month. This idea is really important for two reasons. One is that all women run out of eggs. When you run out of eggs, you're an ovarian failure, also known as menopause. Average age of menopause is 51 to 52. I've seen somebody have menopause at age 13. So I've seen primary amenorrhea where somebody was born with ovaries that never made follicles. I've had women who had their periods and then they ran out of eggs in their

20s. So some people are on different pathways. Now, maybe they were born with less. Maybe something happened to them along the way to make them run out of them faster. So certain things can get in the vault and impact our ultimate egg count. So as we already said, smoking cigarettes, marijuana use, endometriosis, which we haven't touched on quite yet, but we will, chemotherapy, environmental toxins. So certain things can get in here and make us run out of eggs faster. What's also important to understand is that the eggs that are out in one month are all the eggs we have to work with. So when we start talking about egg freezing or IVF, I can only get the eggs that have been sent out of the vault in that month

to grow. I cannot tap into the vault. And this is why if you've had friends go through IVF or egg freezing, and it sounds random, somebody got six eggs and somebody had 24, somebody had to do multiple cycles or months. Sometimes in order to help somebody get enough eggs to have a normal embryo, what we have to do is multiple months. So the 10 eggs that are available this month, I'm going to get them all to grow, not just the one you are normally going to ovulate. Take those eggs out of the body. And then next month when your body gives me another group of 10, I'm going to get them all to grow again and take those eggs out of the body. That is ovarian stimulation for either egg freezing or IVF, trying to say, hey, in this month,

I don't want to let any of these eggs die because I need more of them to get the job done or we're running out of time and I'm trying to expedite your opportunity for conception. So women have this decline in the total number of eggs you're going to have. When you're 37, I think the number is that you have close to 20,000 eggs remaining. So what a huge drop from when you started puberty at half a million. So it's just going down so fast every single month. What is also happening is that because this vaults inside our body, When you smoke the cigarettes, when you eat processed foods, when you get sick, if you have chronic inflammation, you're losing some, but the ones that are here at the bottom, they've been here the whole time. And so in addition to number

of eggs, we have to talk about the quality of the eggs because these eggs down here at the bottom, once you get older, they've been sitting here a long time. And that means that their chromosomes inside of them are much more likely to be abnormal than normal. And that's really the rate-limiting step in people getting pregnant when they're older. Not that my vault is more empty, not that I'm sending out less per month,

but that the ones that have been sitting here have been sitting here longer. And they aren't as good. I use the analogy for the chromosomes. So if we imagine your eggs hold your chromosomes in perfect position so that they're ready to then go be fertilized by sperm, it is like having kindergartners stand in a line for 40 years. Somebody can get out of line. And when that happens, that increases the rate of

genetic abnormalities. And most of those do not fertilize, do not implant or miscarry. At age 40, if you see a positive pregnancy test, your chance of miscarriage is 50%. Because I've been sitting here. Even if you're very healthy, just time and normal life impacts things. But there's choices you make that cause them to degrade faster. And there's things that you do that might be protective. And that is something that we don't ever talk about. When you're 35, your chance of miscarriage is 25%. So there's a huge change that happens between age 35 and age 40 when you're 35 and you start trying to get pregnant.

So if you and your partner wait and you say, everything's good, we're going to wait till we're 35 and you start trying to get pregnant. So if you and your partner wait and you say, everything's good, we're going to wait till we're 35, your chances of getting pregnant per month are going to be approximately 10 to 15% per month. That's not very high. It's not great. Not great. At 40, it's about 5% per month.

So we've dropped dramatically and just seen the positive test. And then if you see it, 50% are abnormal. So the odds of the body is going to choose from the eggs that are sent out that one month when you're 40, the odds that your body is going to choose one of the two eggs that is genetically normal because six of them are abnormal. It's not very probable. So most months, your body is ovulating one that's not going to have the potential to become a live-born baby.

I feel like I better get a move on, Jesus Christ. It's not information to scare people, but it is information that nobody talks about. Well, as you were sat here talking to me about this, the opposite of confronting the truth is regret. Yes. And I can't imagine how much regret you've seen. I wanted to ask you about that regret

because you must have to deliver so much bad news to people and you must see the retrospective clarity that those people suddenly get when they realize that there was decisions they could have made earlier especially for people who are not used to not being in control of things and who just didn't have the data they needed to make the decision. There are people who have been with their partner for a very long time and maybe kids weren't in the plan earlier, but they could have been had they known that it would have been so hard or potentially impossible later on. One thing that I think is important to discuss here when it comes to regret is testing female fertility, because there is a marker of how many

eggs do you have? We call this your ovarian reserve. How many eggs are left in the vault? And one way you can test this is with a blood test called AMH or anti-mullerian hormone. And the other way is to do an ultrasound and see how many eggs are outside the vault at that month. So both of these are actually quite important when you're thinking about how many eggs somebody has. That number does not impact you getting pregnant in one month. And I think that that's important because if you have, well, you have a whole group, you could have a whole group of eggs or you could have less. How many eggs is your body ovulating in each group? So this person, this person who has more is ovulating one. This person who has left is ovulating one. So if I have two people who are the same age

and they have different ovarian reserves, meaning they have a different number of eggs left in their vault, they're going to send out a different number of eggs each month. How many eggs are they ovulating each month? One. One. Yes. Look at me learning. Look at you. So they're each going to ovulate one egg. So what are their chances of getting pregnant? The same. The same. So having a lower egg count does not impact your monthly chance of getting pregnant. That's determined by age, by the

proportion of these eggs that are normal or abnormal. However, if you have fewer eggs, there's fewer that I can get to grow with IVF, and you have overall less of an opportunity to grow your family. This is important because a lot of societies will tell people not to check somebody's ovarian reserve. And this blows my mind. I have a really hard time with this because they say if it doesn't impact your monthly chance of pregnancy, having a low ovarian reserve is only going to cause undue stress. So the American College of OBGYN recommends not checking an AMH level in women who are

not trying to get pregnant and who are not having infertility. I completely disagree with this because you can't make decisions on data you don't know. And if you know you're running out of eggs faster, you very well might make different decisions. You might freeze your eggs. You might try to get pregnant sooner. You might try to just be healthier if you are doing behaviors that you know are decreasing your egg count. You might stop smoking pot. But if you're never giving that opportunity, you're going to live in the regret category where when you find that out later, I wish I'd known this earlier. I wish I'd been able to make a choice when I had the opportunity and I had the eggs remaining.

And so by not testing, by not knowing, we are hurting more women. And I always tell my OBGYN friends, this conversation should be hand in hand with, Stephen, are y'all trying to get pregnant? Yes or no? No. What birth control might you want? Let's talk about it. Oh, should we check your ovarian reserve to make sure that your time is okay? Again, having a good account doesn't mean you're going to get pregnant. Your chance is the same. However, it means you have more opportunity of time to try to grow that family and ultimately a greater chance of success when it comes to IVF or egg freezing because the factors that determine

success are how many eggs you have and how many are normal. A lot of people do ask that question. They ask, you know, they'll say things like, well, my parents didn't have to worry about this or my grandparents didn't have to worry about getting checked and seeing how big my ovarian reserve is. So, you know, why do we have to all start doing that now? We know a lot more now. And I think the honest answer here is that one way to look at this is that when I was your age, egg freezing didn't exist. So I could not have frozen my eggs in my early 30s had I wanted to. Meaning, would you check it if you really can't offer somebody things to intervene or a way to make a change? However, now we know

factors that impact how many eggs you have, and we have the ability to freeze eggs with very high success rates now. It's accessible in almost all fertility clinics with really great egg survival. So this poses the question of, should you know earlier? We also have generations where people are curious and they see things online. They're not afraid of scary health information. Instead, younger generations want to understand their bodies. And I love that. But there's so much misinformation online too, that it's really saying that this is personal. We can talk about eggs in a bowl every single day, but until somebody comes in to my office or somebody else's office to get

their own evaluation done, they're not going to have the true data they need to make that decision. But I think it's great that we're approaching fertility as a health marker, trying to look for signs earlier that things might be wrong, especially given the opportunity to try to intervene. If you find out your sperm count's lower, we might be able to try interventions for three to six months and see if we can get a new group of sperm that potentially has fixed that problem. So say I'm starting out in life with a full ovarian reserve. Or say, you know, here's my ovarian reserve at, say, 20 years old. If I start engaging in unhealthy lifestyle choices, if I start eating processed food, if I become obese, et cetera, does that take marbles out of this jar? Does that take

eggs out of my reserve? Or does that just damage the quality of the eggs in the jar? Both. Both. Okay. So it pulls them out and it makes them less effective. The way I think about it is not that it's pulling them out, giving them an opportunity, but essentially let's imagine it's getting, you smoke cigarettes. The cigarette smoke is getting inside the vault. It is damaging the DNA and some of your eggs, but it's also just killing some of them inside the vault themselves. So that you are running out inside the vault. Ultimately, people who smoke cigarettes go into menopause years earlier than the average age.

Really? Because they have had a destruction of the eggs inside their vault. If I wanted to make sure that my ovarian reserve was 10 out of 10, you know, if I was to live a perfect life in terms of what my ovarian reserve needs to be healthy, how would I live? What would my daily habits look like? That's a great question. I love it. So what can you try to do? Because you can't control everything, but you should be able to control the factors you can. So number one, we're gonna say avoid toxic behaviors. So toxic behaviors, that's going to be your cigarettes,

your marijuana, cocaine, you're going to not have any alcohol. Definitely alcohol, especially in proportion, is showing an increased risk of damage. So a drink here or there, like that's not studied as well, but we know moderate to high drinking levels is associated with reduced egg quality. What's moderate to high? Usually considered four drinks a week. Four drinks a week. So if I have four glasses of champagne a week. Yep. So you have four glasses tonight at dinner, you've hit moderate. That is, I mean, most people, especially in Britain. Oh, well, here too. And I mean, honestly, with COVID especially, we saw so many people

increase their drinking substantially. So you would limit the toxic behaviors. Number two is you're going to limit the toxins in your world that you can. Again, if you live in an area that is a high pollution area, that just might be where you live. But you should not cook in plastic, put plastic in the microwave or the dishwasher. You shouldn't use Teflon on your pans. You shouldn't touch thermal paper receipts. Like at the airport, if they print off a ticket for you or a receipt from the grocery store, that has chemicals in it itself. Takeout food. So when you order your takeout food and it comes to you and it sits in the containers that it comes in, if you're not eating it right away, or even when you do eat it,

you should take it out of that container and put it in something else. Put it in glass, put it on a plate. Because especially with heat, we see leaching of those toxic chemicals into the food, and then you're consuming the food. Even if it's high quality, good food, it now has absorbed chemicals from the packaging that it was in. So microwave meals in plastic, you know, you take the plastic and you microwave it. Shouldn't do it. How do we know this? Have they done research on this or is this just... So there is research done on it. It's always hard to study lifestyle factors in humans and when it comes to fertility, Because what is the outcome?

Is it the positive pregnancy test, the having the baby, the absence of getting pregnant, the irregular cycles? There's so many different variables you can look at at an endpoint. A lot of the environmental chemical studies are done on animal studies, looking at some of these chemicals. But also we can see in population-based studies, we do have now where they've done cohort studies. I mean, they take a group of people and they follow them for years, taking blood and urine samples to measure some of these chemicals and then watching what's happening with their normal behavior, no intervention. Are they getting pregnant when they're trying to or are they not? And we see that greater exposure to these known toxic chemicals

are making it harder for people to get pregnant. When it comes to other factors to try to have your healthiest vault possible, decreasing inflammation is going to be very important. So we think about inflammation and there's two types. So you have acute inflammation, you cut your arm and it's going to react and heal. And that's a normal bodily process. But then you have chronic inflammation where your body is constantly spending its energy fighting that inflammatory state and that inflammation markers, the prostaglandins, the factors in your body that get really high, that's actually pretty toxic to our quality as

well. And that can be disease states as well. So things like endometriosis or other inflammatory or autoimmune diseases. What ways do we voluntarily increase our inflammation? Is that dietary predominantly? Yes. So number one is going to be not sleeping enough. So sleep is when your body heals. Sleep is when your cells repair their damage. So you need to get seven and a half to eight hours of sleep per night. I heard you say in a quote, sleep is probably the number one thing that people don't do that does impact their reproductive hormone system. Yes. It seems so straightforward to say it's not a pill that you take. It is not a major change of behavior. It's not missing out on something in your life.

It is simply giving your body the time that it needs to heal from the normal inflammation that you're going to encounter during the day. Simply prioritizing getting enough sleep is the simplest thing somebody can do to try to improve their reproduction and how their hormones are made and interpreted. We talked about stress earlier. Stress impacts the brain in a similar way. There's different types of stressors very similarly. You have your acute stressor, the Bayer. You have the stress of everyday life. And modern world is a lot more stressful in a lot of different ways constantly. We also see that that stress is so individualized. So it's not like I can say,

you need to go to yoga or you need to do acupuncture or you need to go to therapy. I tell my patients for stress reduction, understanding that having a constantly stressed state, constantly having cortisol be made, is not going to allow your brain to interpret the other signals that are being sent. It's clouding its judgment, and it's going to think that you're not at a place to maybe support a pregnancy, and your reproductive hormones are going to show for that. What that comes down to is that you've got to modify stress in some way for you. So everybody's different. And maybe it is acupuncture. Maybe it is yoga. I like to sit on the back porch in the morning hours with a cup of coffee and hear the birds.

People like to go on walks, therapy, mindfulness, meditation, journaling. Everybody's different, but you deserve taking 20 minutes every day and dedicating it to something that doesn't have your iPad, your cell phone, your computer, the TV, and putting yourself in an environment where you can say, like have that feeling of release you get when your cortisol drops. That's important so that your body can then properly respond when you do have a stressful situation and can allow you to heal, not be under a constant attack. Diet's going to be one of the hugest things that people can make a change in. Processed foods, refined sugar, processed meats, those are not natural foods.

And those are things that come with a lot of chemicals inside of them, a lot of contaminants. We know that processed meats, for example, type one carcinogens, all these sugars have a direct correlation with somebody's ability to get pregnant. When it comes to the direct cause, it's usually going to be sperm quality or egg quality, depending on the study looked at. What about red meat? Oh, I love that question. Number one, I think it's really important that nutritional studies, people qualify meat differently. So it might be all meat, it might be types of meat. So we have to take it in perspective of the limitation of the data.

We know that processed meats impact fertility. We know that red meats appear to impact both sperm production and egg and embryo quality. There was an IVF study done, and the more servings of red meat you had in a week, the less embryos you had developed throughout the process than somebody who had fewer servings. So that's telling us that it's maybe not one red meat in general is bad, one serving, but it's about the amount, right? Everything in moderation, nothing in excess. We know that the healthiest fertility diet, high in fruits and vegetables. Fruits and vegetables are fiber sources. They are antioxidants. They are helping our body function appropriately. They're helping our gut function. They are antioxidants. They are helping our body function appropriately.

They're helping our gut function. They are lowering inflammation. I say meat is okay. I don't eat meat, but that doesn't mean that none of my patients should eat meat. I give them this diet because I think you have to make dietary change accessible. If I told everybody, stop eating meat, nobody's going to listen to anything. But we know that it's the amount, the quantity. So I say, if you're going to eat an omnivore diet, which is going to be the majority of people, have a meatless Monday. Meatless Monday, you automatically can do, and you're going to have

to substitute in some of those other sources of protein that are ultimately better for you. Fish? Fish is great. We should limit fish to three times per week just due to risk of mercury. But fish is a wonderful option. It does have a lot of good omega-3 fatty acids in it. And ultimately, eating more fish and less red meat is such a great substitute. What about skimmed milk and fertility? I've heard you speak a little bit about that in the past. So what's interesting, and I think that we've grown up in this, you know, fat-obsessed culture that has prioritized low-fat, no-fat foods. And number one, fat is important in the production of steroid hormones.

Estrogen, progesterone, testosterone are steroid hormones. So they need cholesterol. The source of that cholesterol is important. So we should have those healthy fats, the nuts, the avocados, the oils. Fantastic. Healthy fats are wonderful. But when it comes to dairy, we've seen that whole fat dairy is associated with better fertility, better ovulation than the skim dairy products, probably due to the processing.

If we view skim milk as the processed version, if I'm going to take out the fat that normally comes in the milk, but still want it to retain looking like milk, it's not just minus fat, right? It's minus fat plus something else. So in the production process, it's that, or it's potentially that the only benefit the dairy really has is being a source of a healthy fat option. And that when you take out that fat, you lose that. So I recommend that if you consume

dairy and that you stick with the whole fat versions, you don't do skim or low fat and in moderation for dairy consumption. I say that if you do Meatless Monday, the rest of your meals for the week, you should have one serving of meat per day. That's going to make you just force you to eat more fruits and vegetables. And then one of those meals, you should have red meat if you like red meat, not multiple times a week. And then you should limit processed foods, sugars, processed meats, all those refined carbohydrates, all the packaged things that are totally fake, that should be very rare. Those are your occasion type of foods, not your everyday foods. The other thing we didn't talk about regarding lifestyle choices is exercise.

Oh, yes. There's kind of two schools of thought here because I have some friends who exercise a lot and they have seen a dysregulated menstrual cycle. Yes. Or their periods have completely stopped. But I also read that exercise is good for fertility. This is a great opportunity to just think about how the ovaries work. We've talked about having your eggs. But if we think about in a given month,

you have that group of eggs that comes out of the vault, each egg's in the follicle. We already said FSH or follicle stimulating hormone is the hormone from the brain that goes and stimulates that one egg to grow. As that egg grows, the follicles growing and making estrogen. That process takes approximately two weeks in the majority of women. And when your estrogen level gets high enough, it tells the brain you have a mature egg. Your brain doesn't know what's happening in your ovary. It can't see. I always say it's like having your best friend who doesn't go on Instagram. They have no idea what's happening in your life unless you tell them. So the only way that the ovary communicates with the brain is actually through the production of hormones. So as that one follicle starting to grow, it is making estrogen. And that

estrogen is then telling our brain, we have a follicle growing. That follicle then is going to open up, it bursts, it ruptures. What's a follicle, sorry? Oh, a follicle is, if we can imagine, this is a follicle. The egg is microscopic inside of it. It is the fluid-filled structure that keeps your egg. So for people that are just listening and can't see, you're holding one of these little eggs in your hand. A marble. I'm holding a marble. So if we can imagine, a follicle is a small fluid-filled structure in which the egg is kept.

Okay, so the egg's inside the follicle. Exactly. And so the follicle gets bigger as the egg gets more mature. It makes more estrogen. That estrogen at a high enough level, and it's very specific, 200 picograms for 50 hours tells the brain you have a mature egg. The brain will then send out LH or luteinizing hormone. It allows that follicle to open up. Then the egg is going to be released and hopefully get captured by the fallopian tube.

So it'll be sucked up into the fallopian tube. But that follicle reforms. So the egg is gone, but the follicle reforms and it becomes a cyst in your ovary called the corpus luteum. And it is now stimulated by LH from the brain telling it to make progesterone. Okay. And what am I going to do with the progesterone? Progesterone opens and closes the implantation window. Without progesterone, a pregnancy cannot implant into the uterus. So this progesterone is going to allow your body to have that egg, if it becomes fertilized and develops into an embryo, the egg gets fertilized in your fallopian tube. It has to grow and develop into a stage of an embryo. So the sperm comes along. Sperm swim through the uterus into the tubes. And that's where fertilization happens. Okay. So the sperm comes along. Sperm swim through the uterus into the tubes.

Okay. That's where fertilization happens. Okay. So the sperm comes through the fallopian tube. It meets the egg, which is chilling there. Chilling there. And then what happens? Then, well, hopefully fertilization happens. Which is like the sperm, which is like the tadpole's head hits the egg. Hits the egg. It actually has a little fusion reaction and pushes its DNA in there. Pretty cool. It then has to grow and develop. So you have a single cell egg, a single cell sperm, they come together, you have two different DNA components, and then you start seeing cell division, just like you would expect exponentially, two cells, four cells, eight cells, 16 cells, into the point where on day five or six,

that embryo is now a, what we call a blastocyst. It's 300-ish cells, and it is now at the stage where it can implant into the uterus. What is so interesting is that most of your eggs are never going to fertilize. They're not going to grow appropriately. They're not going to get into that uterus. But what's so important is that if an egg is coming in or the embryo is coming in, and there's not just the right amount of progesterone, it cannot implant. That's really important because that's the mechanism behind a lot of birth control. But when you think about progesterone starts being made from this corpus luteum perfectly timed after you ovulate to open and close that implantation window so that when the embryo gets there, it's ready. And if

the embryo doesn't implant, hangs out too long, it's going to close. The corpus luteum only lasts for two weeks if it is not supported by a pregnancy. Meaning if we pretend this month you don't get pregnant, you're just having natural periods, then the corpus luteum, after two weeks, it dies. Your progesterone levels are going to drop. And that's the signal to your uterus to shed the lining in preparation for the new group of eggs. That's your body saying, we did not get pregnant this month.

Let's try again. When a pregnancy implants, that embryo makes a hormone called HCG, which is what we check on a pregnancy test. And HCG can stimulate the corpus luteum to keep making progesterone. And that is what allows you to sustain an early pregnancy until there's a placenta. The point of thinking about that, which there's a lot to go into about optimizing intercourse and trying to get pregnant, is that things that disrupt the brain's interpretation of estrogen is going to impact your ability

to sense ovulation or to ovulate and going to lead to menstrual irregularities or absent periods, like you mentioned in some of your friends who exercise maybe more frequently. So on one end of the spectrum, if you are intensely exercising, you're training for the Olympics, you're an elite athlete, your body is going to stop sending out FSH and LH altogether. It is going to say that the calories you're receiving to the energy you're expending do not match up, and you cannot support being pregnant with another human. So it is going to stop the production of FSH and LH, and you're not going to ovulate. You're probably fine because you're training for the Olympics and you don't want to be pregnant

right now. This also happens though with eating disorders, anorexia, for example. We can see that I will say when the brain is turned off, when your brain has decided that you can't be pregnant right now, it takes years of being in recovery for it to turn back on. It has to be convinced for years that the system is going to be intact again. And the part of the brain that controls if FSH and LH are released from the pituitary is called the hypothalamus. So we call this hypothalamic dysfunction. I like to think about the hypothalamus. So we call this hypothalamic dysfunction. I like to think about the hypothalamus as the, you know, airport control station. They're watching the planes come in and sending out other signals. It is interpreting what your body's giving it, and then it's directing

what is happening. Estrogen is also made from fat cells. And this is one of the reasons why being overweight is so impactful when it comes to your reproduction. Because if your body is making extra estrogen, your brain thinks an egg is on the process of growing. So it's because, right, the brain thinks estrogen is only made from an egg. So if it sees some extra estrogen because you're obese, it's not going to send out a strong enough signal to get an egg to grow because the brain wants to send out just enough to get the one egg to grow. It doesn't want 20 eggs to grow. So if it sees that estrogen, it's going to say, oh, an egg's already growing. I'm going to send out less. But there is no egg because you're overweight. It's the fat cells making estrogen. And so exercise comes into this play where

exercising, if you're overweight, can be extremely beneficial for your fertility. Because if you lose weight, you drop that baseline estrogen level down, and now your brain can more clearly interpret the signal from the ovary. So suddenly your system is back in check. Same thing for men. Estrogen, when men are overweight, goes to the brain and the brain, estrogen and testosterone are on the same conversion pathway. So the brain says, oh, Steven's gained some weight. I see his estrogen. He's making enough sperm. We're good. And it's not going to tell you to make as much testosterone or as much sperm as you need. And then you get on this pathway where you have less energy because your testosterone is low, but you're gaining weight and you can't get that testosterone higher. You go to the men's health clinic and they're going to draw your blood and your testosterone

will be low. And they're going to put you on that TRT. and now your sperm count's going to go to zero. So sometimes that entry point to the whole problem was having extra fat tissue. So exercising to lose weight can be very beneficial for your fertility for men and women. There's a lot of talk on HIIT exercise or moderate activity. And for the regular person, whatever you will stick with is the best. If you're trying to get pregnant, you should not be trying to stress your body to new goals, training for the marathon, doing something. If you think going to the gym every single day, is that too much? No.

I usually say going to the gym every single day, if we think about 60 minutes or less, is a normal amount of inflammation from your muscles that is good. Your body should encounter some challenge along the day. Having more muscle is also going to help combat insulin resistance and other issues that come in and interfere with our brain's interpretation of our hormones as well. So we see that both overexercising and not exercising are the extremes that are not going to be helpful for you. But moving your body in addition to helping your hormones function better, less chance of becoming overweight, better interpretation by

your brain of your body's signals, it's also a great way for stress coping and lowering your cortisol levels. So exercise, we should put that right up there with the top things somebody can do. Get more sleep, exercise every day. You mentioned menstrual cycles there and how they can be disrupted for long periods of time. My partner shared quite openly on her social media channels her battle with this. And I think she had a couple of dietary changes. She had some struggles with eating. And that resulted in her period basically stopping for, I think, three or four years. It's returned after sort of three or four years, and she's

very happy about that. But lots of people are going through irregular period cycles, irregular menstrual cycles. What can you say to this? I mean, what is quote unquote normal as it relates to a normal, healthy menstrual cycle and to people that are struggling, what would you advise them and what would you tell them? I love it. A normal period is one that is regular and predictable. So I'll tell a patient, you can look at a calendar and you can say within a couple of days of certainty when you're going to have your period. Now, each individual person is going to have a different cycle length, meaning the day from the start of your bleed, that's day one of your cycle, until the last day before your next period bleed. You'll hear 28 days used a lot. That's not the

average for every single person. Usually it's going to be between 24 to 35 days for the average person. Can you explain this to me? Like I've never heard of a menstrual cycle before. What is it? What happens? So the menstrual cycle before what is it what happens so the menstrual cycle is essentially what we've talked about with our whole eggs right so you have your group of eggs come out of the ovary each egg's in a follicle brain sends out follicle stimulating hormone that egg's going to grow develop and ovulate that's going to put you a couple weeks into your menstrual cycle from there it's going to then make progesterone, get you into that back half of it, that luteal phase, because the corpus luteum is always set at two weeks. And then when

you're not pregnant, you're going to bleed. So bleeding is the shedding of the lining. That's your period. Your ovaries are doing something different throughout that process. So while you're bleeding and on your period, your ovary is already starting to grow the egg that's going to ovulate in that month. And as that egg makes estrogen, that's what stops you from bleeding. So when you have your period, that's the shedding of the lining from the last month because you didn't get pregnant. And growing an egg this month, once there's enough estrogen, is going to stop that process and stabilize that lining. Okay, so typically if there's no other interventions, if you don't have your period, it's going to stop that process and stabilize that lining. Okay, so typically if there's no other interventions, if you don't have your period, it's because you're pregnant.

Because you're pregnant or you didn't ovulate. Because you have to have that progesterone drop as the signal for your body to bleed. The shed. Exactly. So you either, problem A, I didn't ovulate. So that is either I'm out of eggs, I don't have any eggs to ovulate or my brain didn't send out the signals. Like we said, hypothalamic amenorrhea, that's often that overexercising or that calorie restriction or chronic illness. Stress sometimes. I like to think about that one often more as hypothalamic dysfunction, like probably irregularity versus

absent, but yes, stress. And then we've got pituitary end, thyroid disease, prolactin. These are hormones from the pituitary gland, which is where FSH and LH come from. And if your pituitary sends a lot of energy to making thyroid stimulating hormone, it's not going to send out FSH quite as well. And then you have polycystic ovarian syndrome, which is going to be one of the most common causes of female infertility and of irregular periods. And that is when your ovary and your brain have a miscommunication. And so when we talk about irregular cycles, because we should dive into PCOS, what we're saying is that for one single person, it's not occurring at this regular interval for them. So maybe it's 25 days for Jill and 30 days for Mary and 34 days for Susie.

But each of those people should be able to know when her period is coming. The fertile window for all of them is different. And that's why apps and cycle tracking can be really problematic because what the fertile window is, is going to be the five days before and then the day you ovulate. So an egg lives for 24 hours. The five days before you ovulate. Okay. So the five days before you ovulate and then the day that you ovulate. The egg lives for 24 hours.

It has to be fertilized while it is in the fallopian tube in those first 24 hours. Sperm can live in the female reproductive tract for five days. So that is why we will tell people to have sex before and then during ovulation. Put some of that sperm from the locker there a little bit earlier and then get some there right at the time when you're ovulating to see if you can fertilize that egg. If we think about understanding when your fertile window is based on your cycle length, so if we say your cycle is the entire process, and then your period is just the bleeding days, the entire process, if your cycles are on average 28 days, the corpus luteum lives 14 days,

so 28 minus 14, you on average would ovulate on day 14. So the five days before and then day 14 are going to be your most fertile days to try to target intercourse or avoid if you don't want to be pregnant. And if your cycles are 35 days though, it's very different, because now 35 days minus 14 is going to be 21. Here you go, 21. So your fertile window for that person is going to be cycle day 21. So now the five days before and day 21. So those are very different fertile windows, days they should be having sex. It's a lot, isn't it? Do we just have sex every day if we can? So absolutely. Like if you can have sex every day or every other day, and you don't have to track your cycles. If they are coming regularly and you don't have to track your cycles,

if they are coming regularly and you're putting sperm in the presence of the egg by every day or every other day sex, absolutely. And that's one of the things that I see people do wrong the most is have less sex in the idea that they should save it up to put more sperm present when the egg is arriving. I have to say, I mean,

there's a few things I wanted to say about this. So I think what's is arriving. I have to say, I mean, there's a few things I wanted to say about this. So I think what's the first thing I wanted to say? The first thing I wanted to ask is how long on average do different age groups need to try before they hit the bullseye? If you're age 30 and you're trying to get pregnant, you have a 20% chance of pregnancy per month. Okay. This means that the majority of people should be pregnant within six months. Infertility is defined as trying for a year and not getting pregnant within that year. It's kind of going off the curve of that standard deviation.

Importantly, trying to get pregnant means that you're having intercourse, you're ejaculating inside, and you're having regular periods. If you're not able to complete the active intercourse and you're not having regular periods, people should not wait X amount of time to come see a doctor. You should go be seen right away. When my friends tell me that they've started trying, I always think, God, doesn't that just ruin the fun? You know what I mean? Because I have this one friend who was telling me that because they're trying now, sex has become such a... Like a chore. Like a chore.

And if he's away when she's most fertile, then she gets annoyed at him. And I just think, God, it's so crazy what's happening with sex in that regard. That it's, we're now, because we're having kids later and later and we're leaving things a little bit later than ever before we're now having to treat making kids almost like as you say like a chore it's becoming like I don't know there's something about that I'm like oh gosh like well it's a good point because if you're waiting later and you still

want to have more than one child there's a lot of pressure on it if you're starting at 35 and you have that 10 to 15 chance per month if you're starting at 35 and you have that 10 to 15 percent chance per month if you're starting at 38 and now it's 5 to 8 percent per month if you're 40 it's 3 to 5 percent isn't pressure like the opposite of sex right it doesn't sound very fun i think that one having realistic goals is helpful because if you're trying to start your family at 37 and you want four kids it is very unlikely to happen without intervention like IVF saving embryos for the future, which we can absolutely do. And we do that for people sometimes so that they can go have fun with their sex life again. Two, you feel like

you have to track your cycles and time intercourse appropriately when you're older because there's so much that you can't do, right? You only have so many eggs. You only have so much time appropriately when you're older because there's so much that you can't do, right? You only have so many eggs. You only have so much time. And you're trying to do what you can. Understanding your cycle tracking for a woman is a reflection of her full health. How's your brain interpreting your entire body? So it is helpful because if you have irregularity, it is a sign that things are not working normally. That being said, regular sex is good for so many

reasons and in a relationship that if you can establish sex more frequently as just part of your relationship, it becomes less burdensome that you're here recording a podcast at this time or somebody's out of town this one given month. If we remember that sex or if we remember that sperm live in the female reproductive tract for up to five days, most of sperm is going to live there for two to three days. So five is kind of the longest it can. What we have is that, okay, have sex two or three times a week. What about couples that can't? Because I've sat here and interviewed so many sex therapists and sexologists, if that's even a thing. And we often speak about sexlessness, people having sex less and less than ever before because they're so busy and they're

so stressed in their lives. And you must meet so many couples in your practice that, you know, you look at them and go, well, really the problem here is you're just not having sex with each other. A hundred percent. And sometimes it's situational, truck drivers, pilots, there's just a job where it is too hard to have that intercourse during the fertile window. But then also, yeah, high-performing people or who just don't prioritize or don't enjoy that part of the relationship. We certainly do what we call IUI or intrauterine insemination. And this is where you take the sperm and you're putting it inside the uterus. So instead of intercourse, we are taking an ejaculated sample and then processing it and putting it inside the uterus. So instead of intercourse, we are taking an ejaculated sample

and then processing it and putting it in the uterus. Wait, so I could just ejaculate in a Petri dish, get a little pipette, and psst? I mean, you can't do it yourself, but... Why? Well, because most of the ejaculate of your sperm is actually meant to protect the sperm from the acidity of the vagina. So most of that is not ever going to see the inside of a uterus. And if

we put the whole sample up in the uterus, it would cause a huge inflammatory or infectious process. But if we clean that sample and we pellet out, centrifuge it, and get just the sperm, we can then put the sperm into the uterus and avoid having all that protective ejaculate sample with it. You must hear couples doing this kind of thing. People do the craziest things. Tell me about some of the crazy things. People do crazy things. I mean, definitely people are having intercourse and then they're putting tampons in afterwards to try to keep the sperm in place or diaphragm cups. People are trying to get their own versions of pipettes or turkey basters, right? That's what people call it, and try to

pull up sperm and just put it in their vagina. The craziest stories of sperm procurement come from people who are using donor sperm. As you may not know, there is an entire like dark web of sperm donation being connected on Facebook groups and other places where people are not going down traditional roads of using a sperm bank. A sperm bank, pros and cons, but if you're using sperm, if you're using donor sperm, a sperm bank is going through a process to make sure there's no infectious material in there, that the information is tested, that there's limitations, but ultimately, like legally too, that that is your sample. These Facebook groups, people are just connecting where you can meet in a Walmart parking lot and drop somebody your sperm out of the goodness of your heart so that they can get pregnant.

And there was a case in Oklahoma where there was a lesbian couple who wanted some sperm in their relationship. And they felt like going through the fertility clinic or buying donor sperm from the sperm bank was too expensive because it is expensive. And so they found a sperm donor. How much is it roughly? I have no idea. So purchasing a vial of sperm itself is about $1,000. And then each cycle with a clinic to get the sperm inside is typically going to be $1,000 to $2,000. So that's for each month, you're going to look at $2,000 to $3,000. And your chance of it working is based on your age. So if you're 35, it's about 10 to 15 percent. So you're going

to need to do it numerous times. So this couple in Oklahoma, they found a sperm donor on a Facebook group, went and conceived a child. And despite having some paper document they signed saying that he gave them their rights, he sued for custody of that child later and won. So they now split custody with their sperm donor. And I think that this is— Why? He changed his mind? Who knows? Well, he didn't get paid for this, right?

So it was out of the goodness of his heart. He just met them and gave the sample. So part of the issue, too, is that it's not an exchange of a service for a fee or a good, right? It's just you're giving the sperm. So I believe in that case, he said he interpreted that was the situation, and they said, of course it wasn't. But when we look at family building, a lot of people are using what we call third-party options. So donor eggs, donor sperm, gestational carriers, donor embryos even, and there's a whole world to go into there. But protecting somebody's parental rights

is one of the top things that I'm always thinking about when it comes to helping them grow a family. We were talking about PCOS. Yes. I've got a very close friend of mine that struggled a lot with PCOS and I've been there with them as they've been diagnosed and as they've kind of battled with that over the years. But I'm aware that a lot of

people struggle with PCOS. I think it's up to sort of 20% of the population. So officially people will say that it's about 10 to 13% of the population, but that's 70% of people who have PCOS are undiagnosed. So much higher than either of those numbers you or I said is going to be the real number. And what is PCOS? There's a couple different ways that PCOS presents. So how I like to describe PCOS in essence is being born with more eggs in your vault. Okay. So if you're born with more eggs in your vault, you are going to send out more eggs every single month, right? Because you're sending out eggs in proportion to how many you have. Why do you have PCOS? Likely this is due to something your mother did when she was pregnant with you or something she was exposed to because you didn't have that normal decline in eggs from six to seven million at five months to

one to two million at nine months. So you have more eggs. More eggs come out of the vault every month. The brain doesn't know you have more eggs. So it is sending out the same amount of FSH as it normally would for a normal egg count. But that FSH is getting diluted amongst the more eggs that have come out. If we can imagine the same signal is going to 20 eggs or it's going to 30 eggs. So FSH is the thing that basically picks the egg? Yeah, it's like food for the egg. Okay. It's the thing that selects the one egg and waters it like a plant. Exactly. So you have the same amount coming, but there's more eggs eating it. So nobody's

getting a strong enough signal to grow reliably, predictably, meaning you're not going to have that regular predictable cycle. When an egg grows, that's when your body makes estrogen. That's when your ovary makes estrogen. And the ovary is a hormone producing factory. Everybody thinks about the ovary as, oh, it's what makes the eggs, but its real job, its real love is to make hormones. It makes estrogen as it grows the egg. It makes progesterone after you ovulate. If you have too many small eggs come out of the vault, there's not enough FSH to stimulate any of them. The ovary is not making estrogen and it gets bored. So what happens is the pathway to make testosterone becomes upregulated. It starts making testosterone in its board time. What testosterone does in women with

PCOS is it then increases the risk of insulin resistance. It increases abdominal weight. So not that maybe like female body shape we think about, like weight on the hips and thighs, but more of that man beer belly style abdominal weight. You also then are going to have increase in acne, facial hair, and then even male pattern baldness. So you start to see that you have these androgen symptoms that are negatively impacting quality of life immensely. And then as you gain weight, the estrogen confuses the brain and it sends out even less FSH. So you get into this really cyclic pathway where the insulin resistance and the testosterone change your entire body's metabolism. But you're not going to go in and make yourself have less eggs.

So how do you combat PCOS? One way from it, if you're trying to get pregnant, is to try to give medications that have the brain send out a stronger signal of FSH. So you might have heard of medications like Clomid or Letrozole. These medications tell the brain to send out more FSH. So in essence, that's what we call ovulation induction, helping somebody ovulate by having the brain send out a stronger signal. But what we try to do if you're in this PCOS pathway is break down some of the production of testosterone from the ovary, stop that cycle, and try to see if you can reverse back into having healthier normal cycles. So

sometimes that's from medications like metformin. You can have spironolactone, which is a medication that stops testosterone production. This is why women with PCOS are given birth control pills because birth control pills, one, can come in and provide estrogen and progesterone, but two, they also make something in the liver called sex hormone binding globulin that binds to testosterone, drops your testosterone levels, and clinically they make you feel better. Your acne goes away. Some of those androgen signs go down, and it can help break the pattern. And I see that people with PCOS, when they come off the birth control pill, they actually ovulate more regularly at the beginning, and then it starts to get worse as more time goes on as their androgens start to rise back up to their baseline because the birth control

pill was keeping them down. So focusing on some of the other factors that really influence insulin resistance and hormone production in PCOS, PCOS patients, I always tell my patients, it's like a teeter-totter of balance, meaning when you're too stressed or you're exposed to something, it can tip your hormones into not ovulating. So you have to view that system as just very sensitive. Extra stressors, like the cortisol that's coming in, really influence people with PCOS a lot, as does being overweight. And that's why there's a lot of information on trying to encourage PCOS patients who are overweight to lose weight. Importantly,

not all women with PCOS are overweight. You definitely can be thin, be born with a lot of eggs inside your vault, and have the exact same problem. And I want to stress that some people, even if you live the healthiest life, you don't ever see inflammation, you're not stressed, but you have PCOS. it's a disease, and you may not ever get to a place where you can reliably or regularly ovulate in your reproductive years that you're wanting to. And that's not your fault. It's not a failure of you. It's not your fault. Some people truly do need intervention to try to help them get pregnant. And those interventions are freezing their eggs, IVF, those kinds of things? Yep. Ovulation induction, freezing your eggs, IVF, those kinds of things. Yep. Ovulation, induction, freezing your eggs, IVF.

When you scan the ovaries, can you see PCOS? PCOS is diagnosed by having two out of three criteria. So number one, seeing a lot of eggs on ultrasound. Number two, having high androgen signs. So whether it's a blood value of testosterone that's higher than a normal female should have, or just having acne or hair growth. And then three is irregularity or absent periods. So two out of the three of them. So if you have irregular periods and acne, you've met the diagnostic criteria. What causes PCOS? You talked about maybe it's something your mother might have done. There's a lot of thought that PCOS is largely genetic or epigenetic, meaning that when you're

a baby inside your mom, that that environment influenced a lot of how your ovary is going to function later. And there's a huge correlation between different exposures or whether it is insulin resistance in pregnancy and then women being born later in life with a higher risk of PCOS. Certainly, you can back into PCOS by being overweight. And what I mean by that is often patients will present, they'll be diagnosed with PCOS, but the etiology is a little bit different.

If you're very obese, that fat is going to make estrogen. The brain is gonna send out less FSH. You're not going to be ovulating because it's not a strong enough signal. And the ovaries are going to start making testosterone because they're bored. So you have a PCOS presentation, but that mechanism is not really necessarily having a large number of eggs in your vault. When we have syndromes, we have to remember polycystic ovarian syndrome. Syndromes are based on the symptoms you present with. So often syndromes do have different origins for how they present. Is there a way to completely heal from polycystic ovarian syndrome? For some people, yes. Have you seen that? Yes, I have seen people, but most of it correlates within all women. At some point, you're still losing eggs every month, right?

So at some point, you are going to get to a number where the eggs that are coming out of the vault are a number that the brain is going to respond to. So what's interesting is I'll have people say, I cured my PCOS, And I say, well, really, you just are age 38. And at this point, you don't have enough remaining eggs to cause this dysfunctional problem anymore. The eggs that are coming out are now responsive to your hormones. Yes, they did do lifestyle changes and improve things and probably made it so that their ovaries could respond to those signals. So I think it goes together. But PCOS women still go through menopause at the same age. They're born with more eggs and they go through menopause at the same age. So what's happening is they're simply just losing eggs

at a more rapid pace because they have more. And what impact does that have on your ability to get pregnant? When you have more eggs, the number one is what we call anovulation. So the irregular periods or lack of having a period altogether. That is one of the top causes of infertility and certainly PCOS is the top cause of that. It's important to say that not having a period is not normal. So if you're taking birth control or contraception, we'll just put that in a different category for a minute. But if you're not taking any hormones and you're not having a period, it is extremely bad for your health on both ends. And what I mean by this is it's either because

your body has PCOS and has all of these little follicles making a tiny bit of estrogen each day. And in that scenario, you're not making your normal hormones, but also you're at risk for metabolic disease, high blood pressure, cholesterol, diabetes. But also that constant estrogen production, even though it's not high levels, but it's enough to confuse the brain, is stimulating the lining of the uterus to grow. And if you never ovulate, you don't make progesterone. So there's never the signal to shed or to bleed the lining. Cancer.

Cancer. So endometrial cancer is a very significant risk in women with PCOS who do not have periods. And this is why you will see people come in and say that you need to take progesterone or you must be on birth control pills because we've got to give you that progesterone in some form or fashion to bleed off those cells so that they don't develop into cancer. So there must be a pretty strong link then between PCOS and... Endometrial cancer, uterine cancer, yes. If you think about the other end of when people are not having periods, so I'm exercising and I lost my periods for three to four years. You're not making any estrogen during that time. Your brain shut off those FSH signals. The

ovary never made estrogen from those eggs. And having low estrogen is detrimental to your long term health. We see this even when women go through menopause at the normal age, right? Suddenly, you now have an increased risk of heart disease, stroke, osteoporosis, dementia, Alzheimer's once you've entered menopause because estrogen was protective against all of those. If you had that estrogen or that lack of estrogen even earlier in life, those risks, especially bone disease, osteoporosis, hip fractures later in life, they can be extremely high. So it's very important that women know that if you're not having periods, that it's harmful for your full body health. Very often I see young women, they're 20, say, I'm not having a period, but who wants to bleed every month anyway? So not a big deal.

But their brain's not functioning as great as it can. Having estrogen helps the brain think sharp and be productive. And if you're constantly lacking estrogen, you're going to be fatigued, feel cloudy. You're not going to feel like yourself. Replacing estrogen in somebody whose ovaries are not making it, whether it's because the brain's not sending the signals to or you're simply out of eggs early, replacing estrogen is extremely important for your quality of life and your longevity. You mentioned a word earlier that I've not heard before. Endometriosis. Endometriosis, yes. What is this? Endometriosis is essentially an inflammatory

autoimmune condition. So we already talked about, I've said endometrium a couple of times. Do you know what endometrium is? No. So the endometrium is the lining of the uterus. So it is what grows in preparation for that pregnancy to implant. And it is what bleeds when somebody has a period.

You're shedding the endometrium. So it's that inside portion of the uterus. In every single person, they bleed. Some of those cells are going to migrate out the fallopian tubes, which is pretty normal. If you can imagine, the uterus is contracting, it's squeezing. Some of those cells are going to migrate out. Some of those cells from the endometrium. Endometrium. Some of the cells from the endometrium, in addition to bleeding, as that uterus is contracting, you know, the tubal openings at the top, some of the cells are going to come out the fallopian tubes. And that's normal. Okay. So if I go and do an

appendectomy, I take out somebody's appendix while she's on her period, I'm going to see menstrual blood in her abdominal cavity. And that's totally normal. What is abnormal about endometriosis is that your body has an abnormal reaction to that. And instead of saying, oh, Natalie's on her period, no big deal, your body would say, oh my gosh, there's blood in here. It's foreign cells. Attack, attack, attack. And so it becomes a process where every time a woman is on her period, the body starts to attack these cells. And then because it is endometrial tissue, it's responsive to estrogen. So it grows with every ovulatory cycle, every follicle you make. It's characterized by inflammation, and inflammation is what causes pain. So very painful periods is the hallmark of the disease,

although importantly, not everybody who has endo has pain. Pain with intercourse is another one, especially in certain positions. So not pain with like insertion or penetration, but deep pain. So it's like, oh, the classic is when a patient will tell me, I don't like being on top. It's painful inside. Because of the angle that intercourse is happening, it is where she has these implants of endometriosis inside her body, these inflammatory implants. Endometriosis, because it causes inflammation, makes the environment more toxic. So the number one way that all autoimmune disease is contributing

to infertility is by this inflammatory process, which is just toxic to cell growth and toxic to early embryo growth. And we see infertility rates and higher miscarriage rates. Endometriosis, as inflammation lives there, can also turn into scar. So you can have destruction of the internal anatomy and total blockage of the fallopian tubes. So it can go from an inflammatory process to also a complete destructive and obstructive process. It is only a surgical diagnosis. And that's one of the hardest things is that you can't just say, I'm going to run a blood test and see if you have endometriosis. We don't know what markers to check in your blood yet. So the only way to diagnose the disease is by looking, doing surgery,

putting a camera in somebody's abdomen and physically seeing these endometriosis implants. The hard thing is... Sorry, just on the point of surgery, where does the camera go in? The camera goes into the belly button. So it's called laparoscopy. So you put a camera in through the belly button, inflate the abdomen, and you can go and see what is going on. And so somebody who's got very significant pain, your period pain should not impact your quality of life to the point that you want to cancel plans, not participate in your normal activities. If you're canceling dinner, not going to school, those are not normal findings. And if that is the level of pain somebody is experiencing, I'm very concerned that she could have endometriosis.

Many people don't ever go to surgery and get that diagnosis. And that's okay too if we think we have it or your doctor's approaching it in a certain way. Because by the time that you can even diagnose it, the damage is done. The inflammation is there. You've been living with it. And one of the hardest things for us with endometriosis, treatment of the disease. There's treatment. But I have to stop you from ovulating because estrogen will always stimulate even if there's one little cell. So if you're trying to get pregnant, you have to ovulate. So the treatment for the disease does not allow you to get pregnant and be treated.

So if you stop that and you're trying to get pregnant, each ovulatory month, the disease is progressively getting worse. So it's one of these places where it is very tough because we don't want people suffering in pain, but also getting pregnant is so difficult in those circumstances. And prevalence of endometriosis, we say, is about 10% of all women. In fertility clinics, patients with infertility, it's a 30% to 50% prevalence. So in my mind, there are a ton of people walking around with endometriosis or inflammation who do not know that they have it. This is why that falls into the category of sometimes what we call unexplained infertility. Somebody has regular periods because endometriosis does

not impact your period pattern. It might cause pain, but nothing about that process is interfering with your brain and your ovary communicating and your ovulatory pattern. So you're still having regular periods and you're having sex, even if it's painful, but you're not getting pregnant, there's something else going on. And so a lot of patients with endometriosis end up having to come to the fertility clinic, and many of them end up going through IVF because it is one of the only ways we can change the environment of which I can sperm meet is to allow them to meet in a non-inflammatory environment in an IVF lab. I can then drop your inflammation and treat your endometriosis and then put an embryo back inside

because I don't need you to ovulate as a part of that process. So IVF controls so many factors at once because I take the eggs, I grow them, I take them out of the body. Now I can fertilize them in the lab in that perfect environment with the perfect temperature and pH, grow that embryo. I can then have you have a period and suppress your endometriosis. I don't care that you're not ovulating now because I can give you some estrogen and grow the lining and then just put the embryo back in at the right day. And I can see wonderful success rates with that with patients with endometriosis. Just on that point you said about you'll give them a medication that suppresses the cycle, but it stops the pain. Could you be on that medication for say five, 10 years and then

come off it when you want to start getting pregnant? Yes and no. One thing that's very interesting, so a good example of one medication, not our drug of choice, but One thing that's very interesting, so a good example of one medication, not our drug of choice, but one thing that's used for endometriosis is the combined birth control pill. The birth control pill is estrogen and progesterone. If you're taking that pill, your brain is no longer ovulating because it's seeing estrogen, and that's not the same estrogen that the ovaries make, so it's not the type of estrogen that stimulates those endometriosis cells. Women who've been on the birth control pill for prolonged periods of time do not have diminished fertility when they come off of the pill. And in fact, most of them have higher fertility rates than their age-related peers who were

never on the pill. And if we think about it, the hypothesis is that if you suppressed ovulation for 10 years versus your best friend who didn't, and you both had endometriosis, you are now starting your ovulatory cycles and you put a pause in the development of your endometriosis. It's not going to get rid of it. No medication is going to reverse the process or treat it per se, like cure it, but we can halt it from getting worse. And so if you're on the birth control pill or you're on a medication called Lupron, there's some different options that essentially stop the body from

ovulating. Therefore, you're not progressively letting that endo get worse. And then you do have higher rates of success when you come off of that than people who are your age who weren't. So that's one strategy if you know you have it. You have to know you have the disease or have a high suspicion that you do in order to be preventing ovulation all those months. Someone comes to you and they've been diagnosed with endometriosis. What is your first sort of port of call for them? What's the first piece of advice you'd give them or the first suggestion you'd make medically or otherwise? Yeah. So for real honest talk about

how old they are, how many kids they want. We know that women with endometriosis run out of eggs at a faster pathway because endometriosis is inflammatory and destroys the eggs inside the vault. So you're going to run out of eggs faster. I want four kids. How old are you? I'm 25. Okay. So when do you want to start trying to have them? Let's say 30. Okay, 30. And you want a large number of children. Well, I want to know how everything is right this minute, right? So we're going to check your ovarian reserve. We're going to make sure that we're not already on a pathway of accelerated destruction because if we already have a low egg count now, now is the time to intervene. Egg freezing or embryo freezing, meaning taking some of those eggs out so I can save them for

later when I know you're going to have a hard time. Also setting different parameters for the endo patient. I don't let somebody who has endometriosis just pull the goalie and try when they're ready to get pregnant. I'm going to say, we know you have something that increases the odds that you're going to have a hard time. So are your fallopian tubes open? How is your partner's sperm? I want that data before you start trying to get pregnant. The traditional mentality to infertility is so reactive. You have to prove to me you have a problem before I go and test it. That's the classic mentality. You've got to try for a year before we'll go test these different variables. Of course, we're challenging that narrative.

And we're saying, no, go get tested beforehand. But an endo patient is 100% somebody who should. Same with the patient with PCOS. You're not an average person on the street. You have a medical diagnosis that is significantly associated with infertility. You need to approach your family planning journey differently. You need to test all the variables we can before you start trying to conceive. And we need to have an honest talk about your family size. Because if you want four kids and you start at age 30 and you have no problems and you have your kids really closely together, so you're going to want 30, 32. When's your next one? 35, 36. When are you having baby four? You're pushing 38 to 40. and we know that rates are going

to be harder because you're going to have more genetically abnormal eggs at that age so a lot of people don't even talk about this stuff do they like in terms of use that word family planet i think really that's at the heart of what's missing here is we don't do family planning we do like family reaction. Yeah, we're like, oh crap, no family. And then, oh my God, we want to have a family. Now what? Here's what I say to somebody who has, we'll say PCOS or endometriosis, and they want to have a bigger family and they're not quite ready to start, but let's say they have a partner. This is the perfect opportunity to do what we call embryo banking. So it's very similar to egg freezing, but it's IVF.

So it means right now I'm going to get a group of your eggs to grow. We're going to go through the IVF process. IVF is in vitro fertilization. So one month's group of eggs, I'm going to get them all to grow. People with PCOS are fabulous candidates for this because they have so many eggs. The ROI on that investment is very high because number of eggs and age are the two most important factors. I'm going to get that month of eggs to grow. I'm going to take them out of the body. I'm going to fertilize them with sperm,

grow out embryos, and I can do genetic testing to see which ones are chromosomally normal. And they can stay in the freezer until you're ready for them. What? Well, you can put fertilized eggs in the freezer? Yeah, those are embryos. You can put embryos in the freezer until you're ready for them. What? Well, you can put fertilized eggs in the freezer. Yeah, those are embryos. You can put embryos in the freezer. Yes, sir. And that is going to allow us to change the trajectory of somebody who wants four kids and isn't starting until 32, 33. Because now, naturally, having that fourth baby becomes statistically very improbable.

In order to have four children, most people will need to start before age 28. Now, that's not everybody, but most people. So if you want that big family, because that's, like we said, a child's a person. It's a whole different life you're going to have with that person in it. Then we need to say, hey, well, that's a lot easier to go through IVF right now, freeze those embryos, then start trying to get pregnant. What's the difference between me freezing eggs and sperm versus freezing the embryos? So this is a good point. So freezing embryos, even if you're going to try to naturally get pregnant later, is helping you know that you can tap into those embryos, you know, later in life.

So versus doing IVF at age 39, where you have less eggs and the vast majority are abnormal, you're making those embryos now where they're much better. The process for the woman is exactly the same whether you're freezing eggs or embryos. You are taking shots of FSH to get one month's group of eggs to grow.

That takes about two weeks. And then we do a quick procedure to take the eggs out of the body under anesthesia. So none of that is different. What happens is the difference is in the eggs. I always say if you're freezing eggs, it is not an insurance policy on your fertility. An insurance policy pays off when something bad happens. This is an investment. You're playing the stock market. Is it smart to put your money in investments? Does it usually pay off? Well, it depends on the environment when you go to pull that money out. Eggs are potential opportunities. It's fantastic and it's much better than nothing, but it's not giving us all of the information.

Because even if the sperm looks normal and even if the eggs look normal, the real proof of the pudding is seeing how the embryos grow and develop. Because not every egg is going to fertilize, become an embryo, or be genetically normal. And even every genetically normal embryo is not gonna become a baby. So if I take an average person who is age 30,

and let's say we get 20 eggs from going through egg freezing, that is fantastic. You feel super egg rich. That sounds awesome. Now, if we make them into embryos or when we go make them into embryos, you do often lose some eggs in the freeze-thaw of the eggs. Eggs are a single cell, mostly filled with liquid like water and then DNA. An embryo is 300 to 500 cells when we freeze it. So embryos are much, much stronger.

They survive over 99% of the time. Egg freezing, I told you earlier, it wasn't available 10 years ago when I was your age because eggs didn't survive the freeze-thaw. We were trying it, but they're so fragile. It just took a while to get the tech there. Eggs now survive 90% of the time going through the freeze-thaw, which is great, way better than 40%. But it's also not 100. So we have to kind of account for that loss in our equation. So if I have 20 eggs, now I go to thaw them whenever we're ready. And now I have two that don't survive. So I have 18. I'm going to go inject them with the perfect sperm.

And I would have on average fertilization rates of about 75 to 80%. So let's say 14 of them fertilize. Half of those are not going to make it to an implantation stage embryo, even if everything's perfect. So now I have seven that have made it to an implantation stage embryo. And then my proportion of normal is based on my age. So if I'm 30, I'm pretty good because I'm about 60% to 70% normal. If I'm 35, it's about 50-50.

If I'm 38, it's a third normal. If I'm 40, it's about 20% to 25% normal. So you can see how that number of eggs that you have and the outcome differs. For the 30-year-old, the seven embryos, if everything falls perfect, she should have four normal embryos. But that's if everything falls perfect. And what if it doesn't? What if our fertilization rates are lower or not as many embryos grow through the process? Average means that some people do better than average and some people do below. And we don't know that about an individual couple until we

put them through the process. How many embryos can I put in the freezer? You can put as many as you want. If you're trying to optimize your chance of success, you're going to want two to three genetically normal embryos for every child that you want to have in the future. One genetically normal embryo put inside a body has a 65% chance of live birth. And is there an age component to whether the embryo will be successful? So if my partner put one of those embryos out the freezer into her at 45, are the odds still the same? Up until 45, yes. After 45, you start to see a decline, but still ultimately quite successful. I need to get some of these

bloody embryos in the freezer. Yes. So cumulatively after two embryos are put inside, not at once. So I put one transfer or you're not pregnant and then you do the second one. 88% of people have had a live birth. And after three, you played embryos. It's 95% of people, 95% of people. That means that the number one reason why people don't have success with IVF is they don't have enough genetically normal embryos. Nothing about failure to implant or these other factors, but that they didn't have enough. The problem with eggs is if I have 20 eggs in the freezer, how many embryos do I have? You don't know yet. I'm making a whole lot of assumptions. Yeah. And what's the cost difference of freezing eggs?

It is about half as much to freeze eggs as embryos. Okay. So if you don't have a partner, obviously eggs are the way to go. Sometimes in somebody who has very low ovarian reserve and they only have a limited amount of funds, it makes sense to do eggs because I could get five eggs and five eggs and have 10 eggs. And even if I don't know the outcome of it, if that's all the money you had to spend, it was better served to get two months worth than to make embryos and find out that I have maybe one normal.

How much does this cost? On average, we'll say egg freezing is going to be about 10,000 and IVF is going to be about 20,000. Okay. I don't know the UK equivalent for that, but Chachi PT is telling us that on average IVF in the UK is about 3,500 pounds. And in the US it's about $10,000. IVF is $20,000. $20,000. With genetic testing, yes. Freezing the eggs. Yes. How much does that cost? It's about half as much. And that makes

sense because you're doing about half the process. You're still growing the eggs. Yes. How much does that cost? It's about half as much. And that makes sense because you're doing about half the process. You're still growing the eggs, taking them out of the body, freezing them. You'll have to pay the second cost eventually, but it's easier to spend your future money than your current money. And do you have to pay yearly to keep them in the fridge? You do have to pay annual storage fees. How much is that on average? It depends. Typically, it's between $500 to $1,500 a year. We have to talk about the stigma around IVF. We've talked about stigma a few times. And I can imagine that a lot of people, when they hear about freezing your eggs and IVF, especially people who are maybe in their early 30s or in their late 20s, they will reject the idea because of the stigma that that means you're broken and that's not

natural and we've got to do it like this and in the movies it happens like this on instagram and with that couple over there they just had sex and then little bernie was born like you know all of that stuff and i think a lot of that stuff actually gets in the way of even the conversation in the first place i think um i had this conversation with my partner but but I was scared to have the conversation because turning to my partner and going, hey, babe, I think you should freeze your eggs and I should. It's like loaded with a bunch of. It's a bunch of feelings. Yeah, yeah, yeah.

But the truth is that beat one as a couple beat on the same page is so important. So that conversation that you had, I'm so proud of you because some people don't have it. And I'm the first person to ask them, how many kids do you want? What does our family size look like? And people never had that conversation. So it makes it very difficult for family planning. There's a huge stigma about going through fertility treatments, having infertility, freezing your eggs, the whole gamut. A lot of that is because stigma often comes from things that are unknown or uncertain.

So simply by having these conversations and talking about it more, that is so impactful in breaking the stigma because we start to normalize these terms and understand for women, time matters. And yes, there's going to be stories of people who are able to wait later and get pregnant and that's wonderful three percent's not nope nobody but is that likely to be you and that's the question i always say it's a very inefficient way to try to achieve a life goal let's have a life goal of ours and settle for something that's going to give you a three percent chance of success that doesn't make any sense to me once upon a time if you had a business idea it was exceptionally difficult to get going but now in the age of shopify it is exceptionally easy

as many of you will know shopify are a sponsor of this podcast if you don't know shopify it's an exceptionally simple web platform for anybody that's got an idea that wants to transact on a global scale. So things like these conversation cards, which we sell, we've sold using Shopify and it only took us a couple of clicks to get going. So why did we choose Shopify? For a number of reasons, but I think one of the big ones, which goes unapprecireciated is their checkout system converts 36% better compared to other platforms. And here's what I'm going to do to remove the cost for you. If you go to shopify.com slash Bartlett, you'll be able to try Shopify for $1 a month. I've seen Shopify completely change people's lives. And for many of you, I think it could change yours. It's also a unavoidable reality

of the world we live in. I was reading Time magazine and it says that in 1970, the average US woman had her first baby aged 21. And this increased to age 27 by 2022. So the time that we typically have our first baby has increased by six years. Most people are having it in their late 20s, having their first baby in their late 20s. That's again, a consequence of the social factors we talked about. So because of this, there's always trade-offs in life, right? We want longer careers and we want more, quote unquote, freedom in early seasons of our life, then there's going to be a trade-off. Well, the trade-off shouldn't be

that you have one less human in your family that you want. It might just be that you have to do something different to make sure that goal is achieved. You said on a recent podcast you did that studies tell us that if you're not ready to have a family by 32 or 33, then that is the optimal time for the average person to intervene and start

freezing their eggs. It is. And it comes from the way that study was based on the odds of you when you'd be likely to start trying to conceive and the rate of infertility coupled with the rate of decline in egg count and egg quality as you get older than that. Certainly your eggs are better quality and you have more of them younger than that. So if you know you want to freeze your eggs, do not wait until you're 32. But if you are approaching that age and want to have children as a life goal and you're not ready to have them now, you need to go see a fertility doctor, period, the end. And what I mean by that is maybe you freeze your eggs and maybe you don't, but you owe it to yourself to be the one to make the decision. And you can't make it unless you

understand how many eggs do I have? Are things normal for me? And evaluate that information, hear about what the process will be like. You can choose to not do it, but then you made the choice and the risk of regret is going to be lower in the future if you actively made the choice versus I didn't know and I never got the chance. IVF, put simply, is extracting an egg and a sperm, injecting the sperm into the egg, and basically putting it back inside the woman. That's the simplified version for dummies. Yes. So IVF in vitro fertilization, we're

fertilizing the egg outside the body. So in vitro is in glass, but in the lab, in the petri dish. Now, modern IVF, we are taking one month's group of eggs, growing them to embryos and doing genetic testing, and we're freezing them. What are you testing them for? We're testing them for chromosome number, what we call aneuploidy. As we talked about the chromosomes getting out of line as you get older, you can check the number of chromosomes, the presence or absence of each chromosome in a five to eight cell sample from the embryo biopsied. To make sure they're healthy? We'll use healthy as the embryo needs to be genetically normal. It needs to have the right number of chromosomes to have the highest potential for

success. If you're missing a full chromosome, that's going to end up in a miscarriage. If you have extra chromosomes, like an extra copy of chromosome 21 is Down syndrome, that carries its own risks. And many of those are pregnancy loss as well. So we're looking for what we call a euploid embryo, a genetically normal, meaning it has the right number of chromosomes. Importantly, IVF can also be used to eliminate genetic diseases that can be extremely impactful. When we talk about genetic testing the way that I just defined it, testing for euploidy, you have more eggs that are genetically abnormal as you age. That's one of the top barriers to getting pregnant. But if you

and your partner both carry cystic fibrosis, for example, that's a disease that you are going to exhibit the characteristics of if you have a copy of the gene from mom and a copy of the gene from dad. You have about a 25% chance of having a child who would be severely ill or sick with cystic fibrosis. We can make a probe for where your cystic fibrosis mutation is on chromosome 7, and then we can apply that probe to that sample that's been biopsied from the embryo and find out which embryos have zero, one, or two copies of that mutation, essentially not transferring the ones that are going to result in the disease state. And for lethal abnormalities, this is huge. And then for autosomal dominant diseases, like Huntington's disease or cancer hearing syndromes,

you can eliminate that from the family line. Do you then put one embryo into the woman at a time? We do. And so this has changed over time. I think this is where a lot of misconceptions come from IVF. If we can imagine the world where I have a 40-year-old with four frozen embryos, if I've done genetic testing on them,

I would know that she has one normal and I would just go put that normal one in. Before genetic testing existed, she had the same four embryos, but I will just go put that normal one in. Before genetic testing existed, she had the same four embryos, but I didn't know which one was normal. So her odds of pregnancy for a single embryo transfer were much, much lower. So it was commonplace to put more embryos in then to try to up the odds that you'd capture the normal one. Now that we know which embryos are genetically normal,

we want to transfer one embryo at a time. And I always say it's, don't make them compete for resources. Let that embryo have the full surface area of the uterus to have a really nice placenta to grow into, decrease the chance of loss or pregnancy complication down the road. Interestingly, if you transfer two embryos, of course you have a higher chance of twins. You don't see much of a change in the pregnancy rate, just the twinning rate. But even without transferring two embryos, a single embryo transfer significantly increases the chance of identical twinning. Now, overall, it's still very low, but identical twinning, where one embryo

splits, so you have two children who are genetically the same. In nature, that happens at about a half a percent. In IVF, it happens closer to two to three percent of the time, probably just because of that embryo being loaded into a catheter. Maybe its external surface is touched in some way, makes it more predisposed to split after we put it inside the body. That's still ultimately a very low odds of it happening. But if you put it in context of I do 400 embryo transfers a year, then I'm going to definitely see some patients who are having identical twinning from a single embryo transfer. Also, you know, importantly justifying just putting one in at a time.

Because if you put two in and one of them split or both of them split, you could have triplets or quadruplets. If we talk about doing it the old-fashioned way, you know, sex, there's a lot of misconceptions around how to increase our odds of getting pregnant. You hear about women putting their legs in the air after sex

or things like people think if you go for a wee, then you're going to wee out all the sperm and that's not going to make you pregnant. Are any of these things true? There's so many myths when it comes to trying to get pregnant the good old-fashioned way with intercourse. So certainly we can go through a few of them. One of them we already touched on, which is, oh, you should save up sperm for when you're

ovulating. So we see that sometimes men will ejaculate less or couples will actually not have sex trying to save up for that exact day of ovulation. But there's no need to do that. As we know, we want to clear the pipes to keep the sperm coming out healthy and alive and not have dead sperm and that you can have sperm survive in the reproductive tract for up to five days. So you want to be having intercourse up until that ovulatory day. So every other day sex, every day sex, every three day sex, those are all fine. Nobody ever needs to have less sex. So if you and your partner have sex every day, please don't have less sex because you're trying to get pregnant. Number two, the sperm are inside the fallopian tubes within minutes. They have gone from the vagina, gotten through that seminal fluid in the ejaculate,

through the cervix, through the uterus, and into the fallopian tube within minutes, under five minutes. So there's no need to prop your hips up on a pillow for 30 minutes or put your feet in the air. Truly the sperm are into the cervix within two minutes. And the cervix is where they then sit for up to the five days. So the two minutes time that it's going to take you to withdraw, get up, go to the bathroom, the sperm are fine. You're not going to pee out any sperm. You don't need to put any device in to keep sperm in place, keep your get up, go to the bathroom, the sperm are fine. You're not going to pee out any sperm. You don't need to put any device in to keep sperm in place. Keep your feet up, lay in bed. You can go and do whatever you want to do. And in fact, we know that urinating after intercourse for women decreases the risk of a urinary tract infection. So we try to encourage people to get

up and be normal. I also tell people all the time, embryos and plant eggs fertilize when you are up and living your life. So you don't need to just be horizontal to have fertilization occur. What about sex positions? Are there any sex positions that are more conducive with? Yeah, whatever position allows for ejaculation. So this is where variety is the spice of life because as you alluded to earlier, sex can feel a little bit more of a chore when you're trying to get pregnant or you're struggling. So making sure that ejaculation can happen, there's not any position that is going to be better or worse or going to have higher

chance of a boy or a girl or any of that kind of knowledge. If the female orgasms, does that increase the chance of fertility? We do know that orgasm does help, uterine contractions help get the sperm to the eggs faster. So we do know that. How do we know that? How do we know that? There have been studies looking at, there have been studies looking at orgasm and then the speed of which sperm get to the fallopian tubes. We'll just say that. I was thinking of all the causal factors. I was like, maybe it's just bigger and that's just good. No. So yeah, just that those contractions are helping kind of propel the sperm up there. What about penis size? So penis size really doesn't matter. What's interesting is that penis size does tend to correlate with different race and ethnicity,

also with vaginal length. So we tend to see different vaginal lengths in correlation with what tends to be a similar penis length based on that ethnicity or where that person originated from, which is super interesting. But you don't need to… You don't need a smaller penis or a bigger penis as long… The sperm doesn't need to get closer to the cervix. A lot of people obviously think that. Yeah, I know. When you ejaculate, it goes. It gets right where it needs to go. crazy it's super interesting i've learned so much

about um all of this stuff today i think there's probably just two more things i wanted to ask you about one of them is um you mentioned birth control earlier and there's lots of conversation at the moment as to whether birth control is healthy or not and the sort of side effects and risks associated with it. We know everything and nothing in life is a free lunch. There's always trade-offs and side effects. And would you say that birth control, and obviously birth control comes in many forms as well.

It's not just a pill. There's, you know, the coil and all these other types of birth control. Is the pill healthy? I'll reframe and say the pill is not necessarily unhealthy. However, it's very important to understand that we now have a generation of women who were given the birth control pill when they had a sign that something was wrong with their body without getting to the bottom of what it was, which means we're just kicking that can to trying to find that diagnosis now

later in life and causing a lot of frustration. So if your periods were irregular, you got to start on the pill. You took it for 15 years. Now you're 35 and you come off of it. Your periods are probably still going to be irregular, but now you don't know why. You're ready to get pregnant and it can be very frustrating. So the use of the birth control pill as treatment without getting to the basis of diagnosis has been a huge problem in women's health. The birth control pill itself does not cause infertility. It changes nothing about the vault. The eggs are still coming out every month. You're just losing them. None of them are ovulating. The birth control pill itself combined estrogen and progesterone. The brain doesn't send out that FSH.

So it's not impacting the quality or the quantity of the eggs that you have. It does change some of your metabolic parameters. It does change some of your vitamins. And every person is going to have a different reaction to the pill. So certainly some people hate it, but some people love it for endometriosis, or you can have really terrible PMS or what we call PMDD, which is like premenstrual dysphoric disorder, where you have these mental health changes as your hormones change. Having stable hormone levels can be life-changing. So the pill definitely has medical treatments. It prevents the cancer from PCOS.

It prevents endometriosis progression. It can treat pain. It can be something that can be very beneficial. And unfortunately, we see a lot of stigma with the birth control pill right now. On social media, we see so many people talking about how bad it is and how negative it is and how you're harming your health by taking the birth control pill. You're not harming your health. However, it's allowing too many people to not have that discussion about their family planning and not understand how their hormones work.

So I always recommend that somebody stops contraception before they're ready to get pregnant. That way you can understand, are your periods coming regularly? What are the signs and symptoms that something could be wrong so that you're not behind the game when you're trying to get pregnant? Lots of people will be listening to this now that are struggling with a variety of the things that you've talked about, whether it's PCOS or whether they've been trying to conceive a child for some time, whether it's this new word that I learned today, endometriosis, whether they're in late stage sort of IVF treatment and many of the embryos have failed.

What is your message to those people? There'll be, I'm sure, hundreds of thousands of them that are listening right now. Number one, you can't control everything, but you should control what you can. So understanding, getting the sleep, optimizing your lifestyle, you should eliminate those questions from your mind. Should you do it? You should do it. Number two, there's no reason why you cannot ever get, let's say, a second opinion if you're deep in the fertility treatment. Too often I see people who do the same thing over and over, and it's heartbreaking because they're using their time and their money, and you might need a new set of eyes. And I'll

even tell my patients that if they're not having success. If you want to go get another opinion, go get it. I support you. We support our patients getting those extra sets of eyes, extra input, because this is your one chance. There's such a limited amount of time from when most people start trying to when your reproductive window is closed that you owe it to yourself to feel comfortable with the choices that you are making. If you are not getting the information you need from your doctor, that's a red flag. If you can never talk to a doctor, that's a red flag. If your periods are irregular and you don't know why, you need to see a doctor. If your periods are so painful that it's interfering with your life, you need to go see a doctor.

If you know you've been diagnosed with something that somebody told you is going to make it hard for you to get pregnant, please don't be reactive once you don't get pregnant, once you have infertility. Don't try for 12 months and then come see me. If you know you have PCOS, let's test you now. Let's try to start out on the right foot to know that everything else is working and have a game plan to really try to help you achieve this life goal. Natalie, thank you. We have a closing tradition on this podcast where the last guest leaves a question for the next guest, not knowing

who they're going to be leaving it for. And the question that has been left for you inside the diary of a CEO is, what is the most difficult conversation that changed your life? That's such a great question. And I've been in a position to have a lot of really difficult conversations, both for my own personal decision making, changing career pathways, having my own infertility journey. But the most impactful conversation I ever have and one that I react to my patients was after my second pregnancy loss. I was the chief resident. I was the resident in charge of the busiest labor and delivery unit in America. And I started miscarrying while I was on my shift. So I was bleeding in the bathroom and nobody knew I was pregnant. So I had to carry on. So I carried on, did C-sections,

delivered people's babies. And I left and went to my own OB when that shift was over, distraught because I knew that I was losing this pregnancy. And I just had to witness so many families achieve what I wanted to achieve. And my OB, when I got there and she confirmed that I was miscarrying and she said to me, it's really hard to understand the meaning when you're in the middle of the journey. But one day, the world makes sense. And it's your job to not give up hope and to stay on the path. And that I believe that this is going to happen, that you're going to be a mom. And I may not have all the answers why you're struggling right now, but I trust that if you keep going, the odds are that you're going to have the baby that you're meant to have. And when I went on to have subsequent losses,

that stayed with me, that she believed I was going to have the baby I was meant to have. And I'm going to cry now. My daughter, like if any of those other losses had worked out, I wouldn't have my kids, the ones that are my everything, meant to be my children, right? My daughter, that egg that was in the vault, I would have lost when I was pregnant because you still lose eggs when you're pregnant. So I wouldn't have her if any of those had worked out. So the world has a way of sometimes making sense that are so hard when you're in the midst of the pain to understand. And I tell my patients that same thing over and over, that in the journey, it doesn't make sense. But that's not your job in the journey to understand the whys. It's to keep going and not give up. You must see so much of that pain. How do you not, you know, how does that not

come home with you? Oh, it comes home with me and I live it in the moment. So I'm not going to be the type of person who can experience your heartbreak and not experience it with you. So I'm going to cry with you and hug you. And I'm going to take it home and hug my kids and know how happy and how lucky I am to have them. I frame it for all my patients as I'm never going to sugarcoat it for you. You know that I'm going to give you the truth. It's going to be hard to hear sometimes, but we know that we have the type of relationship that you can trust that I am giving you the best information that there is. Sometimes you have to tell them that it's not possible.

I do. Sometimes I have to tell them it's not possible. It's not going to happen. We need to look at other alternatives for family building, donor egg, donor embryo, donor sperm. I have couples who sometimes had no idea the man had no sperm. And we have to completely change what we thought a family would be. So I do tell patients, you know, every week that this plan is not going to work anymore. And it's time for us to step back and really think about what that goal is. Is it a genetic child? I mean, that was plan A, but maybe it's just a

child, a life, you know, maybe there's other ways to get there than what we were trying for. So there's a lot of pain in the job. I always say I have the best job and the worst job in the same day every day. What's been your hardest day in work? The hardest for me are going to be mostly in my past, you know, training in obstetrics, you know, fetal death, stillbirth, loss of a highly desired, I mean, loss of any pregnancy, loss of life. Those screams of those parents, I'll never escape them. So pregnancy is not health neutral. We act like it's our, once you get pregnant, everything will be fine. Every single pregnancy could have complications.

And I think it's really important that we enter into that space with the knowledge of what it is and what it isn't. But the loss of life is always going to be the hardest. Ashley, thank you. Thank you so much, Stephen. Thank you so much. You're doing, you know, there's kind of two sides to this. I have a huge amount of gratitude for the fact that you're, through your clinic and your work,

you're helping people to realize these very important dreams that they have and you're illuminating all of the darkness that causes the uncertainty and the doubt and all of the things that come with trying to build a family. And you're doing that through information, but you're also doing that in such a compassionate, human, honest way. And then secondly, because you do things like this, and there are so many people that don't have the opportunity to go to a doctor or a fertility expert and sit down with them because of the country that they're in or the cost of it or the time they have or whatever.

But by making this type of information accessible to millions of people, by committing your time to do podcasts and things like that, I think you're going to be helping so many hundreds of thousands and millions of people that you'll never get to meet. So on behalf of all of those people who I can feel at home,

on the tube, on the train, on the plane right now that want to express their gratitude to you, and I'm sure that they will message you to do exactly that, I want to say thank you on behalf of all of them as well. I've learned so much.

I've learned so much. My mind has been changed, so I have no doubt that there's millions of people listening right now that have also experienced the same thing. So thank you, Natalie. Thank you. And thank you for holding space for this discussion.

There's stigma here. It's not the most fun topic to always discuss about. And it's something that you're bringing it to those people who might not come to my channel searching for it, but they need to know the information. So by putting it in a place where they're looking for other things, thank you. Bye.